Principales investigaciones sobre el cáncer de mama en la ASCO 2024

This podcast episode is made possible, in part, by a grant from Lilly.

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here’s your host, Breastcancer.org senior editor Jamie DePolo.

Jamie DePolo: Hello, I’m Jamie DePolo, senior editor at Breastcancer.org. I’m podcasting live from the 2024 American Society of Clinical Oncology Annual Meeting. I’m joined by Dr. Eleonora Teplinsky, a board-certified medical oncologist who specializes in breast and gynecologic oncology. She is head of breast and medical oncology at Valley-Mount Sinai Comprehensive Cancer Center in Paramus, New Jersey, and a clinical assistant professor of medicine at the Icahn School of Medicine at Mount Sinai in New York. 

She’s also the host and creative force behind the Interlude podcast, which shares the stories of women who have been affected by cancer. Dr. Teplinsky is going to summarize some of the top breast cancer research presented at ASCO this year. 

Dr. Teplinsky, welcome to the podcast.

Dr. Eleonora Teplinsky: Thanks for having me. 

Jamie DePolo: So, in your opinion what was the top, like the best breast cancer study presented?

Dr. Eleonora Teplinsky: All right.

Jamie DePolo: If there’s just one. 

Dr. Eleonora Teplinsky: Yeah, there’s definitely not just one.

Jamie DePolo: You can do more than one.

Dr. Eleonora Teplinsky: But I would say the top one definitely is the DESTINY-Breast06 trial.

Jamie DePolo: That was this morning.

Dr. Eleonora Teplinsky: That was this morning. So, what DESTINY-Breast06 is, this is looking at Enhertu or trastuzumab deruxtecan, which we know right now we use it for HER2-positive, metastatic breast cancer, and then HER2-low.

So, two years ago when this study was presented, it really created this new paradigm of you’re either HER2-negative, you’re HER2-low, or you’re HER2-positive. And we can use trastuzumab deruxtecan if you’re HER2-low, but the way we’ve done it, prior to this study being presented, is, if you’re hormone receptor-positive you get all of your endocrine anti-hormone therapies , then you get chemo , and then you get trastuzumab deruxtecan. 

So, DESTINY-Breast06 said, hey, what if we give this drug before we give chemo? How are people going to do? Is it going to have better outcomes? And so, that’s where, that’s the goal of this study. So, bottom line, what they showed was that if you give trastuzumab deruxtecan before you give chemotherapy, after all your endocrine therapies, people do better and that’s, that’s huge. 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: Side effects were pretty similar and it was about a six-month improvement in, you know, reducing the risk of recurrence of death, so that’s really significant. And we’ll have the full numbers, we’ll share all that, but you know, and the side effects again, some side effects are a little… What they did was they gave people either trastuzumab deruxtecan or chemo.

So, when you look at side effects you’re going to have some more things that we see more with trastuzumab deruxtecan, sometimes nausea, with certain drugs, hair thinning or loss, interstitial lung disease or pneumonitis, inflammation in the lungs can be a little higher with Enhertu. You know, but on the other hand, chemotherapy is going to have other side effects. So, it’s a balance.

But it’s the improvement in outcomes. And so it raises the question of, one, well is everyone going to get it before chemo? Are there certain people that would get it before chemo? And you know, keep in mind it’s not yet FDA-approved for this indication, so we might start to use it, but we’ve got to frame that. And the other thing they did in this study was they looked at ultralow. 

Jamie DePolo: Right, which there’s no specific definition for that, correct?

Dr. Eleonora Teplinsky: No. And this is where it gets interesting because we have some data that says even patients who are completely HER2-zero may benefit. It’s not robust, it’s data, and so this ultralow is where there’s, like, even a touch of HER2 you’re considered ultralow. So, it’s going to raise the question of how are our pathologists reading and calling it, how are we going to define it, right? So, it’s going to require, it’s not just looking at a pathology report anymore it’s going to require these conversations with the pathologists, so it’s going to take a little bit of time. And a question that was raised is, well, look if this is mostly everyone? Can we just give it to everyone?

Jamie DePolo: Right. 

Dr. Eleonora Teplinsky: And so, I think that those are all still questions that hopefully will evolve and answer themselves over time.

Jamie DePolo: Do you think we’ll see new, different HER2 testing because of this?

Dr. Eleonora Teplinsky: I mean, yeah, there’s a lot of discussion now about how do we test? And like, again, even should we test? Or does everyone just get it? So, I think we will. I think it’s got to be more precise, you know, and again there’s not going to be, I mean, even just in two years we’ve gone from negative and positive to negative, low, and positive, and now we’re adding more gradients to that, right, negative, ultralow, low, positive. So, I think it’s going to evolve and I think it will evolve quickly because we need to have that information so we know who to treat. So, I think that this is something that will move fairly quickly.

Jamie DePolo: Okay. And one other question about that, is there any sense that people could just get Enhertu after hormonal therapy/endocrine therapy, and not chemo?

Dr. Eleonora Teplinsky: Well, that’s really the crux of that study, right. So, can we give Enhertu, and then wait for chemo, you know, unless they developed a progression of disease? 

Jamie DePolo: I see.

Dr. Eleonora Teplinsky: So, that’s where we’re still, right, like right now prior to this morning endocrine therapy, chemotherapy, Enhertu.

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: After today, is it endocrine therapy, Enhertu, and then chemo? That’s what, you know, and that seems to be better based on DESTINY-Breast06, but again is that for everyone? Not yet FDA-approved. How do we define ultralow? So, these are some of the questions. 

Jamie DePolo: So, that’s the top one. Was there anything else that was kind of up there with that or…?

Dr. Eleonora Teplinsky: Yeah, I mean, I think, you know we still haven’t had the, some of the other sessions that are coming, but the other thing that I think was really important was we saw an update from the NATALEE study. So, the NATALEE study is looking at -- we’re going to pivot now to early stage breast cancer. 

Jamie DePolo: Sure.

Dr. Eleonora Teplinsky: And so, for early stage breast cancer that’s hormone receptor positive, HER2-negative, for stage II and III we start to think, can they also get a CDK4/6 inhibitor along with the endocrine therapy, so along with tamoxifen or an aromatase inhibitor? And we have Verzenio, or abemaciclib, already approved, but those are really more for higher risk patients. They’ve got to get certain lymph nodes, or lymph nodes and grade III, or a tumor size greater than 5 centimeters, so it’s a more narrow population, and abemaciclib has side effects that are tough. So, now came along the NATALEE study, which actually was presented last year at ASCO.

Jamie DePolo: Yep.

Dr. Eleonora Teplinsky: And looks at ribociclib, same idea, given to you with endocrine therapy, but a broader patient population, and they found that it reduces risk of progression or death by about 25%. And they included lymph-node-negative patients. Now, the drug’s not yet FDA-approved, and a big question has been, well, is the benefit in the lymph node negative patients there? Right? Or is it more in the people that have more, you know, disease at higher risk for recurrence? 

And again lymph-node negative, do you need a drug that’s got all these side effects? And so, that’s, they presented data on the node-negative study, on the node-negative patients, rather, and they found that yes, they benefit. But for me, it really raised the question of, well, they didn’t separate out the different types of lymph-node-negative patients.

Jamie DePolo: I see.

Dr. Eleonora Teplinsky: So, in my mind, a person that has a 2.1-centimeter tumor, with an Oncotype of 26 is very different than someone who has a 4.9-centimeter tumor, with an Oncotype of 48, right?

Jamie DePolo: Of course.

Dr. Eleonora Teplinsky: So, do both of those people benefit? 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: Right. So, that’s where, I think, there was excitement, but also a little bit of like…

Jamie DePolo: We need a little bit more info.

Dr. Eleonora Teplinsky: We need a little bit more. You know, and again it’s that, it’s about, you know, it’s about a 3% benefit, which is there, but it’s modest. 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: And is it worth the side effects?

Jamie DePolo: The side effects.

Dr. Eleonora Teplinsky: And I believe something like a quarter of the patients discontinued the drug, so, you know, so these are the questions, right? Like and I think it just comes down to who needs more? Who needs less? 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: And we’re moving in that direction, but we’re, you know it takes time. 

Jamie DePolo: Sure. And it’s also, I mean, I’m assuming, this could be me not being an oncologist, but it’s a discussion with the patient as well. 

Dr. Eleonora Teplinsky: Yes.

Jamie DePolo: Like what, what are you comfortable with? What side effects are you willing to tolerate? And, you know, if this gives you greater peace of mind, is that worth it? Those kinds of questions? 

Dr. Eleonora Teplinsky: Exactly. I mean, I will say I say to patients all the time… Some people will tell me I will do anything to make this not come back. 

Jamie DePolo: Sure.

Dr. Eleonora Teplinsky: I will take every medication. And other people say, I don’t want to have these side effects and I will accept that there may be a little bit of a greater risk. And so, that’s that shared decision-making and really sitting down, sitting down and saying here are the benefits, here are the side effects, and the thing is, you can always start it and stop.

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: I think that’s a piece too, but to add to all that is the cost of these medications and coverage. 

Jamie DePolo: Oh, right, right.

Dr. Eleonora Teplinsky: And even though insurance may approve them, people may have high cost, high deductible, so I think the pharmaceutical companies do have some patient assistance programs, but like that’s all another layer of things to, you know, deal with. 

Jamie DePolo: Sure. Sure, that makes sense. Now, were there any results that you thought were immediately applicable? That you were going to go back when you see patients this coming week that you were going to put into practice?

Dr. Eleonora Teplinsky: You know, so I think DESTINY-Breast06 is interesting and that may be something we think about, but again we always, it’s not FDA-approved for this indication.

The thing that I thought was very interesting, and I mean, look, there are so many studies and we can sit here all day, but this study, I think, was very interesting is looking at patients who are estrogen-receptor-low. So, again, here’s a new low, right?

Jamie DePolo: Right, exactly.

Dr. Eleonora Teplinsky: But we see this all the time, people get their results and they’re technically estrogen-receptor-positive, but the expression is 5%, right? And 5% is a lot different than 100%. So, we always grapple with, you know, these patients have a cancer that behaves like it’s triple-negative, where we kind of treat them, you know, more aggressively, and then do we give them endocrine therapy? 

Jamie DePolo: And does it benefit?

Dr. Eleonora Teplinsky: Yeah, it’s 5% expression. We’re giving them things with hot flashes, and joint pain, and osteoporosis, and all, and so we grapple with that all the time. So, this study, and I think was very actionable, they looked exactly at this question. They looked at the ER-low, and do they benefit from endocrine therapy? And they had 7,000 patients, so that’s a pretty big number.

Jamie DePolo: Yeah, yeah.

Dr. Eleonora Teplinsky: They had all gotten chemotherapy and what they found was that when they really broke it down -- I could spend a lot of time talking about this one, too -- but when they broke it down, the people who really benefited from endocrine therapy were the ones who had neoadjuvant [before surgery] chemo and did not have a pathologic complete response. And so, those had about it was like 25% increase in the risk of death or progression if they didn’t get endocrine therapy. So, I think that that’s something actually that’s very actionable. 

Because we now have numbers that we can say to patients, we can say, look, you’re estrogen-receptor-low, you know, and here’s how the numbers break down, and you can give them some statistics that they can use to make that decision. Because before, we’ve said, we don’t really know, and so I like having numbers, I like having data that we can talk to patients about, so I think that’s something that’s immediately, you know, actionable. And then there’s a lot of stuff coming that’s really exciting, so we’ll see, you know, and we could talk about that. 

Jamie DePolo: Sure, I mean, if you want to. I know that there was some research that’s, like you said, it’s coming, but we’re not going to see it. 

Dr. Eleonora Teplinsky: Yeah.

Jamie DePolo: So, what caught your eye in sort of that category?

Dr. Eleonora Teplinsky: I mean, a lot of new drugs, a lot of new, so datopotamab deruxtecan is an ADC [antibody-drug conjugate], another ADC, right, that’s coming.

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: Antibody-drug conjugates, similar to trastuzumab deruxtecan, but it targets a different target. So, the way antibody-drug conjugates work they target a particular receptor antibody and then they deliver the payload to them. 

Jamie DePolo: I think of it like, I don’t know if this is accurate, but like a smart bomb almost. 

Dr. Eleonora Teplinsky: Yeah.

Jamie DePolo: So, it’s like, it’s targeting this one thing and then when it hits there inside the cancer tumor, it sort of explodes and let’s go of the chemo.

Dr. Eleonora Teplinsky: Exactly. And then the chemo, kind of that payload, kind of trickles out a little bit and it’s got some bystander effect, so it kind of hits some of the surrounding cells.

Jamie DePolo: Okay.

Dr. Eleonora Teplinsky: And that’s one of the reasons why Enhertu is very effective. Actually, the way I talk to my patients about it is like squirting jelly into a jelly donut because when you... 

Jamie DePolo: Okay.

Dr. Eleonora Teplinsky: Right. 

Jamie DePolo: Yeah. 

Dr. Eleonora Teplinsky: It oozes out and then touch all the nearby stuff and get everything sticky, so it’s kind of the same way.

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: Like, you know, squirt it in there, that’s your target, but then it oozes out. 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: And so, datopotamab deruxtecan is another ADC, exciting for hormone-receptor-positive, HER2-negative, but it’ll be interesting to see how that plays a role with -- now we have trastuzumab deruxtecan, we have sacituzumab govitecan. Like, so, I think the question is going to be, as we get this plethora of ADCs, how do we use them and how do we sequence them? So, that’s coming. There are some other drugs that are being looked at that are exciting as well, so you know these are all things that are not ready yet.

Jamie DePolo: Not quite ready for prime time, but coming.

Dr. Eleonora Teplinsky: Yeah. And I think the challenge is you see all this amazing data being presented, and some of it is very early, and these are first-in-human trials and it may take years before we see an FDA-approval. You know, even ribociclib in the NATALEE study, presented a year ago, still doesn’t have FDA-approval. And I think that’s frustrating a lot of times for patients and providers, is we’ve got this drug, but insurance is not going to cover it, and so like, you know, a lot of challenges. And I think a big other topic that we’re seeing a lot of discussion on is circulating tumor DNA [ctDNA]. 

Jamie DePolo: Yes. 

Dr. Eleonora Teplinsky: Lots.

Jamie DePolo: Yes. So, if you, could you just sort of briefly explain what that is for the audience?

Dr. Eleonora Teplinsky: Yes.

Jamie DePolo: And then, you know, it’s been around for a while and people ask me about it.

Dr. Eleonora Teplinsky: Yeah.

Jamie DePolo: I’m like, yeah, there are studies, but I don’t know if it’s ready for prime time yet. 

Dr. Eleonora Teplinsky: Yeah, absolutely. So, I think the best way you can just think of circulating tumor DNA, is that all of our cells in our body shed DNA into the blood stream and so do cancer cells, and so you can pick that up. So, circulating tumor DNA, you know, people always think of it as the Signatera test, but there’s many other companies that do circulating tumor DNA. But these are tumor-informed assays [tests], most of the time, where they actually… the way Signatera works is they get a sample of your cancer and they kind of profile it, and then they make an assay that can be detected in the blood. So, it’s called tumor-informed, they’re picking up your particular tumor, and we can pick up these cancer cells in the blood.

And so, we know, based on data that’s really coming more rapidly now, which is great, but that a positive circulating tumor DNA, and especially multiple positives, kind of serially, really predict, are prognostic for a recurrence, okay? We know that within a certain amount of time, someone will develop a recurrence.

So, let’s say you’re getting it done and you get a positive test. Now, it can be a false-positive, but let’s say it’s not. You get a scan because you want to find it, and the scan, if the scan is positive then we found it and we can start treatment. If the scan is negative, meaning it says, well, if there’s cancer cells in the blood, but there’s nothing showing up on a scan, there’s no mass.

Jamie DePolo: There’s no tumor, right.

Dr. Eleonora Teplinsky: There’s no lesion, there’s no nodule, but then what, right? So, we tell people we know most likely you’re going to develop a recurrence, but I can’t find it. 

Jamie DePolo: Right, and I don’t know when.

Dr. Eleonora Teplinsky: I don’t know when. And so, living with that is really hard. So, I think the two challenges that we need to really answer, or the two questions that we need to answer before we can use it in prime time, is, one: does finding it early make a difference? You know, meaning, if you found your recurrence based on a circulating tumor DNA and then a scan, rather than waiting until someone had symptoms, does it make a difference in your overall survival? You know? And we have some data that says maybe, it’s looking at you know scans, not ctDNA, but just looking at scans, and showing that maybe for HER2-positive and triple-negative, stage II to III, finding something on a scan may make a difference, but not a great study. None of these are great studies, right? So that’s like a problem.

Jamie DePolo: Right. 

Dr. Eleonora Teplinsky: So, that’s one piece of it. But then the other piece is, what do we do if we find, if we have a positive ctDNA and a negative scan? 

Jamie DePolo: Exactly.

Dr. Eleonora Teplinsky: Because that’s most likely. 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: They’ve shown the lead time can be anywhere from eight to 12 months, in some cases up to three years, so like, right? I mean it’s paralyzing. 

Jamie DePolo: Right. I don’t know, but you don’t really want to start treatment if it’s just…

Dr. Eleonora Teplinsky: No, no, you can’t treat based on ctDNA. 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: I mean, maybe one day, you know, but not right now, so you have to wait until you find something on a scan that you can look, that you can see.

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: And so, a lot of clinical trials now are starting to look at this, where they say, okay, you’ve got a positive ctDNA, can we put you on this drug to try to reverse it? So, until we have those answers we really, you know, it’s not being widely used.

Now, like, I think patients want this test, and I get it, and I think that our job is to really sit down and go over all of these, you know, pros and cons, right? And then patients make their decisions. I mean, the test is available, so some people, you know, and I’ve had some patients who say to me I need to know, you know. 

Jamie DePolo: Right. 

Dr. Eleonora Teplinsky: I need to figure out my insurance, my work. Like if I’m going to have a risk, you know, of recurrence, I’ve got to figure this out. So, you know, I think that there are situations, but in general, we’re not, you know, widely using it right now.

Jamie DePolo: Everybody doesn’t get it. 

Dr. Eleonora Teplinsky: Yeah.

Jamie DePolo: Well, let me ask you this, because there’s also a test -- there’s circulating tumor DNA and there’s circulating tumor cells. Is circulating tumor DNA better, more indicative, than circulating tumor cells?

Dr. Eleonora Teplinsky: You know, I think we just don’t know yet. A lot of the recent research is with circulating tumor DNA, but I think there are a lot of tests out there, right? There are so many tests and then, the other part of it that we, gets kind of mixed up in all this is tumor, like genomic testing of the tumor, right, and genetic testing.

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: And these are all very different things and so we do for certain, you know, especially for our patients with metastatic disease, we will do genetic testing on the tumor. It’s called somatic testing, to see if they carry any mutations that we can act on. So, it’s all like, you know, a lot happening, which is really exciting.

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: Some of it ready, some it not ready.

Jamie DePolo: Right. Yeah, because people, yeah, they keep asking, like, well, you know what about this test? Is it going to help? 

Dr. Eleonora Teplinsky: Yeah.

Jamie DePolo: I’m like, I don’t know. I don’t think so because it’s not commonly used. Like, it’s not going to be done on every single cancer. 

Dr. Eleonora Teplinsky: It’s not. And I think that in other tumor types, you know, colon cancer circulating tumor DNA can actually be used to help guide chemotherapy choices.

So, I think that right now we’re very clear that all the data in ctDNA does not support, like, making decisions about avoiding chemo, right? If you have a negative ctDNA you should omit chemo. Like we’re not there yet, but I’m hoping that as we learn more about outcomes and treatments that we’ll be able to use ctDNA in both a predictive and a prognostic way. 

Jamie DePolo: Okay. And one more question on that, not to belabor it, but is the circulating tumor DNA is that always indicative? Like does it have the same characteristics as the original cancer? Because I know sometimes when cancers recur, they can have different features.

Dr. Eleonora Teplinsky: Yes.

Jamie DePolo: So, like, the original was hormone-receptor-positive, recurrence is hormone-receptor-negative.

Dr. Eleonora Teplinsky: Yeah, so it may not pick it up, because remember, it’s a tumor-informed assay, so it’s only picking up what you sent it to test.

Jamie DePolo: Oh, right, okay.

Dr. Eleonora Teplinsky: So, if you sent your biopsy, you know, your pathology report from 2022, let’s say, and all of a sudden your, what’s there is a new cancer, you know, is a completely new cancer it’s mutated, it might not pick it up.

Jamie DePolo: So, it might come back negative. 

Dr. Eleonora Teplinsky: It might come back negative. And there is about, in one of the studies we saw, about a 20% false-negative rate. So, I tell people about that, too, that, you know, you can have this false reassurance.

Jamie DePolo: Sure.

Dr. Eleonora Teplinsky: And maybe that there’s not enough volume, like, amount of cells to detect in the blood, so that’s also part of it. So, I think, part of the work that has to happen in this space is refining the technology, right? And getting it better. 

Jamie DePolo: Sure. Okay, that makes sense. Was there anything else that caught your eye or were those all the big ones?

Dr. Eleonora Teplinsky: Oh my gosh, there’s so, so many. And then I think if we think about it, kind of early-stage and metastatic, I think that early-stage, it’s really just kind of answering some more of these questions about, you know, where can we escalate? Where can we de-escalate treatment? And we’ve also seen some data, you know, starting to talk about sexual health. We have a poster that we’re presenting tomorrow about sexual health, and you know diet and exercise, and lifestyle modifications and saw some data here about using weight loss medications in patients. 

And so, I think that that’s a part of it as we think about survivorship and thrivorship, right, for all of our patients, not just early-stage, for metastatic disease as well, about how do we really tackle all of these long-term issues that people are surviving in?

You know, when we did our poster on sexual health, 1,000 women answered our social media survey about sexual health and we found that so many people are not getting the information they need from their doctors about sexual health. 

So, these are, I think, some of the topics that are starting to emerge.

And then metastatic, really a lot of it DB06 [DESTINY-Breast06], I think, definitely a big one, but also just hearing more about what’s coming, some of the newer drugs. And then with the DESTINY-Breast07 trial they presented also, was looking at can we give Enhertu even earlier in HER2-positive, metastatic disease, kind of as the first-line treatment? 

Jamie DePolo: So, even before endocrine or…

Dr. Eleonora Teplinsky: So, for HER2-positive, typically if they’re HER2-positive, metastatic, their first-line actually is not endocrine therapy, their first-line is going to be Herceptin and Perjeta . These are HER2-based therapies, and just, again, hearing about some of the newer drugs that are coming. 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: And figuring out more of, you know, I think what we saw that was really great is just some treatment paradigms, right? How do we think? How do we sequence? I mean, I think we can end with that, is there’s so much new stuff coming and when you have all these drugs how do you know which order to give them in? 

Jamie DePolo: Got you.

Dr. Eleonora Teplinsky: That has the most efficacy, but also spares toxicity.

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: That’s a big one, right?

Jamie DePolo: Right, and I know there’s the whole what’s the right-dose sort of initiative too.

Dr. Eleonora Teplinsky: Yes.

Jamie DePolo: Because when the studies are done -- and I get it, maximum dose because you want maximum effectiveness – but, could somebody do just as well on a lower dose?

Dr. Eleonora Teplinsky: Yeah, and I mean we talked about, it wasn’t presented at this meeting, but there was recently a study about Verzenio for early-stage breast cancer and showing that dose reductions didn’t sacrifice efficacy. 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: So, then it raises the question, well, should we start everyone at the higher dose or can we go middle, right? 

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: And it’s 50-50. Some people start everyone on a middle dose, some people start at the high dose and work down. So, I think these are really important questions because if we’re asking patients, hey, you need to take this drug that causes diarrhea, joint pain, fatigue, for two years.

Jamie DePolo: Right.

Dr. Eleonora Teplinsky: You know, I think we have to start thinking about how do we give them the same benefit, but maybe a lower dose?

So, these are all really, I think it’s important, and I love to see that we’re really thinking about the patient, and really in a patient-centered way, with the patient at the center of all of these treatments and all of these side effects and everything.

Jamie DePolo: Right. Dr. Teplinsky, thank you so much. This has been really helpful. 

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