(Guest Lecture): June 2022 - Updates in the Plasma Cell Leukemia (PCL) Field

As you might know, today's topic is updates in the plasma cell leukemia or PCL field. And as much as I would like to tell you that hundreds of publications have been written and so much more is known about PCL, in reality, that's not the case, which is kind of what we're going to talk about today. What updates did we have because there was one or two? And then why aren't there more? And what can we do in order to further plasma cell leukemia research? Because lives are on the line and we can't wait for a cure. We can't wait for somebody to decide that this is their life's passion. We need to do all we can in our power in order to make this happen. Very passionate about this. Very excited to talk to you about it today. It's my pleasure to introduce Paul to you. Paul Clupton is a patient diagnosed in 2014 with primary plasma cell leukemia. There's primary and secondary. As you know, plasma cell leukemia is a rare and aggressive variant of multiple myeloma and he has been very fortunate to find treatment at the Division of Cellular Therapy at Duke University Cancer Institute. His wife Vicki and he have two adult children and a grandson who is truly the light of his life. Full treatment has allowed Vicki and Paul to do what they love best, which is travel the world, albeit with some extra precautions to keep infections away. His career in the pharmaceutical industry has given him insights that he is currently putting to use as an advocate to lower drug pricing, especially prices for anti-cancer drugs and very specifically CAR-T therapies with recent contributions posted by Health Affairs, the Institute for Clinical and Economic Review, and the Centers for Medicare and Medicaid Services. He also is a frequent author in our myelomacrowd.org website with the different news articles that are published. Paul is an excellent person and very qualified to speak to us today. I'm excited to hear from you, Paul, and share a little bit of what you have to say. The time is now yours. Thank you, Audrey. In the past, what we've done is go over some of the research that has been published over the prior three to six months. And I can say, interestingly enough, over the last, since the beginning of the year, I've been able to find only one paper that deals with plasma cell leukemia. I'm not even sure if it's very applicable to us. This is a paper that dealt with, that summarized research findings coming out of a European group where they tried to come up with biomarkers that would predict which MGUS patients most likely would progress to PCL at some point in time after they hit the myeloma stage, which would actually make them secondary PCL patients. Clearly, this would be of interest to MGUS patients, but I don't think there's a lot of interest for us who have already actively living with PCL and have already gone through the variety of treatment drills. The reason for that is, in my mind, pretty simple. You know, big pharma is simply not interested in PCL or to include PCL patients in their clinical studies for two reasons. You know, one, PCL patients, especially relapsed patients, tend to be very sick patients and including clinical studies may give the clinicals a little bit of a negative outcome that they're trying to avoid. Most of us have a variety of chromosomal markers that doesn't just make us high risk. As PCL patients, we're typically labeled as ultra high risk patients. So when we see data come out in publications, the publications are not coming from commercial groups like Bristol or Janssen, J&J or whoever that tend to come out of our academic and treatment centers. And the big publishers in PCL are the Mayo Clinic in Minnesota. And they, for a good reason, that they probably or actually shouldn't say probably, they definitively treat more PCL patients than any other treatment center in the country. There are also a couple of European groups that are somewhat active. One of them is a Spanish group, Spanish Italian group. Then there's another one that comes out of one of the universities or the medical schools in Vienna that gathers data from a variety of treatment centers throughout the EU. What we get in terms of research as active patients is pretty much nothing but retrospective studies, where people try to come to grips with, well, what has the experience been as to what works, what doesn't work? There is hardly anything that you'll be able to find in terms of induction treatments that tends to be very dependent on which physician is treating you at the start of your journey. There is very little written in terms of maintenance. And again, that is very physician or treatment physician dependent as to what they believe works best. There is a school of thought, again, coming out of Mayo, that for PCL patients, Velcade, Dexamethasone works best. Other centers, they lean more towards RVD. Other centers, they'll do a revel in Velcade and try to leave out the Dex because patients don't hate Dex. So there really is no consistency. There has been a long standing debate within the myeloma, within the PCL physician community as to what works best in terms of, you know, once you get patients out of inductions, should they go to a single auto, should it go to a tandem auto, an auto stem cell transplant back to back? Should they go to an LL stem cell transplant? And over the past couple of years, there have been a couple of papers that have, I shouldn't say definitively, but they've given a stronger recommendation than before that the tandem auto tends to work better for us. It all depends on which physician's hands you end up in. And so, you know, you may not find in your own person's position that a tandem auto, that he or she is a believer, or a believer that tandem auto works best, they may go the LL round, but they may go the LL round. And so, you know, you may not find that in your own person's position that a tandem auto may have had a very negative experience with a single auto, and basically conclude that that's it for them. They don't want to go through the process again, regardless of whether it's another additional auto or regardless of whether it's an additional, you know, a single auto, or a single auto. So, you know, that's the recommendation. And so, I think that's the recommendation. Then you have a time of relapse. It's almost impossible to find, you know, anything, any guidance or consistent guidance as to what people will do at time of relapse. Processed testing, you know, is a very important part of the process. The process typically tends to be you go through another induction treatment, and here you have large varieties between different treatment centers. Some physicians or treatment centers, they may go the VDT PACE route, which is an ugly treatment route that I feel sorry for anybody who has to go through it. I made friends with somebody who's passed away. In the meantime, you ended up going to VDT PACE with Darzalex on top of it, which was just sheer hell for the individual in question. And, you know, it didn't exactly have, well, it put the patient into complete response, but only for a period of about three months. And, you know, that's the other issue that we ended up dealing with at time of relapse. Relapse tends to be extremely aggressive. People try, physicians try different things. And, you know, there's a number of things out there. My own physician at Duke, she swears by what's called Big New Beam, which is a combination of carmineustine with the opposite, adriamycin and nalphaline. She said she had the best results with that. I can't find anything in the literature that Big New Beam has, you know, a large following. But here you have a physician who's kept me going for almost nine years. And, you know, I tend to do things she knows what she's doing. And so you end up with, you know, an induction treatment typically followed with additional stem cell transplants, either an additional auto or an aloe. And after that, you end up with more maintenance. And again, it's all over the place here. You know, we as patients tend to not be included or not being welcomed into the clinical community. Companies just, you know, their trials don't go on or surround the PCL patients because of relatively poor outcomes. So you see a lot of literature, for example, these days about, you know, the magic of Sarplisa, the magic of Darzalex early on in the game. And none of these studies say anything about PCL because they've all included, they've all excluded PCL patients. So, you know, for us, it's really potluck as to whose hands we're into. And you know, you have to have faith in the physicians that we're dealing with. But there is no, there really is no common set of guidances out there, you know, especially at times of relapse. So, you know, in terms of, you know, new research to report, I'll be very frank with you guys. Over the past six months, there is literally nothing for us active PCL patients that we can hang our hat on to say, well, you know, at time of relapse, this is something good to do. Yeah, that's the, you know, I'll phrase it bluntly, that's the bad news for us. Unlike my along with patients where you have so much being published with the, you know, by specific antibodies that are determined to almost miracle drugs, different CAR-T programs, you know, some of which have very good success. Again, PCL patients, you know, for us, it would be really trial and error. Yeah, Larry, thank you so much, Paul, for what you've shared. I'm just going to stop you right there because I want to provide a little bit of hope to this conversation because it is, it is bad news. It is bad news to hear that in the past six months, there have been literally no publications aiding active PCL patients. But that's where, you know, I get so passionate about this, but that's where we have to come in. And Paul, you did an incredible job explaining that there is no standard of care for PCL patients. And I think one of the things that Health Tree Cure Hub can help answer is what should be that standard of care? What is the most successful regimen for PCL patients? So if you're unfamiliar with Health Tree Cure Hub, I'll explain it a little bit and then I'll show you a little bit and then we'll be able to talk a little bit more. But Health Tree Cure Hub is a portal, for lack of a better word, that allows you to privately enter your data. After you enter your data, and we even have a team called the Patient Navigator Team who can help connect with your clinics that you see and get your information for you so that the process is 100% easier. And after that data is securely and privately uploaded, it is anonymized, and then our researchers look at that anonymized data to conclude different findings, such as looking at all of these validated looking at all this validated data of PCL patients, it seems like those who did this induction regimen had a better prognosis than those who did the other. I mean, obviously, I'm using very broad terms here, but I hope to show and explain to you the urgency of this. And again, I think Paul set this up beautifully. Nobody else is going to do it. So we need we need to do it, you know, and that's why I am. I'm passionate about this. I'm fierce about this because your lives matter to me and the future PCL patients matter to me. And I feel like we have the potential to start finding out some answers. And then as our PCL community grows, and more people trust to enter their data, because I know it's a lot to ask. I know that it's your information. I know that that's private information. And of course, we would never sell your information. We never share it without it being anonymized. It's not even legal to share data without anonymizing it, just so you know. But we have the potential to make a difference in the PCL field. And the bigger our numbers can eventually get, the more doctors are going to become attracted to this gold mine that we have. So not only our research team is working on it, but other specialists like the Mayo Clinic at Rochester are able to look at this information and ask important questions that we're not even thinking of in order to find a better quality of life, a standard of care, et cetera, et cetera, for PCL patients. So, Audrey, let me interrupt you and ask you a question. Do it. How many active PCL patients do you currently have and how three? So I should have come prepared, but let me let me tell you right now. So in our. And in fact, let me just share the screen with you. So that you can see with me what I'm doing. We have this PCL chapter, which constitutes for some of the number. So I know you can I know things are let me try to hide these, you don't see them. And make this big so you can see that. All right, so. We go here to chapters. There's different communities. We're trying to do this with other communities that have little to no research as well. So amniotic dosage, non-secretory myeloma, PCL. I mean, this is important. For all of us right now, we have 90. Three people in the plasma cell leukemia chapter. I believe that in health to cure hub that aren't a part of our chapter, we have about 10 to 15 more. So right now we're sitting about 100 people that have PCL or their loved ones have PCL. That we could we will ask to to contribute in this very important research project. Does that answer your question? Yeah, it does. And the reason why I asked is, you know, we send out a survey. Remember, I think about a year ago. And I think, you know, the survey, you and I ended up putting a good amount of time in there. You know, the response is that the end of getting back, I think it was all five or six people. So yes, we had, you know, you really could not draw any kind of conclusion out of that. You know, the data were all over the place. It was it was an acute reminder that, you know, myeloma is a very hermeticenious disease and plasma cell is definitely no exception to that. There were very, very few similarities in terms of, you know, the makeup of patients. You know, which makes things which makes things very different. Very difficult if you have 93 patients, maybe another 10 more, say 100 patients contributing at that point in time. You stand a chance for statistical power. Yeah, I agree. I completely agree. Anything below, you know, 20 isn't going to give you much power at all. I agree. I think an important thing to to know is that was kind of UNI's initial PCL survey through I think we even did it through Google Forms or something like that. And and this our research team has significantly grown since then our health care hub team has grown since then. And then our PCL chapter has grown since then. So the we I'm grateful that the growth that was provided this last year, I think, will provide us with more manpower and ability to provide more accurate statistical research in the PCL field. But yeah, that's an excellent point. Well, one thing, you know, we talked a little bit earlier on about induction, stem cell transplant maintenance. What I would like to touch upon is also long term issues. You know, there are some of us, few of us who have been living with this disease for, you know, a good amount of time. And these days, what they're saying, a PCL patient who makes the past 18 months is, you know, that's a success story. But, you know, what we're starting to see, or at least, you know, from my own experience, I've been in maintenance now for eight years. And, you know, so there's a slow but steady buildup of toxicities from maintenance treatments, you know, drugs like ravelamate, Velcade, you know, things that we are on have never been studied over such long periods of time. And so, you know, as patients, we start running into weird stuff. And in essence, your bone marrow gets totally destroyed, you know, through prolonged treatments. And your body starts making up in crazy ways. Crazy ways. What, you know, how it copes with a defective bone marrow. But the crazy ways leave you with, you know, some things that gets physicians scratching their heads and say, you know, what's going on here? And that's, you know, there's, there are no studies about that whatsoever and how to deal with these things. So again, it's, you know, a popular kind of situation. And that's, you know, I just want to throw it out, you know, it just doesn't mend the time of relapse or whatever. For those of us who are fortunate enough, you know, to live with PCL for a long period of time, you know, we face other things that just get progressively more difficult for our physicians even before relapse. That's, you know, if you have patients and health treatment, Audrey, you know, the longer term history of maintenance, you know, say three years plus, it'd be interesting to know what it is that, you know, that these patients are dealing with. Definitely. And I'm writing down the ideas you have and I'd like to actually open it up to the group. If you would like to participate, if you'd like to either write in the chat, kind of your thoughts on the discussion so far, or even raise your hand to be able to speak to us. Unfortunately, if you raise your hand like this, physically, I won't be able to see you. But if you click reactions, which is found at the bottom of your screen, if you're on a desktop or laptop computer, it's a little smiley face with a plus button on the head, I guess. If you click reactions, there's that raise hand button. And then if you're on a tablet or a mobile phone, if you click the three horizontal dots that say more, and then raise hand, you'll be able to communicate with us that way. So Jay, I see that you have your hand raised and it's great to have you in the group. If you want to unmute and share your thoughts with us. Okay. Yeah, I, you know, I listened to all the stuff that Paul said, you know, I'm two years out this week. I was diagnosed two years, two years ago this week. And, you know, I know that there's not a whole lot about plasma cell leukemia because, you know, there's no clinical trials. There's not a whole lot of research. But the way I look at it, I look at plasma cell leukemia as not a terminal disease. I look at it as a chronic disease that can be treated. And that's how I approach it. And I'm currently on maintenance with crypolis and Revlimid. And, and I've been on that since about two months after my transplant in November 2020. But, you know, even though there's not a whole lot that has been, you know, said about plasma cell leukemia, there's been a whole lot about multiple myeloma. And whenever I sit down and talk to my oncologist, whenever I go there, you know, if you think about it, a lot of these treatments, the newer treatments that are out for multiple myeloma, a lot of people have to fail, you know, one, two or three treatments before they can get that. With plasma cell leukemia being a rare and aggressive form of multiple myeloma, my oncologist says, you know, throw that out the window. We're treating you as an aggressive multiple myeloma. So, you know, so a lot of these new treatments that are out, you know, it's like, yeah, we're going to do that because there is no standard treatment. And that may not be a bad thing because we get the advantage of getting to kind of try these, these new treatments, the CAR-T, the, you know, any other new medications that are out. Sometimes even before the multiple myeloma folks get to. And that's, you know, that to me has been helpful. I've been on, you know, crypolis since I was diagnosed. You know, the only time I wasn't on it was, you know, whenever I had my transplant and, you know, the two months after that. And that's that along with the replimid has been, you know, a lifesaver to me. And it's kept things, you know, I'm still in, you know, stringent, complete response and MRD negative. And, you know, I'm planning on staying that way. And, you know, so, you know, even though, you know, not a whole lot is written about PCL or anything like that, you know, it's not hopeless to me. It's hopeful by just hearing, you know, and seeing all the new treatments for multiple myeloma. And, you know, Paul had asked about, you know, how many people are in this group here. There's also a Facebook page for plasma cell leukemia that I'm, you know, that I, you know, participate in. And that's a lot of good information in there and a lot just to hear other people's experiences. For instance, I've been having, you know, I was having some muscle cramps in my hands and legs and somebody had put something on, you know, this morning about that, you know, how they're treating it. And I got, you know, and how, you know, a lot of it comes from the, the Revelemid. And, you know, and I said, okay, I'm going to try that because I'm sick of the cramps. So, you know, I try to increase my water as much as I can, but, you know, that's, that's one of those things. So, you know, that's, that's how, you know, that's how I approach it. And, you know, so that, you know, I don't have a, you know, a dismal, hopeless, doom and gloom type feeling about it. I, you know, I, you know, I, I'm back at work full time seeing patients and things are going good. I'm so glad to hear that, Jane. Thank you so much for your positive perspective. I love what you were saying about having room to hope in, in PCL because of the progress in myeloma. And I think that's one of the other things that I would like to, to see is how, how PCL patients fare compared to multiple myeloma patients when it comes to these immunotherapies. I mean, I'm hopeful. Paul, have you seen anything about PCL reaction to CAR-T? Nothing. And that's, you know, I agree with Jay, you know, we do live with a chronic disease and personally, I'm a, I'm probably a exhibit A for, or it should be exhibit A for being positive since I've been doing this for, you know, I'm in my ninth year now. I do know that things work, or at least I've had the good fortune to end up with a regimen that has, has worked for me as, as, as worked for Jay. Again, Jay, you know, it's an interesting discussion here. You know, we are, we are this high risk group or ultra high risk group. So technically, you know, a lot of the new things can be of value to, as you know, my own oncologist at Duke, she says, the longer we can keep it going, you know, the more options we will have in the future. And that's, you know, the way we have to look at things. There's a tremendous amount of good research coming out and including your research for your high risk myeloma patients. So I'm, I don't think you and I are on a separate page. You know, I'm trying to look at it from, you know, what's next for me. You know, I think my oncologist and I have agreed on a plan. Because I happen to trust her very much. I mean, she's called it right for the last nine years. So I'm comfortable with whatever she proposes. But there is, there really is no standard out there for us at any, at any part or at any time point of our, of our disease. And, you know, that's, that's basically key point that I'd like, you know, people listening into this thing to take away from. But at the same time, and, you know, I didn't do enough. No, again, I am exhibit A for living with this thing for a long period of time. So I know it can be done. And, you know, I don't look at the world as a dismal world. You know, for me, life is good, period. There are no complaints here. Yeah, thank you, Paul. Eileen's raised her hand. Eileen, good to see you. If you want to unmute and share your thoughts. Hello. Thank you so much for having this today. I came across something, I don't know if you did, but it was published in April of this year, April of 22. And it was, it's from blood research. And it's called an update on plasma cell update on primary plasma cell leukemia. So if anybody hasn't seen that, it's a very, very, very good, you know, it's kind of a summary of some things that they have found. Like it says, a lot of these articles on plasma cell leukemia are they're kind of looking back over, you know, what patients have, how they've been treated, results they have had. But they do, it's a very good article. I can share the reference to you afterwards if need be. But it talks about like the clinical characteristics and biology, goes into treatments, you know, induction, the stem cell transplant, and then emerging treatments. And I'll just say right now, I just thought I'll look in emerging treatments to see if they say anything at all about the CAR T cell. And it just says, you know, they go through all of them and they say they may change treatment landscape for patients with primary PCL, the BCMA targeted T cell resulted in a deep response, you know, for heavily treated patients with multiple myeloma or the extra medullary plasma cytoma. But it did say a phase one study of the anti-BCMA CAR T cell therapy enrolled two patients with relapsed refractory primary PCL. They benefited from the therapy, but they said the duration of the response was brief. And there's a reference to that. I didn't have a chance to look that up, but there's a reference to the trial, I think, that they were in. And it says further BCMA targeted immunotherapies in patients, you know, are required. So, I mean, not much there, but hopefully maybe there's starting to be some studies or, you know, clinical trials where maybe some PCL patients can, you know, get enrolled. Like you say, it is limited. But they do talk a little bit about, you know, a little bit of the difference between multiple myeloma and the PCL and why a little bit historically, you know, those earlier treatments, the PCL patients did not fare as well as multiple myeloma. They didn't see the success that they did. And now they're seeing that the genetic features of the primary plasma cell leukemia is not the same. You know, it's different than myeloma. And so therefore, you could see why maybe the treatments, you're not going to get the same response in patients. And they're finding out more about, you know, the genetic characteristics of, you know, the patients with, you know, primary plasma cell. But this is a really good article. I don't know if you saw that one or not. I'm familiar with the article in question. And I think if my memory serves me right, wasn't that an update from the International Myeloma Working Group or the PCL chapter of the IMWG? Well, it is an update. So yeah, it's out of Korea. No, that's not coming out of IMWG. No, but it does say it's an update. But no, it's out of Korea. Yeah, I love it. I'm grateful for you sharing it with us. And I included my email in the chat, Eileen, if you want to email me that I can make sure to distribute it. Yeah, I'll send you the reference for it. And it's really, I've read it many times. Every time I read it, because there's a lot in there. Now, the one thing they don't have anything really on is like the maintenance. Okay, they've got induction, the stem cell, they even talk about like tandem, you know, versus how patients did, a lot of things, but they don't say much about, you know, maintenance, which is like, is that so important to us? Right, right. I will write your email down. Perfect. And I was diagnosed almost two years ago, too. I was diagnosed in August of 2020. And so much like what Paul says, Oh, my goodness, it kind of depends on where you're at, who your doctors are. Because, you know, I the way the where I'm at, I mean, they wanted me to get me to a stem cell transplant as fast as possible. So, you know, my doctor did I responded extremely well. Within just, I don't know, three months, I was going for my transplant. But she never even mentioned like a tandem. And the way our facility works, well, they kind of, you know, my oncologist hands you off to the transplant team for the transplant. So when I go see the doctor, you know, on the transplant team, he looked at me and just said, you need a double a tandem. And I was like, what, you know, and I never really even so here he you know, again, had a total different viewpoint. And then after my transplant, when I went back to my oncologist, they said, you know, they brought and she just was like, No, you will not need because you know, she explained it as there's these emerging therapies like the car T cell, there's this new thing, new things coming up, and she does not see, you know, tandem as kind of really, at this point, you know, as a procedure that, you know, is the way to go. So it's interesting. And it makes for me, it makes it very, very hard. Oh, for everyone. I mean, I don't know. Oh, yeah. Not only is the disease super personal and difficult to understand genetically, but then you have seven different specialists saying seven different things. It's very, and that's even in my, you know, the same, you know, facility. Yeah, my facility. Yeah. Yeah. No, I appreciate you sharing your experience. And again, I'm just grateful that you are proactive in your care and searching for articles and finding things I spent the first year. Now, again, I, you know, it's kind of was good, kind of not good, but either going to, you know, seminars such as these or through other, you know, IMF or whoever, as well as online, which was awful, because I mean, I really didn't think I was going to last a year. I didn't. And here you are resting. However, I sure learned a lot about the disease. And I can, at least ask, I think, better questions or I understand it now, but it was horrible. Yeah. To see, like you say, what's, you know, kind of what's out in the literature and things like that. It is not, it is very dismal. Yeah. Well, thanks for sharing a little ray of hope with us today with that article. It will be good to share with others. So thank you so much. Steve, I saw that you had your hand up. Do you want to speak? What a silly question. I know. As soon as I said, of course, of course you do. Young people would know better anyway. Okay. Sorry. My family has a nickname for me. My nickname in my family is Pollyanna. And I have led my whole life always thinking the best will happen. I don't want to hear about the bad stuff of plasma cell leukemia. I don't want to, I'm not interested in now because anything you tell me, we don't, oh, it's so rare. It's so deadly. I, you know, on and on, we have not enough patients. We have no money to make, you know, all this stuff is going to make me not enjoy my day. Now I'm older than most people here. I'm 81, you know, and I'm in total remission after the stuff. In fact, one doctor said, if I hadn't seen the original biopsy, I wouldn't even know that you have plasma cell leukemia. I thought maybe just, he goes, there's not one, I'm MRD negative for plasma cell and for multiple myeloma. It's two years now. I don't want to hear about this stuff that, oh my God, if it comes back, but then when it comes back now, I will say, well, I've enjoyed every day up to this point. Let's do the research. Let's see what's going on and I'll figure it out. I view this whole conversation as a positive, not as a negative. There's no papers written on it. Well, that gives some guy or woman a chance to write a paper on it. There's no money into the trials. Well, hell, then we have less competition to fight for the money from the government or from the drug companies. I'm not going to let anyone depress me. And my favorite thing is live each day as if it were my last. And I'm not going to be told how bad it could be some other time. I don't want to hear about it. Now, I'm sorry if that's my emotional stuff, but that's the way I am totally, I am totally in remission, MRD, two years now. I think it's a brain thing for me. I think it's an outlook because I almost feel like took my way out of plasma cell leukemia because the first time when they told me I had that, oh, this guy who I fired, by the way, this doctor, the first thing out of his mouth is, oh, you may only live six months to a year and a half. I fired him. I don't want to be surrounded by a doctor that is doom and gloom. I got the greatest doctors, Dr. Costa, Dr. Bredega. It's always, come on, you're in remission now. Great. Terrific. Terrific. I don't want to hear doom and gloom because if I'm in doom and gloom, then my wife is in doom and gloom. And if she's in doom and gloom, then my sons are in doom and gloom. And if they're in doom and gloom, my grandchildren are in doom and gloom. So everything that you just shared about, I don't want to hear now. Maybe, say a year now, I come out of remission, okay? And I have it again. I'll be more than happy to talk to you about all the fact that there's no papers written on it and we'll figure out what to do. But I'm not going to let this year, if I have a year left, be ruined. I mean, I did that for a month when I was first diagnosed. I woke up in the middle of the night crying. I woke up in the middle of the night sweating and terrified until I found I'm surrounding myself with optimistic people. You are one of them, young lady. You're one of them. I saw how you changed things. I'm happy you did it because I want to hear that. Hope, hope, hope. Until there's no hope. I understand. I do understand. I think it's good though to recognize, we showed we had 93 people in that group. Unfortunately, not all of those 93 have the same privilege of you as being MRD negative, right? There are many patients out there who are in a different situation than you are. And I love that for your mental health, for your life. You're saying I'm sticking to the positive. I love that. But it's also our job and our responsibility to let people know the reality of the situation so that then we can create urgency for research. I don't think you're negating any of that that I said. I just wanted to make it clear to everyone. Totally agree with you. Yeah. 100%. But for me, as of today, I get it. My wife made me a nice bagel sandwich for lunch. I mean, that's better than that, man. Thank you so much. And Eileen, thank you for sharing that. That's really helpful to have. I'm excited to look that up. I'm going to write that down here. Paul, I think you'd agree. This is an excellent conversation that we can keep continuing. I mean, hearing what people want to know, getting people excited and involved in research and in helpful research. I mean, that's our goal. So thank you to everyone who contributed today. Paul, do you have any closing statements before we finish up today? Well, probably one. I just want to echo what I forget what the prior speakers first, Steve, I just want to echo what Steve, both Steve and also Jay said that not everything for us is doom and gloom. I live life to the max and I feel like pinch myself every morning when I get up that I'm one of the very fortunate ones. We will just keep on plugging along and I hope for the best as time goes on. At the same time, if we can use the Health Tree database to make some progress, that would be truly grand. I agree. I agree. Thank you so much, Paul. And thanks for your preparation for today. It's exciting to come together as a group and talk with each other. I know I didn't really get to show Health Tree Care Hub and so in a future meeting, I will make sure to show that. However, in the resource email that I'm going to be sending out, I will explain what Health Tree Care Hub is, how to get started and then even show you a video of what it's all about and then the contact information for our patient navigator team so that you're able to get in contact with them and either create a Health Tree Care Hub account if you don't have one in order to accelerate PCL research or if you do have an account, make sure that it's filled out accurately and validated so that we can start using that important data. Again, anonymized private data for research. So thank you again to everyone for participating today. It's so nice to be together. I really appreciate you. Let's meet again in October to continue this conversation about research opportunities for PCL. How can we use Health Tree Care Hub? What doctors might be interested in listening to us? What questions are the most important ones to answer? And continue this helpful conversation as well as if there's any updates between now and then. I look forward to seeing you in October and that date and time will be announced later. I'll make sure you know about it when we're meeting again. You might want to join us tonight at 7 p.m. is the Amelioidosis Community Chapter launch. We're going to be hearing from Dr. Jeffrey Zander. And then the 23rd, we have two events at 2 p.m. Eastern is the African-American Myeloma Chapter, Taking Your Fitness to the Next Level with Vanya. That's going to be an excellent, fun event. And then the 23rd at 7 p.m. Eastern is our Immunotherapy Treatment Chapter. We talked a little bit about bispecifics today, but we're going to really get to know this immunotherapy with Dr. Cesar Rodriguez, who I really admire and is one of the top myeloma specialists in my eyes. The link to sign up for those events and even more events that I haven't mentioned is found at the bottom of the slide and will be found in our follow-up email that I've been mentioning that will be sent out within 48 hours of today's conclusion, the event's conclusion. Another thank you to our sponsors, Russell Myers Squibb, GSK, Genentech, Janssen Oncology, and Avni. And thank you to each of you for helping us build this PCL community. It's truly a pleasure to be with you, a blessing to be with you, and I hope that you all have a great rest of your day. Thank you for taking the time to be here today. Take care, Audrey. Take care, everyone.