Working In Oncology
Working In Oncology

Episode · 5 months ago

Using Expanded Access & “Right to Try” for Experimental Drugs w/ Ajeet Gajra

ABOUT THIS EPISODE

For patients who have run out of approved treatment options, hopes of fighting disease can feel diminished. Fortunately, through existing and new programs, patients have access to alternative drugs. Educating physicians more on the program availability can lead to an increase in options for patients and a more positive outlook to recovery.

Dr. Ajeet Gajra, Chief Medical Officer at Cardinal Health Specialty Solutions, joins the show to discuss experimental oncology drug use through the Expanded Access Program & the Right To Try Law.  

Here are the show highlights: 

- Expanded Access Program vs. The Right To Try Law

- Hesitancy & Barriers to Use Programs

- First Steps & How To Stay Up-To-Date on Programs

- Tips for Office Staff w/ These Programs

- Success & Future Use of Drugs 

Check out these resources we mentioned during the podcast:

- Dr. Gajra’s LinkedIn (https://www.linkedin.com/in/ajeet-gajra-md-mbbs-facp-77059748/

- Dr. Gajra’s Research (https://ascopubs.org/doi/full/10.1200/OP.20.00569)

- Cardinal Health (https://www.cardinalhealth.com/en.html)

 

To hear more interviews like this one, subscribe to the Working In Oncology Podcast on Apple Podcasts, Spotify, or your preferred podcast platform.

You're listening to working in oncology,a podcast and video show that spotlights oncology practice staff and industry influencers who workbehind the scenes to shape the future of oncology. The more knowledge the oncologycommunity shares with each other, the more we all grow. Let's get intothe show. Welcome to working in oncology. I'm your codes for the day,Alicia Evans. I'm joined today by Dr a Jeep Gaza, chief medicalofficer at Cardinal Health Specialty Solutions and Co author of a recent study published inJCO oncology exploring request for access to experimental drugs. Dr Gayja, we thankyou for coming to the show today and welcome Policia. Thank you so muchfor having me. I'm happy to be here and very eager to talk aboutthis important, but often ignored at topic. Absolutely so. I've been really lookingforward to our conversation. Your study was pretty eye opening and I thinkyou can really help kind of fill in some knowledge gaps today that will helpour listeners really expand their patients access, potentially to experimental drugs. Sure.So, before we jump in the conversation, can you tell our listeners and viewersa little bit more about you, your background and what you do.Surely she has. So in my current role I serve as a chief medicalofficer. He had Cardinal Health specialty solutions and I've been here over two yearsnow, but at heart time a clinical, you know, medical oncologist and hematologist, and the start of the journey was back and there was combating myselfback in the late s when I chose the field of hematology oncology to pursueafter intermadicine training, because I always thought, you know, oncology is the ultimatebarrier, sort of, and you know, other substance written about thecancer being the ember of all maladies and I felt like that that that isso true at or at least was so true to me back in the day. So, you know, this field has been very gratifying because it's affordedto me my three loves, which is clinical research, education and, ofcourse, patient care, which supposed to my heart. And I was ableto serve bed rooms by working part time at the vmatical center. I've spentmost of my time in academic practice, though, until about two thousand andseventeen, when I made a transition to industry focused on clinical research and thenhere cardinal continuing that kind of work. That seems like you've had kind ofan extensive oncology, kind of range of experiences. Certainly, and you know, at the the clinical practice, even though it was an academic practice,I had the opportunity to work in a community setting, in a large TertiaryCare Cancer Center and, like I said, also in a different system, ofwhich the BEA system is a unique system. So I had the benefitof all three and in you know,...

...being able to compare and contrast almostwith the good bad of each of those. So, before we jump into whatwe want to talk about today, is your recent research on the useof expanded access and right to try requests, and I hope you think, sir, ups in this conception about the two programs and maybe discuss maybe theINS and outs of each short. Yes, so you know, this is interestingbecause while in practice, and currently I'm not in active practice, Isee patients were in a variant the basis. But you know, I had theopportunity to be exposed to and work with the expanded access program myself andin fact, the first time I used it for a patient who had arare form of lung cancer would run through all of their treatment options but,you know, the patient in the family were still wanted to try something else. And so, looking through the clinical trials website, I found that therewas a drug which was in being tested but was not a fe approved,not available. So then I was able to reach out to the manufacturer whowas willing to, you know, give out the drug from this patient.And but we had to jump through several hoops. So we had to firstand foremost, we get to learns from our Institutional Review Board or a protectionof, you know, patients best interest, and then they to submit a requestto the FDA. So this in effect sums up the expanded access programwhere a drug which is available it may also be used in other settings,but can be tried in an indication or in a dislease where it's not currentlyapproved, but you have to get your IRB approval any up to get anFDA sign off. And and then, and of course, the manufacture,the by form. A company has to be willing to to offer this drugto the patient. Of course there's an informed consent process. So this,if fan and NASIS program has been in parlance, has been in use sincethe late s and one thousand nine hundred and eighty seven, I believe,and has helped literally hundreds of thousands of patients gain access to agents outside ofa clinical trial. You know that they might not have had access to butagain, you know, if you're a busy provider, as many of ourlisteners might be, it seems daunting for our singlication and I have to goto my Irb, I have to go to the FDA this, this seemslike just don't have the time to do it, but it is a veryfeasible as doable and of course, once you learn how to do it andthe more support you have in your institutional practice, the better you can doit. Now fast forward to two thousand and eighteen. A new methodology ornew process, new pathway, was signed into law called the right to try, and the difference between expanded access and right to Trib really is that wouldwrite to try. You don't have to go to the IRB, you don'thave to go through the FDA sign up, so obviously it's a much abbreviated process. However, however, the manufacturer still has to be willing to providethe drug and also there are very clear...

...and strict criteria for what patient,what individual, can qualify for right to try. So for that, reallythree things happen to be mad in terms of their disease. So they haveto have a life threatening disease. They have to have used up all availableand FB approved therapies. They cannot, you know, they should not eitherqualify or clic or trial or should not have access to one in so andof course they still have to provide written informed consent. So those are sortof the patient essentialities in to qualify for a right to try. But thenthere's also the other conditions that have to be met, which are for thedrug, you know. So number one, phase one studies should have been completed. It's because we want to make sure that we at least have adose which has been identified and you know, that safety has been assessed in youknow, it's proven to be safe for use in humans. So faceone testing should have been done. This agent, if anyone's going to applyfor right to try, should not, could not have been approved or licensedby the FDA for any use. So it's not like okay, I havethis drug works in lung cancer. Can I use in press cancer? Not. If it's FB approved, already when you cannot access it by right totry. And the third is that, you know, the manufacturers should havealready filed an I and the application with the FBA, which of course isstandard. But out there cannot be a clinical home. So sometimes the FDAwill notice that, oh, there's maybe a problem or maybe a safety signalor some concern with an agent as it's being developed, and so they mightput a clinical whole on the I and d. So again, you know. So if there's a clinical hole, then that drug cannot be accessed throughright to try. And again it's the safeguard the patient's interest, because theFDS put a hold on it for a reason and for safety or some ofthe concern and so then we don't want to unnoyingly expose a patient to sucharms tin. No long answer, but that's an overview of these two expendedaccess and right to try it. There are some other terms that come upsometimes. Compassionate use. Yes, so you know, you bring up avery valid point, police her. So Compassionate use has been long used,quite honestly, to describe the expanded access program because what we were doing throughthat was helping our and still are is and when I say we, Imean as on college dis as fellow oncologist. It is a method off getting accessto a drug which for which is not approved or indicated by the labelin in a given patients condition. So if a drug is approved for I'llgive you an example. You know when you're on collegeist and Alfa for listeners, know that you know neighbors, friends, family all reach out to you.So you know there's someone that reached out. Unfortunately, they had,they have a brain tumor, they have a brain cancer and you ustill andthey have, you know, already used up the two, two, threestandard frequent options, and so they really...

...want to try Meuno therapy. Soyou know. But you mean therapy is expensive and it's not approved for glioblestiment. So so they are obtaining this immuno therapy medication then expanded access programs.So in a way this is compassionate use, but because the manufacturers willing to providethat, but right to try, in a way is also a formof compassion use. So I guess my point is that compassion of use isa broad term utilize for off label, which is another term use of thesedrugs which are not approved by the FDA for a given disease. But again, they have to be provided by the manufacturer and I think that is apart of the compassion, the Compassionate uses coming from that, you know,the manufactures willing to provide access to these agents. Okay, and so thiskind of brings us back to your research. And I mean we've already established thatthese terms are sometimes use interchangeably mistakenly. In your research. I was verysurprised to find that such a small percentage of providers had attempted the rightto try pathway. Yes, at least you know. So that was apart of the reason why we conducted this. So it had in my role hereat Cardinal, I support also one of the divisions called a cardinal helpregulatory sciences. So there's a whole, you know, Great Team of scientistsand pharmacists and other regulatory specialists and that division that work with FDA and otheragencies to get a drug from the Preiind I ind to you know, finalapproval stage. So anyway, so, as you pointed out, there's evenin people who are, you know, very well worst with this work.They can sometimes be confusion in terms of off label compassionate use and then EPexpanded access and right to try. So through our summits, so cardinal conductsummits meetings of providers, physicians, but also sometimes apps like counties and PS. But this story was directed towards positions to assess if they understand the differencesbetween a right to try and expanded access. Now, even though we conducted thislate two thousand and nineteen to early two thousand and twenty, you knowperhaps we were now even thinking about publishing this. But then, unfortunately,as we all know, the pandemic happened and, as we know, theaccess to medication, in this case anti viral therapy or what was hoped tobe undervit therapy. You know that we heard so much about compassionate use ofthe area's drugs for covid nineteen and so that made us think like, oh, we're I mean, we had the information already. So in fact thatwas a reason to for us to go ahead and publish our findings, reportour findings, because you know some on Cologists, you know that this isthe director towards oncology drugs. But we...

...also, in our work and ourresearch, realize that, you know, this has been done for community basedon cologists in the past and really those for the reasons to report this inJC or on college practice. So it's summaries. What you're researching, brewof Research Rather, is kind of an assessment of physicians knowledge of these programsand their experience with each of these programs, exactly the knowledge and utilization. Sodo they know about this? Have the utilize it? And we alsowanted to ask them if they utilize it, what is their success rate? Arethey able to gain access with the drug that they requested or not?So and again, you know, in a spiritful discussion, we say thatclearly in our paper. This is simply based on a survey or on recall. So it's not like we're asking them for, you know, specific evidence, like I'll show me the number of times you've did this, but youknow what was their overall impression? Yeah, and so on the results. Isee that about forty six of your physicians, forty six percent, excuseme, had actually attempted the EA program while really surprising, the only fourteenpercent tried the right to try program or attempted yes, at LEASTA. SoI mean part of it is because expanded acts has been there for so long. You know. It's therefore literally dozens of years to time, eighty seven, whereas right to try is very new. I will say they'll. Right totry has garnered a lot of media attention, even while it was abill and it was being discussed on the floor of the Congress and to thetime that it was signed into law. There's been a lot of media attentionon this, but you'll write it. Despite that, it was a littlesurprising that less than half of the physicians had access for tried to utilize EAP, which isn't therefore, you know whatever, forty years or thirty five years andonly fourteen percent, like you said, had attempted to use the right totry, and so you think that some of it is attributed to rightto try being just the kind of a newer program correct. And it seemedthat the success rates were slightly bigger, of course, for expanded access,since you had more more attempted than the right to try. Zecht yes,you know, remarkable success rate. So for those that used expanded access,almost ninety percent, or eighty nine percent, were successful in gaining in a getgaining access to the drug that they requests, and this is pretty impressive. And then with right to try, was slightly though. It was someoneLord Seventy three percent, but still not not, you know, something toignore. It wasn't. It's a remarkable that three fourth of the time you'resuccessful. And Mind you, neither off these programs, neither the EAP northe right to try, mandate the manufacturers to give out, you know,the drug that's requests. It's completely up to the manufacturer whether they want togive out, to give this drug out or not. But you know,if you're getting access to a drug ninety...

...percent of the time, that's quitein a mark of statistic in my mind. It seems remarkable to me. Sowhat do you think are some barriers? Is it just a knowledge, oris the earth these programs difficult to access? I think you're right upboth front. So what our takeaway was, you know, so we had somequestions varied in our survey to assass if the physicians are able to distinguishbetween the two programs, and only about a fourth of them. So twentyseven percent of them correctly identify that for right to try, you biopass theIRB and you bypass the FBA. So so you know so the vast majorityactually didn't realize that that was a major difference. The other thing that weasked to assess, you know, to gage their knowledge in awareness, wasfor the expanded access, which requires FDA sign off, I would say,or Fba to view. You know, how how often do you think FTBAsigns off or approves and expanded access request? And only three percent came up withthe correct answer. So, believe it or not, the FDA hasapproved ninety nine percent of the requests for expanded access and only three percent hoursplans actually, you know, give us the right answer that over, ninetyfive percent of the time you have the approve. That so, which againtells you that there's just lack of awareness. And then we also ask them,you know how often you know, how many patients do you think?And Mind you, this was only a year into right to try, becausethe seray started in the fall of two thousand and nineteen. Where's the rightto try? Legislation was passed in two thousand and eighteen. So we askedthem, you know, how many patients do you think thus far have benefitedfrom right to try? And again, you know, only about eleven percentwere able to guess the correct answer. So there's definitely, you know,some lack of understanding and you brought up valuable terms in terms of anthing.It August modeled sometimes in people's heads. But also the process has been dauntingfor expanded access, and we'd write to Quich mouths. It's much simpler.Oh really, so it's the so expanded access will require more support. Correct, then, COR right to try program okay, because you would have toIrb and you have your own irb sign off now to, you know,facilitate expanded access use and act and utilization. You have to. It actually madeit much simpler in the past. Up under two thousand and fifteen,I believe, you know, for expanded access the entire IRB, so theentire board have to approve and expanded access request. But to simplify because alot of times, you know, these requests are coming in in dire circumstancesor in you know, when unfortunately a patient has limited time. Perhaps so. So the FT modify that guidance and said that expanded access going to begranted by one IRB member. So you know, if you were want toaccess something urgently, even a one single...

IAR. Remember, I can authorizeor approve in expanded access request. But still there's multiple staps. There's Irb, then going to the FDA. The FD applications long, I'll tell you. I've done in myself. But but you know, the reassoring thing isthey do respond very quickly. The median time to response, I think it'sthree to four days at the FDA and, like I said, they do apromajority. They have a pro majority of the request. Of course,you know the physician, like all of our listeners, you have to makesure that you know they are trying to do the right thing for the patient. You know, we don't want to just throw something and see if itsticks. But if there's some scientific rash now and it makes sense, thenit's definitely worth pursuing. So if I read, how do I read?Sorry, how do our listeners begin the process? So let's start with expandedaccess. What we would be the first step to take right? So again, even for expanded access, you know, suppose we have a patient who unfortunatelyis progressing through available treatment options, but you know you and maybe there'san ongoing to incod trial, but the patient may not qualify because of certainonline conditions. Or they may just not be able to travel to the faroff institution to participate in such and generally, most on collegists are aware of otheragents or which are being attested in a given disease. Other way,they can use resources like clinical trials dog out that lists all of the trialsI'm going in a dilease, and so if you identify a drug or youknow that may potentially benefit your patient. Also, the patient has to bein reasonable condition. If someone's very in very, you know, very frail, or that what we say performance status is very poor, you know thatmay not be the best candidate because at the end of the day we don'twant to harm the patient. But there are some patients work, you know, in reasonable performance status and some of them can be a bust. Soit's very simple. I would first start with the making out preacher the manufacturerand saying I have such a such patient and you know, might I haveaccess under expanded access? By the way, there's no legislation that requires manufacturers tolist on their website whether they offer expanded access, you know, programor not, and you know by making an outreach to them. So theymay say yes. If that is said then that's my green light. Igo to my irb with my case history and say here's the circumstance, here'sthe data for the drug. Would you approve this? Assuming they approved that, simultaneously, I will complete my whatever it is, six page FT applicationand send that packet off with my irb approval and, you know, redactedpatient history and why it's appropriate for that patient. I would send that tothe FDA. Expect a response within a week and then with that, withthose three things, I will go to the manufact sure and, like Isaid, I've been through this myself several times, and then you get yourshipment. Of course there still has to be an informed consent for the patientbecause you're giving them an agent that we...

...don't know how they might react to. But that's the job the RB to make sure that you have a properinformed consent of the in place. So and you know, then you start. So that would be the EAP program right to try. And you know, I had sort of left full time practice by the time this legislation cameout, so I can't play. Cannot claim to have the first time experiencewith this. But again here I think very often what I'm noticing is thatit's more driven by the patient. But the patient cannot do with themselves becausethey have the physician and even the FDA guidance as that the physician is thebest person to decide, you know, whether this drug maybe beneficial or that. You know, some benefits may outweigh harms, because it's not like everyperson has the right to try any drug or anything. So so you know, the drug already should be purposed, even though not approved, you know, for their condition and like we went all the criteria before, and reallythe application on the FEU website is quite simple. But again the manufacturer canbe mannated and again my suggestion will be each other manufacturer for us ask ifthey're willing to share the drug, you know, through a right to tryand mechanism. If they deny, then it's not worth while going through theextra stops. And sometimes you'll come across a manufacturers say, you know,we cannot do right to try, but we can do expanded access. Soso you know, then you might have to take the longer pathway by youjust to have access to the agent. Okay, so for both approaches youwould go to the manufacturer first. I would I think that that way.Yeah, that would streamline your efforts and that way you're not trying to,you know, walk on a path that's going to lead to nowhere. Andit sounds like right to try, especially because there's been kind of recent pressand it's kind of a new, new process. These are often patient initiatedrequests, very to releasious. So you'll see a lot of stories and someof them, of course, very heartrending. But, you know, advocacy,and especially when there are children involved in such and especially with red diseases. I mean, you know, here we're talking about cancer, but thenthere are other diseases. There's muscular dystrophy, there's spineless atrophy, all kinds ofother neological and other conditions that predominantly affect children or even newborns, andyou see a lot of stories, you know, of parents trying to makethis kind of outreach. So but yes, you know, a lot of timesit is, I find, patient of the family's sort of driving this. But then the physician and the team has to support them also guide them, you know, what may do, what may not be appropriate. Thecool of course, of course the physician needs to be as deeply involved intheir process and the whole actually the whole care team really and these decisions.So our ecology office staff is very busy. Things are always moving, it's alwayschanging parts. How can they stay up to date on these processes?What do you recommend right? So I...

...feel as though you know somebody easierfor practices and physicians and teams and, you know, offices which are alreadyinvolved in research. I think that makes the process a lot simpler because manyof these steps you're going for participation in clinical trials anyway now with right totry. I don't believe that you can do that for every patient every time, but they can be select circumstances where it makes a lot of sense totry and pursue, you know, a treatment option for a given patient.You know, certainly I haven't forgotten my full time practice days and very conpisentof how you know the amount of clinical workload and work for responsibilities that lieon the oncologist, research team office staff. You know it the entire team,and and so this certainly would add more work to what they're trying todo. But I feel it's to the same order as it is to enrolla patient on a clinical trial, because you know, especially, even thoseactivities take a lot of time and effort. So I believe in my mind thewidget a work that's involved. It is about the same as enrolling apatient on a treatment trial. So it's not an overwhelming it's a standard.Of course, if there were a lot of patients like that, it willget a will bombing. But you know, that's where you have to pick andchoose. You know who the program might actually work for. And thenanother piece that came up in your research that I was curious about is canthese requests be made for a small population of patients? So can we?So I say I have three or four patients in the same situation. CanI make one request for all of them? And is that possible for both programs? Great question, you see. So possible. This is possible forthe expanded access program not for the right to try program. The right totry is an individual based program based on individual need. But for expanded access, yes, it is possible to, you know, requested for a smallgroup of patients. Do you have any stays of any helpful tips for officestaff as they are filling out this document? Any tips on how to communicate withpatients while they're going through this proces which I'm sure it is very stressfulfor all parties involved. Right. So, you know, I think anyone inoncology and you know, everyone that touches a patient, starting from,you know, the intake folks to the nurses, to the nurse practitioners,research coordinators and the back office folks. You know that may not be meetingthe patient, but I think it's we have to be careful. I feelas though you have to temper the patients and families expectations. A lot oftimes, you know folks, unfortunately they're desperate or are losing hope, theytend to amplify, you know, the possibility of success with anything. Andso I think you know, while effort...

...is to be laughed we cannot,obviously, first of all, we can I guarantee that, you know,I medication will become available. Number two, even if it becomes available, itmay not work, and a number three not only may not at work, it may cause a serious side effect. So so I think counseling the patient, loved ones family is so critical and I think the messaging should beuniform across the team, because human nature is such that we always tend tobelieve the you know, one person who gave us the most hope when we'redown or when we're saying and what you do want to do is that inthis process of unfortunately, you know, oncology care or fighting cancers a rollerco emotional roller coaster as it is. So you don't want to get themtoo high and then let them fall too hard. So it was okay toexplain and say that we're going to try this but we don't know what theoutcome is going to be, so that you know they're that would be mysuggestion to entire team so that again, if we gain access, that's agood day and then, once you know, will have to be another a goodday after several weeks to see that, you know, a medication working,that it's so Davin's, an honest conversation and the temper your I meanyou're excitement of getting the possibility of a due treatment with the realistic outcome.So for someone who has gained access to a drug and have has had success, so for either of these program how does that success affect the future useof this drug? So does that expand the drugs used like permanently to thatpopulation. How does how does it affect the the rollout process? A greatpoints. So releases. So I think in this regard the two programs areso different because with the expanded access program there's a more robust back reporting.So you know they're recording in terms of outcomes, in terms of what happensto any given patient, is captured much more assistantly and much more consistently.Number one, with the right to try. First of all, the programs verynew. Also understand who's the watchdog for? You know, all ofdrug therapy in this country is the FDA. And with the right to try programwhat did we just say? That you bypass the FD. So soI think you know, many have criticized the right to crib program saying thatthere wasn't enough oversight. You know, of course, the counterpoint is thatoversight slows things down and sometimes these patients don't have that kind of time.So I think both camps have valid arguments, but we have the legislation in theform that we have it, and so with that I think it's stillan open question terms of how the follow is being managed. Currently there isNope, to the best of my allege, there isn't a consistent way of capturingas to how many patients are benefiting from the right to cry program.However, in my reading, as of...

...last year, the FDA has instructedmany fractures to report to the FDA. You know, how often are themeeting with the right to try utilization and in so so right now, whatwill happen is in any kinds of outcomes follow up? They those are laiddown for right to try by the manufacturer. You know. So what happened?What was the outcome? The manufacturers capturing it, but there isn't doesn'tseem to be a consistent way of them putting it into a large national databaseor what have you. So so information somewhat fragmented, but I feel likethat is much better organized with the EAP program because, you know, it'sjust been around longer and a lot of the bugs have been work at workedout, and also it has more oversight. Okay, so there's additional reporting hopefullycoming in the future that we can hopefully build off of that correct andthere's been a lot of requests were you know, by the FDA for transparency. That if the right to try is a good thing and a manufacturers aresupporting it, well then let's get that word out and, you know,put that out in an accessible area or database so that everyone knows what's goingon. And your earlier point about you know, if there is success,that doesn't automatically, that doesn't automatically obviously spend a labl organ f the approval, but you know, the manufacturer does capture all of those real old examplesas case reports and then case series which can help them, you know,as they are developing the drug further or going to the FDA for final approval. So in the case of, you know, the patient that I mentionedat the beginning, I had obtained a drug called or Latinum for them andthat drug was in you know, in a developmental stage that I only hada number, not even a real name. But since that time, you know, it's been approved, fe approved for that rare form of possible lungcancer and is now available for use in public. So you know, sothere are and even the patient that I mentioned, they gain a lot ofbenefit from that. Ultimately, you know, the cancer unfortunately progressed, but youknow, they did, it did help them by time. So allof those and a rule or case supports. Case series kind of get compiled togetherto indicate success. Aside from, you know, the work that's goingon in a tent for trial excellent. So there is some tracking to MrGashua, this has been a really great conversation, so much insight and tothe to processes that I think that not everyone is has been exposed to whatis actually it's pretty recent. For any of our listeners who want to reachout to you with follow up questions or want to continue the conversation. What'sthe best way for them to do that? Sure, yeah, at least you. Thank you for having you, but you have books. Anyone canreach me. I'm on Linkedin. Is Achieve Gazra had Linden. The goodthing about having a rare name is there aren't too many of me, sofind me easily. Also, I will Polish a rral. That ad ismore at the cardinal level, but we...

...can certainly you can gain access throughthat route as well. But again, I greatly appreciate the opportunity and fora listeners here, hopefully this has helped you somewhat a game, some confidencein terms of, you know, the crew programs, because they are talkedabout quite often so thank you for sharing your insights. I'll be sure toinclude links to your linkedin and also your cardinal health website in our show notes. Again, I appreciate you being a guest of the show today. Thankyou for having me. Are You satisfied with your patients curtsy to therapy,or are you just settling? You can improve patient outcomes with bioplus specialty pharmaciespower of to the first ever two hour, two day to gather promise it's fasterand easier for you and your patients to learn more. Visit bioplus Rxcom. You've been listening to working in oncology. To ensure that you nevermiss an episode, subscribe to the show in your favorite podcast player. Ifyou're listening in Apple Podcast, we've love for you to leave quick rating ofthe show. Just have the number of stars you think the podcast deserves.Thank you so much for listening. Until next time,.

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