Why do some patients respond to immunotherapy and others don’t? Why do some tumors in some locations respond when others don’t? Dr. Marshall has a “gut feeling” about our microbiome.
HOW ARE YOU MANAGING THE IV FLUID CRISIS?
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John Marshall, MD: Hey, everybody. John Marshall for Oncology Unscripted with Dr. John Marshall. There is so much going on in the unscripted world today, that we better jump right in.
And I know if your site is like my site, then you're having issues with IV fluids. This is all the gossip and business news of the week with every hospital system. Not every hospital system, 60 percent of the United States gets IV fluids from one plant in North Carolina. The Baxter plant there, and they have had a very, very hard time. So, we have to be, of course, forgiving about that and understanding, but we'll come back to the issue of why 60 percent of our supply comes from one plant in the United States in Western North Carolina.
[00:01:01] let's talk about the impact of this. on all of us today. So, if you are one of those health care systems where you got your IV fluids from Baxter, if your team's like our team, we are trying to figure out sort of like it was during the pandemic, how do we stay open? How do we continue to deliver the care that we deliver for our patients, not knowing when we're going to run out of our current supply of IV fluids, and I know with every system out there, at least I think with everyone I've talked to so far, there's sort of a two pronged attack of how can we conserve. What are we giving now that is just our old training of internal medicine of surgery of whatever disease we focus on. That training of what we give for fluids and how much fluids we give, how much of that is still okay, and the right thing to be doing. And how much of it could we actually not do? You know, we think about hydration around chemotherapy in our world. Well, how much could we, in fact, change from cis to carbo. Cis needs a lot of IV fluids. Carbo doesn't really need any. There's certain diseases, maybe head neck, certainly testicular cancers, where cis is the right answer. I think it's been asked and answered. But there are a lot of other cancers where maybe carbo is the same.
[00:02:28] I take care of GI cancers, for example, and in cholangiocarcinoma the regimen is gem/cis. Can I switch to gem/carbo? I don't know. Would the insurance company cover it if I switched to gem/carbo? Yeah, there's some cost savings on one side, but I don't really have data that gem/carbo is the same as gem/cis in cholangiocarcinoma. So I got to make a decision on the fly. I've got interest in trying to manage this for the time ahead, but I've also got to try and optimize my patient's care.
[00:03:03] Can I flip IV antiemetics to oral antiemetics? Probably will work pretty well, but what if a patient has a bad cycle on their oral antiemetics? They're going to blame the change from IV to oral, right? And if I change, do I have to go back and re-preauthorize? You know what a lovely job that is to get preauthorization for everything you do. So, if your center's like mine, then you're spending a lot of your day, trying to do the best you can to keep the shop open and offering all the care that we give to patients across the board and your cancer business, so that you can make sure you deliver the best patient care you can while at the same time trying to conserve.
[00:03:50] And just like with the pandemic, I think about tele visits, for example, we didn't really do those before the pandemic. And now we do a lot of them. What changes are going to happen? What SOPs are going to change as a result of this fluid crisis? We'll see, and maybe we'll report on it on Oncology Unscripted sometime in the future when that plant goes back online.
[00:04:14] But let's, let's talk a little bit about that plant. So, you know, it's a lovely part of the country. I can understand why you'd build a nice plant there, but then why would so many of us, over half of us across the country, get all of our product from that one plant? It really speaks to the sort of supply chain issue, that's out there, and that we'd be so vulnerable as a health care system to rely on just one building and one group of people to provide us with such a critical need. And so, maybe this will spark a sort of look into that.
[00:04:49] But we encounter this and other places, right? There's like one plant that makes, leucovorin and so when they had trouble making leucovorin for a while, what did we do? Well, we partly decided we didn't care. We don't really need leucovorin that much. Or we went to Costco and got oral folic acid. By the way, that'll work to replace the fancy leucovorin that we give patients with our 5-FU or for rescuing from methotrexate. Actually, folic acid won't really rescue the methotrexate, so don't try that at home. But you get the idea. We made changes.
[00:05:24] We've had other drugs. There are other examples where there's really one plant that makes that particular medicine. And when it has trouble, then what do we do? We don't have access to that particular medicine. So, it's not a new problem for us, but I don't think we've ever seen the kind of impact that we're seeing now, from this one plant, the Baxter plant in North Carolina. So hopefully we will make it through, and hopefully we will have learned some critical lessons that will improve our efficiency while maintaining our excellent standards of care.
GUT FEELING: IS OUR MICROBIOME THE KEY TO BETTER CANCER CARE?
[00:05:58] John Marshall, MD: Today, really what I want to focus on for our main topic is something that, I don't know, doesn't have a lot to do with IV fluids. It has a lot to do with our world around us and our world inside of us. And this is what we call our microbiome. And you might know why I'm thinking about this a lot. It’s really all about understanding a couple of things that have emerged. One is, why are some people responding to immunotherapies and certain diseases and certain locations of that disease are responding to immunotherapy and some are not.
[00:06:37] And on the other side, that really touches my world a lot, is this new phenomenon of young people with colorectal cancer all of a sudden coming up with this disease, and those are young, healthy people in their twenties, thirties and forties. Almost every one of them, 90 percent of those tumors, are in the rectal sigmoid space. So not the distribution that we're used to seeing in colon. So, what the heck's going on there? And we think both of these things. may have something to do with the microbiome.
[00:07:08] Well, we are medical professionals, so we must be, in fact, experts in the microbiome, right? We all went to medical school or some sort of medical training, and of course, while we were there, we learned about the bacteria that lived in and around us. Or did we?
[00:07:28] The reality is, at least in me when I went to medical school, you know, a thousand years ago, and even today, the current curriculum, only a few hours of the four years of medical school are spent on understanding bacteria and other critters that live In our bodies and on the surface of our bodies, you know, you memorize the bacteria that are there, you get it right on the test, and then you forget about it.
[00:07:58] And now, though, we're recognizing that maybe just maybe this is an incredibly important part of our overall health. We did evolve. I think you believe in evolution, with bacteria inside of us, and it's not just that bacteria that we can collect and measure in our poop. The way I'm increasingly thinking about it is it's a bunch of lakes of different ponds of different kinds of bacteria, different concentrations of bacteria that live in different parts of our body. Probably connected to each other, but maybe lake one can't really see what's going on in lake four, if you will, because they're different pools going on there.
[00:08:40] we don't even know how to measure it. You know, we, you go to the CVS. And you'll be able to see clear as day on that aisle that they seem to know about microbiome. There's rows of probiotics that you can take and buy and take at any drug store anywhere in the country, which suggests that somebody thinks they know how to make a healthy microbiome.
[00:09:10] I'm not sure I do. There's certainly no button in my electronic medical record that I can click and say, let's do a microbiome test on this patient. And so, we need to understand better what the heck's going on with our microbiome. We need to study it. We need to do deep dives on it so that we can Understand what it has to do with our health, how to make a good one, and from that, I think we'll have great advances in the treatment, not only of cancer, but many, many diseases.
[00:09:42] The reason I wanted to focus on this this week is that this week's JCO had 2 papers in it that actually bring this point solidly forward. One is a lung cancer paper. What this group did was look at the Escherichia association. What the heck is Escherichia? You know it as "E." in E. coli. So, they were looking for evidence of Escherichia in the tumors of patients with lung cancer. These are non-small cell lung cancer patients, and they were looking at immune checkpoint inhibition and the outcome if you had the bacterial presence there versus not. And the reality was there was a big delta. In outcome if the tumor had the Escherichia present in it.
[00:10:33] So this was really strong evidence that some microbiome presence in the tumor was in fact going to improve the outcome with immunotherapy. So, this was controlling for PD-1 and all of those other different variables. But this was a very important observation.
[00:10:52] So important that there's a beautiful little editorial that goes along with it.
[00:10:57] The second paper in the same article was more in my area. And this was a rectal cancer study. And in this study, you may have seen some of the data where in microsatellite stable rectal cancers, there have been some combinations of immune therapy generating some responses. Well, you know, in metastatic microsatellite stable patients, we're not seeing much in the way of responses, at least not in liver mets, et cetera. We see an occasional one in lung metastases. So, what they did was they took microsatellite stable rectal patients and not only gave them chemo, which would be the normal thing to do, they gave them combo immunotherapy as well. And lo and behold, in this group of patients at a 50 percent path CR rate. Now that's much better than one gets with chemotherapy alone, much better. And so, it suggests that when the tumor is still in the primary location, maybe some juxtaposition, maybe some overlay with microbiome, some interaction with microbiome there locally, but we saw a much better benefit when there was some microbiome in the neighborhood. So, both these papers suggest that immunotherapy may have some role to play.
[00:12:13] You know very well, all of us cite the data, in mostly kidney cancers, sometimes in melanomas, where you took stool transplants, so you're going to borrow somebody's microbiome, who's a responder. And just think about this, you don't know what's in there, but you know that that person seems to be benefiting, so maybe if I gave them and this other patient who's not benefiting with this stool, then they would benefit. Lo and behold, some of those people benefit. So, we know, we can see it, that there's something going on with the bacteria inside of us that's influencing our health, our response to therapies, etc.
[00:12:53] I am not an expert in the microbiome. I'm trying to be. I'm actually trying to learn and see what's out there. There isn't a lot. There's not a lot of publications in space, and I think a lot of people are picking and choosing. We are just starting, if you will, in this science, and we need to hurry up and figure this out.
[00:13:11] So stick around and watch a couple of interviews that we've got with people who are really smart about this. One is somebody who's really looking at the science behind microbiome. How do we measure it? What's going on there? What's a good one? But another is one of us, an oncologist, who's actually applying this microbiome thoughts, beliefs, to prospective clinical trials and getting some very interesting results. Click on the next one and watch these interviews.
MICROBIOME MATTERS: INTERVIEW WITH DR. CHRISTIAN JOBIN
[00:13:39] John Marshall, MD: I told you I was going to have the smartest people on the planet to interview, and I've got one of them here who has joined us. He survived the storm that just went through the middle of Florida, so we're grateful for that. Probably stirred up the local microbiome. This is Christian Jobin.
[00:14:04] Christian Jobin, PhD: They moved the gators around, so they have to relocate the gators.
[00:14:07] John Marshall, MD: Oh, wow. But that's good.
So, thank you for joining us on our discussion in Oncology Unscripted. So, you and I don't have a script. Tell us about microbiome. I've heard you speak. I know what you're doing. But, you know, so many of us don't
[00:14:25] Christian Jobin, PhD: thanks for having me here. It's a great pleasure to talk to you, and to try to bring some education to microbiome. A couple of little definitions here. So, microbiome, if you look at the definition, it's the assembly of genes within a microbial community, but often people think that microbiome is a bacteria, a group of bacteria, but it's an ecosystem. So, you have bacteria, fungi, yeast, and viruses. So, it's a collective assembly of microorganisms that lives a different location, right? So, on us, inside us, everywhere. So, I'm not going to throw numbers, but they are there.
[00:15:04] They are there from the beginning of your life, acquired through a vertical transmission, birth canal or skin acquisition, throughout your childhood. Your sample, you geta petri dish. You build your microbiome, and you maintain it, or not, depending on your lifestyle. Right? So, it's an amazing collection of microorganisms that responds to environment, stress, diet, and exercise. All things that we foresee as important to prevent cancer, and/or to maintain good health. So, they are part of that habit.
[00:15:41] And, and how do they do that? These microorganisms, you will think that, oh, it's just a bunch of microorganisms. They don't do that much. No, they do a lot, right? They occupy a territory within your system. If you think about the gut, they would occupy you know, trillions of microorganisms in there, and they are producing various molecules. They are responding to the diet you give them and to prevent infection. So, all of this is an active contribution to your health and the balance of this community maybe put you at risk of developing cancer or non-responding to therapeutics, for example.
[00:16:24] John Marshall, MD: So many people think they know how to build a microbiome. I always joke that CVS has an aisle where you can buy probiotics, right? And then what's the right way to live? What's the right health? What do we know? You know, in medical school, I've been saying that we don't really learn anything about this because we thought it didn't matter. But now that we, we're still not changing the curriculum, by the way, the current curriculum doesn't have much on this today.
[00:16:50] Christian Jobin, PhD: True. That's a shame.
[00:16:51] John Marshall, MD: But do we know how to measure it? Do we know how to make a good one?
[00:16:54] Christian Jobin, PhD: Yeah, we know how to measure it. We don't have a precise definition of what is good as a microbiome. Like this is the microbiome you should have. If you don't have this one, you're in danger of developing XYZ disease. Not really. We could screen a microbiome at the genomic level from different locations. So, most of the time, the non-invasive will be feces, but you could take saliva and say, oh, this microbiome may be associated with head and neck cancer, or the microbiome here in the feces associated with, you know, early onset colorectal cancer, for example. We kind of try to build this, but we're not ready for prime time, but that's the long view on that.
[00:17:37] Could we re-establish your microbiome once you have that information that this microbiome is damaged? I say damaged because I think microbiome is like an organ. So, it's damaged because, you know, maybe inadequate lifestyles, maybe episode of XYZ antibiotic treatment. So, it's damaged. How do we damage that? To your point, if you go to CVS and buy probiotics because they say it will maintain a good health function, there's no data. No data on that. We don't know what we're buying because they are not FDA, you know, scrutinized.
[00:18:14] John Marshall, MD: Could I take this a step further from my own stupid concept is I always describe these to patients and to my audiences as, it's a rainforest, the soil in a rainforest, or it's what the conditions that allow for a coral reef, the complexity is needed. And what that CVS bottle is doing is if I plowed the rain forest, and I'm planting a bunch of pine trees. It's not A rain forest, right? It's a row of pine trees.
[00:18:42] Christian Jobin, PhD: I love that image. You, you get it exactly.
[00:18:46] We call, you know, there's metrics in microbiome, characteristics, we'll say diversity, alpha, beta diversity, and the more diverse, most of the time, the healthier your microbiome is so that, if in a disease case the microbiome is less diverse. The way to fix that is not to put billions of bacteria that are from, Bifidobacteria genera or Lactobacilli genera it's not the way. Some have multiple components into their probiotic, their cells, it will be maybe six of them, but this is a very tiny segment of diversity. So it doesn't fix diversity if you are in a diversity low, state of microbiome. Prebiotics, fermentable food, so food that maintains your ecosystem, are a better way to go than trying to put something that you buy in a bottle that you don't even know if they are alive. You don't even know the quantity of them. You don't even know if they will stick or just pass. So, it's magic thinking.
[00:19:53] John Marshall, MD: I want to ask two angles on this one. You mentioned earlier about identifying people at risk. The observation in my world, early colon cancer, 90 percent of these patients are having rectosigmoid tumors. So not normal distribution of tumors. So, I've thought there must be some sort of local environmental thing through the microbiome that's happening there. I do want to talk about your thoughts about immunotherapy in the microbiome, but let's start with that one example, what's your thinking about detecting risk in that patient population.
[00:20:31] Christian Jobin, PhD: No, absolutely. So, you know, the survey of microbiome is very critical. So, if you take a microbiome from feces, that is an assemble of microorganisms that pass through, you know, elimination of feces. So, they could be coming from, you know, the proximal colon all the way, so you don't know where they are. If it's a rectal colon, and you could sample it, you have a local idea of what's going on there, that could be more reflective of the immune environment. Because if I want it to be sampled in terms of relationship between microbes and cancer, it will be the engagement of the immune system.
[00:21:14] These microorganisms are fully equipped with different molecules and surface proteins that, the hosts, us, could detect through millions of years of evolution. So, we have a way to know, hey, these microbes are there, and here's how I'm going to respond to it. So, it impacts the immune environment locally, they are within that tumor. And having information of who is there may be very critical for a therapeutic intervention, for example, in terms of rectal cancer.
[00:21:47] John Marshall, MD: Skip to the other side quickly about, you know, your concept of the role that the microbiome is playing in therapeutics with our immune therapies. There's a lot of talk, a lot of action in that space. Part of what we covered here with our papers. Any thoughts as to what's going on there?
[00:22:03] Christian Jobin, PhD: beside that, it's extremely exciting time and we're collecting data throughout the world. we don't have a precise understanding
[00:22:10] John Marshall, MD: I want to make sure everybody hears you say that so many people come in sure of what they're doing, and I don't think we are. Are we?
[00:22:18] Christian Jobin, PhD: No, we don't. patients are extremely well educated. They know what's going on. They go, you know, they know the microbiome. They could search. They see clinical trials. They see some data. They see the promise and they think they could get a new way to get treatment.
[00:22:34] But, I mean, we're experimental all the way in. We don't have a precise understanding. The hope is that eventually by dissecting and slicing the microbiome, we will have a better idea of who is contributing to a partnership with a XYZ drug. So, we will have a precise way to help the patient if the patient is missing these microorganisms, for example, or a molecule that is produced by the bacteria to adjuvant with therapeutics. But we're just not there. Not there.
[00:23:09] John Marshall, MD: I have one comment. I'm really hopeful that bourbon is good for your microbiome, but we can talk about that at the end of the day today.
[00:23:17] But I have a fun question for you, is that, you know, I have some religion in my heart and soul. And my soul is the question. So, I keep thinking about where the soul resides. I keep thinking about the microbiome and these creatures and this ecosystem that lives within us. And increasingly, I think the soul is within our microbiome. What's your vote on that?
[00:23:42] Christian Jobin, PhD: So, listen to your microbiome and guidance for your life.
[00:23:47] John Marshall, MD: So, you know, we think about what we feel, we feel it in our gut.
[00:23:51] Christian Jobin, PhD: Yes.
[00:23:52] John Marshall, MD: That’s why I'm saying that's where it must be.
[00:23:53] Christian Jobin, PhD: That gut feeling. Yeah, absolutely.
[00:23:55] John Marshall, MD: Exactly. All right.
[00:23:57] Dr. Christian Jobin, I thank you so much for your time. I know things are busy for all of us right now, but we really appreciate your coming and sharing your knowledge, and excitement, quite honestly, about this field. So, we really appreciate you joining us.
[00:24:10] Christian Jobin, PhD: Thank you Dr. Marshall. It was a pleasure.
HOW DOES THE MICROBIOME AUGMENT IMMUNOTHERAPY? INTERVIEW WITH DR. SUMANTRA PAL
[00:24:12] John Marshall, MD: I promised you all a great set of interviews, and you're going to be very glad you clicked on this one to hear Dr. Monty Powell talk about his science, which is why we're here. I'm dressed like a real doctor today. I got a badge. I've been seeing patients today downstairs. He's a real doctor, too. And so, we thought we would pretend to be our real doctor selves and talk to you about how microbiome could be a tool in treating cancers.
[00:24:40] And so I'm going to hand it over to you, just to let you tell the gang. What's your sort of thought process was how you've begun to apply it and some of the results you're seeing in your clinical trials.
[00:24:54] Sumanta K. Pal, MD: it's a really long story and I'll try to sort of abbreviate it. First of all, thanks for having me. You know, this whole premise of the microbiome wasn't really anything on my radar until one of my biostatisticians approached me, in fact, and this is the craziest story, but my biostatistician had a lot of friends in the agriculture industry. And there, you know, we manipulate the microbiome left and right to increase the longevity of livestock to, you know, get crops growing the right way, and he was asking me, why don't you do this in humans? And so about a decade plus ago, we started doing some basic studies, looking at the stool microbiome in patients with kidney cancer, which is principally what I focus on in the clinics. and then this series of papers came out, Science and Nature, really sort of linking the composition of the gut microbiome to immunotherapy and that's when we really decided to sort of take a step back and say, could we potentially do something to influence the gut in a way that has the activity with immunotherapy.
[00:25:50] John Marshall, MD: It’s sort of like religion or believers and non-believers and a lot of this to me spins down to, we don't really know what we're believing in, what microbiome is. I was talking earlier about how it's, you know, even in our own GI tracts, my world, it's probably a bunch of different pools or lakes that are connected. And so the microbiome in pool one might not be the same in pool four. and they may not even talk to each other. And so, you know, in terms of measuring and, and then believing scientifically that this is important . Did you run into much issue as you tried to push this forward as a clinician in a clinical trial scenario?
[00:26:28] Sumanta K. Pal, MD: you know, I will say that we're just in a state of the science where, you know, we just don't have complete definitions of the microbiome across the board. You know, these studies that have linked immunotherapy to outcomes, with respect to the microbiome have all been done a different tumor types. They've all pointed to different bacteria, frankly, that are associated with improved clinical outcomes. In melanoma, it's been Bifidobacterium, Ruminococcus and kidney and lung cancer, Akkermansia. So, I think that's induced a little bit of skepticism. But, you know, I’ve slowly become a believer over time.
[00:27:00] John Marshall, MD: So, tell us what, in the end, what you decided to do and maybe some of the early results that you're seeing.
[00:27:05] Sumanta K. Pal, MD: So, this also comes from a contact at my hospital, the first case of biostatistician, in this case, the chair of our immunology department, Peter Lee, MD. He's been working with a company in Japan, that has a product called CBM588. This is a product that's been used for generations in Japan to just take care of general GI ailments.
[00:27:23] and people in Japan apparently swear by it. You know, you can buy it at the equivalent of a local Rite Aid or what have you out there. Very safe product. And it's comprised of a single strain of Clostridium butyricum. There have been a lot of preclinical studies and some retrospective studies suggesting that it can boost the impact of immunotherapy. So we've done at this point, two small randomized trials, and these are tiny studies, 30 patients each 20 in the experimental arm, 10 of the control arm, in each of these, but we've shown that CBM588 can augment the activity of nivolumab and ipilimumab, one of the typical regimens we use up front in kidney cancer and also cabozantinib and nivolumab, another common frontline regimen.
[00:28:01] So we're actually trying to push this forward. There’s a trial that may be rolling out in SWOG in the next year or two. It's going to look prospectively at any TKI/IO or IO/IO regimen plus or minus CBM. So that's going to hopefully be the proof of the pudding.
[00:28:16] John Marshall, MD: It's awesome. And I'm assuming well-tolerated. Do you notice a tox difference when you're given the probiotic?
[00:28:21] Sumanta K. Pal, MD: No, we were hoping actually that we would mitigate some toxicity by using it. We haven't really seen that. We've just seen this really interesting signal in terms of boosted efficacy.
[00:28:29] John Marshall, MD That's wild. Give me a theory, I mean, when, when you've had a couple of glasses of wine, why is this working?
Sumanta K. Pal, MD: You know, both of our studies were published in Nature Medicine and usually Nature Medicine requires very sort of rich mechanistic data and we, we supplied that, you know, we had pretty rich bacterium profiling studies with metabolic pathways. If I'm being totally honest with you, at the end of the day, we really didn't identify a single sort of MOA for what we were seeing with CBM588.
[00:28:57] I do believe that there's probably some truth to the possibility that these bacteria get into the lower gut and start releasing short chain fatty acids into the circulation. And these short chain fatty acids are really the ones that we think are driving the improved T-cell response that you get with immunotherapy. This is something that's really challenging to prove because these short chain fatty acids are very labile. We're talking about butyrate or propionate. These are in and out of the system very quickly, but you know, it's something that we're working on within our team now.
[00:29:26] John Marshall, MD: Are you seeing the same thing in your cancers that I see in mine where we're seeing responses in lung but not liver and different regions, or is it not really playing out for you?
[00:29:37] Sumanta K. Pal, MD: you know, it's a brilliant question. In fact, I'm working with one of our junior colorectal colleagues at City of Hope to design a study where we're looking at the difference between liver and non-liver metastasis in that specific context. I haven't really sort of seen that as much in renal cell, but we're at such a nascent stage in this field. I definitely think it's worth looking at.
[00:29:57] John Marshall, MD: Hell, you're further along than the rest of us, so don't give me that we're in a nascent stage. At least you're further up. You got one flight of stairs up when the rest of us are just trying to decide which stairs to walk up.
[00:30:07] Let me ask you one sort of really bizarre question. I've been, lately, I don't know if you're a religious man at all, but I've been increasingly thinking that the microbiome is where the soul resides. Where are you on that stance, a pro or con on that?
[00:30:21] Sumanta K. Pal, MD: Oh my gosh, you know, we're going to have to do some sequencing studies and figure it out. I just, I don't know.
[00:30:26] John Marshall, MD: Well, to me, it makes sense that this is this other creature that lives inside of us that we don't really understand and talks to us, but we're not listening to all that well. And so, to me, it fits very nicely for the way God communicates with us all through our microbiome and our soul.
Dr. Monty Powell, just the world's expert in kidney cancer and really an innovator in bringing this kind of novel approach of trying to harness and influence our microbiomes to improve outcomes from our patients. I know you're a busy man and I know catching you this afternoon was not easy. So, I appreciate it very much. Dr. Monty Powell.
[00:31:02] What an amazing subject the microbiome is. I'm convinced that there's so many important things that we are going to discover over the next few years in this space. Yep, better therapies for cancer patients, yet better ways to live to prevent disease and maybe discover why kids get diabetes. Who knows what we're going to figure out as we uncover the microbiome. Join us next time on Oncology Unscripted with John Marshall to find out what's cool and happening ahead.
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This transcript has been lightly edited for clarity.