Dr. Guannan Wang (00:02)
Hello everybody. This is Dr. Guanan Wang. I'm a genomic scientist and the founder of Vetomics. We are a genomic diagnostic company committed to delivering high quality, high clinically actionable diagnostic tests for pets with cancer. In recent years, precision medicine has transformed how we treat cancer in human patients, shifting away from

one size fits all approaches to targeted therapies tailored to each individual's genomic and molecular differences. In veterinary medicine, we're making progress, but we're still facing some big hurdles. For example, we don't yet have the kind of deep, comprehensive genomic insights into canine cancers that we see in human cancer.

And the primary clinical data in dogs is still quite limited. On top of that, getting access to the right drugs can be tough. I think more education and robust data will be essential to drive broader adoption of precision oncology and ultimately improved outcome for our patients. At Vetomics,

We are committed to contributing to the data generation and education, as well as to facilitating the conversation on genomic or omics guided precision medicine in veterinary oncology among the veterinary community. Today, I'm thrilled to be joined by Dr. MJ Hamilton, who has been at the forefront of innovation in veterinary oncology.

After training at Colorado State and Michigan State, Dr. Hamilton went on to build oncology departments across the Northeast and has been advancing cancer care ever since. But Dr. Hamilton is perhaps the best known for founding the world's first mobile oncology practice, private veterinary specialists.

I had the pleasure of touring his mobile unit. Although it's a mobile unit, but it's a fully equipped oncology clinic, complete with everything you'd expect in the specialist office. It's quite remarkable. Dr. Hamilton was also one of the earliest adopters of precision medicine in veterinary oncology, among the first few to treat dogs

with targeted therapies guided by tumor genomic profiling. This was four or five years ago when the data on the drug use in dogs was quite limited, mostly to only beagle studies in the FDA submissions. With the mentality of needing and wanting to figuring this out, he dug deeper into

PK, PD, and drug metabolisms to understand how these drugs work and metabolize and how they can be safely and effectively used and even combined. Through this effort, he generated some of the earliest anecdotal data on dosing, scheduling, and efficacy for targeted therapies in real world dog patients. With that, I'd like to have a warm welcome

of Dr. Hamilton Welcome to our podcast.

MJ (04:01)
Thank you for having me, it's nice to be here. It's good to see you again.

Dr. Guannan Wang (04:03)
Yeah.

Good to see you. Yeah. I've always ⁓ wanted to have these conversations. obviously, we are offering genomic diagnostics and our primary ⁓ users right now are veterinary oncologists and you being one of the earliest adopters. So I've been wanting to ask these questions. So shall we begin?

MJ (04:27)
Go for it.

Dr. Guannan Wang (04:28)
first few questions surround around decision making in recommending genomic testing. So how many new patients do you see weekly on average?

MJ (04:43)
Weekly? Probably.

Probably new ones at least. on the day. Depend on the week I should say, if it's a really heavy week of new consults can be 20. New ones.

Dr. Guannan Wang (04:52)
wow, okay.

Okay,

this is a dog patients or cats?

MJ (05:03)
within all the current patients.

Dr. Guannan Wang (05:06)
that's a lot. Yeah. And considering that this is only a fraction of the patients that come through the GPs and get referred to specialists Yeah, there's definitely a need there. And do you recommend the genomic testing for all patients, for all new patients? Why or why not?

MJ (05:27)
I don't,

I tend to have kind of two populations where it tends to come in most commonly. One are the owners that are absolutely do everything owners where they've been on the internet and they've seen every treatment as well as every internet folklore or rumor or anecdotal report of anything to do with their pet's cancer. And they want above and beyond, you know, things that are potentially novel. ⁓

So I certainly offer it to them. They tend to usually be quite hungry for it and they're open to hearing that information. Whereas some pet owners are really in such a difficult spot just emotionally with what's happening that going above and beyond your standard treatment recommendations is probably not something they're going to be receptive to. The other population that I use it most for is patients that are really hard where we have a very limited number of treatment options already just knowing their diagnosis.

and you're looking for something novel to try to give you one more option that you may not have been aware of.

Dr. Guannan Wang (06:34)
OK, so percentage-wise, I know this varies Case by case. But percentage-wise, do you think like 30 % or?

MJ (06:44)
I think 30 is fair that I either recommend it or need it on.

Dr. Guannan Wang (06:47)
Okay, okay.

Okay, okay. So it really depends on the diagnosis, the owner, ⁓ financial, emotional state, and the current state of the patients.

MJ (07:05)
Yeah, there's some cases where it's just really not needed. It could be not indicated. It could be a cat where we don't nearly have as much to go on. ⁓ So there's so many unique situations out there, but I don't need it or necessarily think that it's indicated for every case.

Dr. Guannan Wang (07:15)
Mm-hmm.

Right, Yeah, definitely. I agree. So the current data that's supporting the ⁓ genomic guided treatments or cancer management is relatively limited in veterinary space. There is no doubt about that. Most of what we infer from is, of course, from the human space. That's both a blessing and a curse. So of course, we should leverage the

human data. But on the other hand, we also have to recognize the uniqueness, the differences ⁓ between species. we've already seen that in the genomics side. And I have no doubt that this, applies to the clinical side as well. Yeah. Most of the

Canine cancers are studied ⁓ through the lens of human comparative genomics. We've learned a lot, but we've also started to recognize that there is more to it that we should take into consideration for dogs or cats specifically.

Yeah, Okay, that's good to know. I think you've already, stated very well of the factors that influence your decisions to recommend genomic testing. this is ⁓ depending on the current data we have, the standard of care therapy, whether it's effective or not.

and the patient states and the owner's situations. So definitely a lot of factors to go through that decision.

MJ (09:04)
I

will say too as far as recommendations, there's some where I will slip in the information into their ⁓ consult summary, even though I hadn't talked about it, because I can, you you have to read the room sometimes when you're doing a consultation, and if they're overwhelmed, we say, okay, let's wait till visit two before we give them this, but I'll put it in their consult so that way when they do sit down, they'll see it, and then it's ready to be brought up at the next visit. So sometimes I have to stagger it that way.

Dr. Guannan Wang (09:14)
Mm-hmm. Yeah.

MJ (09:35)
for some tumors.

Dr. Guannan Wang (09:36)
now, obviously you are among those that frequently

use genomic tests for your patients, right? So from our perspective, from a genomic diagnostic service perspective, we notice a pattern that our frequent users, you know, tend to use our test for newly diagnosed cases, right? For the cases that based on all the factors that you just stated.

and can benefit from genomic testing. But we also have another cohort of doctors. They are aware of ⁓ genomic testing, They tend to send the most challenging, the last resort cases. or you know,

This case has gone through multiple rounds of testing through other services. And then finally it came to us. So what's your experience? Does that align with your experience?

MJ (10:43)
I do have that population too where I use it. I have multiple right now where ⁓ they're either resistant to traditional standard therapies or I have to, I need something novel because the pet has a specific condition. So for example, I just submitted one this week. ⁓ It's just a standard lymphoma case, which for most oncologists we have, you know, plans A, B, and C ready in our heads. However, this patient has a condition where they had a severe

adverse reaction to an antibiotic prescribed by a dermatologist, which is nobody's fault. We unfortunately get random things that happen like that. And they had major bone marrow changes to where they were neutropenic, thrombocytopenic, and anemic. It was life threatening. And now the patient still remains thrombocytopenic. And so that was pre-lymphoma. And then this past week was diagnosed with lymphoma.

So I add the panel so I could potentially bring out some novel options that normally I would not use in a lymphoma or need to use in a lymphoma because it's a very dedicated owner and we want to be sure we give them everything. And so of course I started standard therapy with them, but I really feel like I need a longer list of options compared to your typical patient because I know some of my drugs are not going to potentially go well. So that's a unique case where it's a hard case. ⁓

Not supposed to be hard, but in the end it may end up being hard.

Dr. Guannan Wang (12:10)
So how you make your decision depending on the case, Yeah. I like also to dive a little

deeper into the barriers ⁓ to genomic testing adoption. So obviously, It takes, I think, 20 years for ⁓ the human oncology space to get to where they are today, where ⁓ genomic testing is a routine practice ⁓ in their cancer diagnosis and cancer management. It takes time.

and a lot of data. Coming from veterinary space, So what are the main barriers? Do you see that we need to overcome before we can, you know, like apply more?

MJ (13:01)
Probably the cost of testing and the ability to fully educate owners on potential side effects. You know, the cost comes with most new diagnostic tests and technologies that the costs end up start out higher and then come down over time. So we know we're in that phase right now. And as far as side effects go, for a lot of the drugs that end up coming up as potential options from genetic testing,

Dr. Guannan Wang (13:04)
Mm-hmm.

Mm-hmm. Mm-hmm. Mm-hmm.

MJ (13:31)
We have pretty limited data. Some of us have clinical experience with them, and then there are some papers out there which are quite helpful. But in the end, it's still limited.

Dr. Guannan Wang (13:43)
Absolutely. I'm 100 % with you on that front. I think that's what we are here to work on. But again, it takes time. For example, in terms of the limited data, right now we have a pretty comprehensive whole exome sequencing.

platform, right? So this gives us a lot of confidence in terms of, okay, we are detecting all mutations, we're detecting the whole coding exome that we are very confident that we are not missing out in terms of finding a driver. But you know, that was not ⁓

available until now. it's definitely fair to say that we don't know much. And this is only one side of the equation. The other big side is, you ⁓ know, the clinical data, you've contributed to generating a lot of the early anecdotal data, and then we published some but there's not nearly enough. And it's in general, very challenging to have like a

well-powered, large-scale, prospective trials for dogs. And there is, I think, ⁓ a big missed opportunity there, even from the comparative oncology space, right? But right now, we are working off of primarily high-level human data,

So that's definitely a lot to work on in that front. it's not even just from the oncologist, from the care provider perspective, even from the owners, they want to see more data to be comfortable.

At the end of the day, they are the ones who will be paying for the test and will deal with the consequences of the test.

MJ (15:37)
Yeah, and efficacy too. mean, we said, you know, side effects and costs, but the efficacy is also part of it. You know, if I spend this on this test and I spend this on these drugs, how much more time does it give me with my pet? The other big unknown, we try to be as transparent as possible on all those things. I find that most people that are driven to want to look into genetic tumor profiling

Dr. Guannan Wang (15:43)
big, big part of it.

Yes.

Mm-hmm.

MJ (16:07)
They don't really care a whole lot. They're so driven to leave no rock unturned that they'll take what they can get. But I still am very transparent about all of it and a lot of the unknowns.

Dr. Guannan Wang (16:19)
absolutely. Thinking ⁓ positively, right? So we have all these issues. in your mind, how do we ⁓ improve education and access to genomic guided options?

MJ (16:39)
⁓

It kind of takes drive and mentorship, I think. The drive to want to try something different because what you've got, you know what you're going to get because you've used it for years. And then mentorship in that working with other people that have tried before you. And the same thing comes with ⁓ many other drugs and oncology as people come up through their careers is you'll talk to a colleague and say, have you tried this? Have you tried that? Or what do you think of this?

and establishing that relationship and then bouncing ideas off of each other and that does tend to build things. I know there are other oncologists across the country that I've been working with that have started to use genomic testing and the different drugs and we talk all the time. have phone calls or text messages back and forth just to share experiences and things like that. So that does also tend to foster more adoption and use.

Dr. Guannan Wang (17:25)
Mm-hmm.

Okay, absolutely. we haven't officially launched for too long. we soft-launched last October, and after, completing almost 100 cases, we finally officially launched earlier in March.

We haven't done a big marketing campaign and that, So, but I think part of it is because ⁓ really the education piece and also how do we really show benefit? Because in my mind, I'm sure in yours as well, getting a genomic test done is the first step. Getting a...

actionable report back is the second step, but it's not the final step, right? It's not the end of the story just because you have some actionable mutations that you can act on means, we are just halfway there. the true measure really is how dogs or cats, respond to your genomic guided treatments.

And does that really help improve outcome compared to conventional standard of care therapy? I think that's the true measure of success.

MJ (18:57)
Yeah, it's gonna take time.

Dr. Guannan Wang (18:59)
It's going to take time. that's a big part of our services that we don't consider delivering a report to Dr. Hamilton is the end of our service for, for example, Kiki, because ⁓ we want to follow up and see what you treat Kiki with.

and whether Kiki responds to the treatment, to our recommended treatment, and whether that truly improves the outcome. So yeah, I see that a continuum of care. Yeah.

MJ (19:36)
It's similar to all things in oncology, all new drugs that come out, all new tests. Everybody tries to come to market with a certain amount of data, which we all really want. But even after that, it still is forthcoming. takes years. mean, look at Palladia. It's such a different drug now as far as how we view it compared to when it first came out. It's come so far with so much data from so many diseases compared to when it first came out.

Dr. Guannan Wang (20:04)
Yeah, absolutely. And then there are more drugs, right? So we now have access to a lot more targeted therapies and immune therapies, right? So I know a lot of people think that immune therapies is the next big thing.

which is not wrong, right? So to encourage your immune system to fight your cancer is probably the best way to go. But there's a lot granularities to that statement, right? Even in human oncology, immunotherapies, is not completely figured out yet. And for the ones that respond, they are most of the times are very

very ⁓ much stratified by some biomarker tests. For example, for keytruda, there are multiple biomarkers that indicate the response to ketruda. That's the human PD-L1 antibody, similar to the Gilbetmab wet map that's made available by Merck

for dogs use. There is the tumor mutation burden. There is the microsatellite instability. There's the PD-1, PD-L1, IHC. So a lot of these biomarker stratifications goes into predicting whether a patient respond or likely respond. And even with that,

the response rate is less than 50 % to say the most. So there's a lot still to work on. And I think the biggest thing is that, you know, we are trying to push right now is to get some stratification going based on genomics, omics, whatever methods that works most effectively to stratify these patients.

predict responders or non-responders. I think non-responders, sometimes we think, ⁓ know, only responder matters, but actually non-responders or, a less favorable responder group that's information, right? That means that you should not waste your time and money probably on this drug that may not, work for your pets.

MJ (22:29)
And I've had that situation too, where I've run, you know, the VetOmics panel on a dog and according to the label, it was a candidate for a certain immunotherapy. And then I got their panel back from you guys and there was nothing suggest that patient would remotely be a responder. So that was part of the conversation with the owners is I said, Hey, this product is approved for what your pet has. But according to this genetic panel on your dog, I don't see anything to say that it's going to be a responder.

Dr. Guannan Wang (22:46)
Mm-hmm.

MJ (22:58)
So we add that because some of the therapies are really expensive.

Dr. Guannan Wang (23:02)
Exactly. Yeah.

Yeah. Yeah. It's good to have some stratification going on All right. So next, some questions I've been dying to ask you, ⁓ knowing how you ⁓ practice. decisions ⁓ in drug prioritizations,

for any ⁓ given Vetomics report. we have a range of therapies recommended. right now, we have an average of three for every case that we've tested, ranging from one is very rare, all the way to six. Sometimes from a genomic scientist perspective,

The most challenging case is not the ones that have very few options because we always find some options. It's that how do we prioritize treatment if there is so much actionability for this patient in their tumor? It comes down to determining what is the most likely driver.

for this dog or cats. And when we determine that, and what is the best drug for the patients right now, we don't have the plethora of the drugs that are available for human patients yet. right now, we have 18 target therapies that we're recommending.

And some of these drugs, they are ⁓ early generation drugs, there is a saying that for precision medicine to work perfectly you have to have the right patient, the right mutations, the right drugs, and the right timing. So everything has to kind of click. So even if we have

our genomics down. So right now, I'm very confident with the genomic insights that we have. But then there's also the drug side. Can we get the best drug that could respond another point I want to make is that the presence of a certain oncogenic mutation, such as the BRAF or TP53, does not

guarantee response for that indication. You really have to ⁓ dig deeper into, is this mutation present in the majority of the tumor cells? Or it's only like 2%, 3 % only a minor clone, right? Because we want to, ideally, target the most prevalent driver mutations in the major clone

So the minor clone could be responsible for resistance later on, but then from the upfront treatment, we have to target those that are most likely drivers and then treat with the best drug that are available to us, that has the most data.

Yeah, and how would you ⁓ stack up with the standard of care therapy versus the genomic recommended therapy?

MJ (26:28)
So I usually look at ⁓ what is the patient on currently for a standard of care therapy? What are the side effects of that current drug? What am I worried about? And then I look at what is on my list of options that you've produced and ranked. And sometimes your top drug that you would recommend or think might be an option would be quite dangerous with what they're on. And I have to say, I can't.

I can't risk drug number one. And I'll tell owners that. So for example, say the dog is on carboplatin, straight up carboplatin, and your top drug for me for their tumor is Palbociclib There's no way in hell I'm giving the two at exact same time. So not the same time. I can stagger them, but I cannot do both at same time.

Dr. Guannan Wang (26:59)
Okay.

Mm-hmm. ⁓

Mmm. Yeah.

Not at the same time. Okay.

Mm-hmm. Mm-hmm. Yeah.

MJ (27:23)
go look at that and say your

second drug is a olaparib for that patient and it's already on Carbo. And I have in my experience had really nice experiences with a olaparib and that it tends to be really well tolerated in my patients so far. So I'll say, I can do that. I'm much more comfortable with that. Um, let's try to integrate this into your care because it's safer. I mean, it's number two, but if we're trying to keep your pet from having adverse side effects, which is a very high priority for everybody.

Dr. Guannan Wang (27:28)
Thank

Okay.

Yeah.

MJ (27:54)
Let's consider that.

I also look at, you will often add what is the scientific support for use of that drug. So you do the A through D system as far as scientific support. So I also look at that too. Sometimes that doesn't always match. Your second line drug may have the most support compared to your first or your third within that category. So I try to weigh all those options.

Dr. Guannan Wang (28:09)
Yes.

Yes.

MJ (28:24)
And then in some instances ⁓ price comes in too. Luckily recently we've had some relief and that some of the prices have come down on some of the drugs which is incredible. So that is a consideration too.

Dr. Guannan Wang (28:39)
it sounds like you tend to stagger standard of care therapy with the

genomics-guided targeted therapies. It's not you exhaust standard of care therapy and then you start genomics-guided treatment.

MJ (28:48)
safety perspective.

All right, so for the owners that want to be aggressive, ⁓ we do integrate it with standard of care, but it is staggered for safety purposes. Because most of us oncologists are quite comfortable with our standard repertoire of drugs and when we're going to have side effects, when we're not, and when that window is. And so I will often layer in a targeted therapy once I think I'm beyond the standard toxicity window for their current drug.

Dr. Guannan Wang (29:01)
Mm-hmm.

MJ (29:23)
to try to give us an opportunity to use it. And then we get braver and braver and start to move the two therapies together. So that tends to be my approach. And I have many patients where you're past that phase and you can use everything together all at once, where there isn't any staggering. They're getting standard care ⁓ on regular schedule as well as their targeted therapy at the exact same time.

Dr. Guannan Wang (29:34)
Yeah. ⁓

Do you see a day where you would ⁓ start off with genomic-guided therapy?

MJ (30:01)
I'd like to. ⁓

Dr. Guannan Wang (30:02)
and what

it takes us to get there in your mind.

MJ (30:08)
What it takes to get there are all the things we're working on is knowing more about safe and effective dosing and side effects. Knowing and having the confidence that that single target therapy is going to be enough. We're trying to get there, I just don't think that we're there yet for a lot of the drugs. There's a couple where I'm confident that we can treat with just a targeted drug, but not a whole lot.

Dr. Guannan Wang (30:15)
Mm-hmm.

Mm-hmm.

Yeah, it requires a lot of data. It requires a lot of data. our hypothesis-driven clinical studies is exactly ⁓ dealing with that to generate more data, not from a prospective, very clear-cut clinical trials, but from real-world patients.

we have support for that, there's also like a big ⁓ movement towards real world patients' data in the human oncology, space, right? Because the efficacy you see in the clinical trial may not translate directly into the effectiveness, into the real world patients. So how the drug

works in the real world patients is in a way matters more than some clinical trial study. That said, so the way that you are staggering these standard care therapy and genomic guided treatments make it harder for us to have clean data.

MJ (31:50)
It does. It is horrible for your data. It is, but this is me as a clinician. I have to keep my patients safe and answer to their owners every week. And I can't, and I also can't in good conscience hold back something that is proven as standard of care in exchange for something that's not. But I fully admit I'm not helping the data.

Dr. Guannan Wang (31:52)
Exactly, yeah.

Mm-hmm. Yes.

Mm-hmm, yes.

You're

not helping the data.

MJ (32:17)
It should

be one drug only at once no other concurrent medications I Get it. It's just clinically. I can't I had a lot of trouble doing that ⁓ And the drug there it is it's just my responsibility, but yes, I'm I'm not helping the data that way

Dr. Guannan Wang (32:22)
In turn. Yeah.

I... yeah, yeah, yeah, yeah. That's your responsibility.

I mean, that's why I think It's a marathon, right? It's not a sprint. think we'll always be collecting more data. If the signal is strong, we'll detect it, right? We'll detect it. If the drug really works and even amongst others,

If we are powered enough, we have enough cases, so we'll detect it. And once we do that, once we have that ⁓ signal well validated, I think then that will make you maybe more confident to use that as a single therapy or a very controlled combination. ⁓

MJ (33:06)
But I...

Yeah,

but what I can certainly say is I think that I'm at least contributing data or information relative to tolerability. And for any clinician to start these novel drugs they haven't before, they have to have some feel for what's tolerated. Like that's just the first step to dip your toe in the waters of using these drugs. Because it's your biggest fears. What is my dose? What are my side effects going to be? Can they tolerate that? And that is so important to get started. And that's how it was for me when I first

Dr. Guannan Wang (33:33)
Yes.

Yes.

Absolutely.

MJ (33:55)
start with these drugs. I had something somewhere to give me a clue about what could be tolerated so I didn't hurt the patient. So well, that's what I'm contributing at least.

Dr. Guannan Wang (34:03)
Absolutely.

Yeah.

Now you're contributing so much, MJ. Yeah. terms of the efficacy side, so we'll get there. right now, ⁓ I mean, even the prospective of clinical trial is not completely out of the picture. Right. So we haven't been able to

do that for a lot of the diseases. It doesn't mean that we won't be able to do that, right? So I think it comes down to the awareness that we need to do that. And it's not an endless game that we have to constantly do. For every new drug, yes, of course. But for one drug, we need to do one trial, right? One good trial, one good set of data, whether this works or not working as well as the standard care therapy.

And then we have our answer there. And we can move on to the next thing. Yeah. And you probably said this, but are there any specific tumor types or cases where you would bypass the standard of care therapy and then go straight to genomic? I think you said that. I'm a little fuzzy.

MJ (35:18)
I would not use standard of care.

Dr. Guannan Wang (35:20)
not with Standard of Care,

MJ (35:25)
It's my obligation to always start with what we know.

Dr. Guannan Wang (35:28)
Mm-hmm.

Mm-hmm. Mm-hmm.

MJ (35:31)
Once in a I'll have an owner that on their own accord says, do not want stand-up care therapy. I only want targeted drugs. And we talk about that too, the knowns and the unknowns. And I'll go with their wishes as long as I don't think that quality of life-wise, I'm going to hurt the pet But we understand that survival-wise, it may not be what we're used to. So not many. Not many.

Dr. Guannan Wang (35:38)
Yeah.

you

Hmm, okay. Not

not many yet. again, this takes many years, right? In human medicine, there's a trend right now of approving these novel drugs, newer class of drugs ⁓ as ⁓ frontline therapy. It was not used to like that. It was always like a third line, right?

after you exhaust pretty much everything. I think we are still at that stage with even less data. Yes. Yeah.

MJ (36:26)
I hope

to get there. really think that dosing is a huge challenge right now. All that data, it's coming and people are doing it and it helps a lot but that's my biggest concern is that we don't have the dosing dialed in as well as we need to.

Dr. Guannan Wang (36:30)
Yeah.

Yes, And you contributed a lot of the dosing data that we currently recommend and a lot of our doctors are adopting. So that's a big deal.

MJ (36:54)
and forth. It's part of the community of doctors that try this. And I've had trouble with a couple of drugs and then contacted oncologists across the country and said, hey, give me your experience. What has been tolerated by your patients? And so I've evolved some of my dosing too from that.

Dr. Guannan Wang (37:09)
Yeah, absolutely. and I also want to take it upon us to facilitate that communication. That's why we have the forum. That's why we have the emails. So if you are not comfortable ⁓ using certain drug, we can connect you with other doctors that have experience, have successful experience with that drug.

I think a recent example is the combination of carboplatin and olaparib. One of my doctors ⁓ is not comfortable using the combo, but then you have ⁓ many, many cases of ⁓ success of using that combo. That's actually one of ⁓ most ⁓ safe

combos that works pretty well in certain drugs.

MJ (38:04)
So far for me,

a olaparib has been a nice addition for many patients, but I have also heard of people that have had bad experience with it. And I did notice the dosing between mine and theirs is different, and so that's a conversation that

Dr. Guannan Wang (38:19)
Okay, absolutely. Yeah.

MJ (38:22)
data has to come, but I did notice that they had posted about their bad experiences with it and I looked at their dose versus mine, so there's absolutely something happening there. It's great that we can compare and contrast and then try to find what works.

Dr. Guannan Wang (38:23)
Mm-hmm.

Okay.

Absolutely. Absolutely. Yeah.

MJ (38:42)
be my dose is too low, their dose is too high, and we've got to figure out what the middle one is.

Dr. Guannan Wang (38:46)
middle one to minimize toxicity, but also maximize the efficacy, right? yeah, definitely, So, ⁓ you know, we've talked about the safety of the drugs. I think that comes to my question that how do you assess the

risk benefit balance of some of the target therapies, namely small molecule inhibitors compared to conventional chemotherapy, for example, or radiation therapy. I know that some of my doctors think that they have a similar amount of toxicity.

So I want to hear your thoughts about that because my understanding is that some of them are more manageable because they are ⁓ targeted. what about the administration of these drugs? Are they easier or more difficult compared to chemotherapy?

MJ (39:54)
as far as giving the drug or side effects.

Dr. Guannan Wang (39:57)
Both. All right. can owner give the dogs the drug? Yes. OK.

MJ (39:59)
Most of these are oral, so giving them is usually not an issue.

Most of the time, with all

pet medications, there are some pets that are very challenging to give oral medications to, no matter what is. That will always be. So thankfully, most of our patients are dogs and easy to medicate. But it is a factor. Like, I won't even run the panel if I know owners can't give oral meds. Like, if they can't even give their nausea meds or something like an anti-inflammatory, there's no way.

Dr. Guannan Wang (40:19)
Mm-hmm.

MJ (40:31)
You know, it's feasible to be given another drug no matter what it is. it's part of it. And every veterinarian runs into that when we work around. Side effect wise, you all of us oncologists work very hard to minimize side effects. We don't like them. Our staff doesn't like them. Our pet owners don't like them. it's a huge priority to keep them not having adverse side effects. For all of us, even for drugs that we're already very comfortable with, it's going to happen sometimes. And it sucks. And we do everything we can.

Dr. Guannan Wang (40:35)
Yes. ⁓

Mm-hmm, yes.

MJ (41:01)
to help out that patient, that situation. So as I said before, I have to know that a standard drug is tolerated first before I'll try a targeted therapy. Thankfully, most of the targeted therapies have gone well, but I've certainly had cases where they did not go well. That's a huge learning point that you try to share with everybody. This is the drug I gave, this was the schedule it was, this was the disease I used it for. And I've had a couple of cases that were

Dr. Guannan Wang (41:19)
Hmm.

Yes.

FC.

MJ (41:30)
really not good. But I've had so many more where the side effects have been so well tolerated that it's encouraging. So, yeah, that's what do.

Dr. Guannan Wang (41:40)
OK, yeah,

yeah, Perfect. ⁓ And same question for immunotherapies that are available currently. Yeah, we've had quite a few.

MJ (41:53)
Yeah, so ⁓ the immunotherapies, thankfully I found to be quite well tolerated for what's on the market, ⁓ which is great. ⁓ Side effects have been pretty minimal. They also have been, when possible or indicated, they've also been received well concurrently with other medications. ⁓ So thankfully it's been pretty well, but I still take a bit of a staggered approach with those.

Dr. Guannan Wang (42:01)
Okay.

MJ (42:23)
You know, I really want to know, you tolerate one before we can add in something else, no matter what it is? ⁓ So I've had pretty good experiences with the immunotherapies tolerability-wise. Just like the targeted drugs efficacy-wise, we're still working on that.

Dr. Guannan Wang (42:35)
Okay.

I know, yeah, that's question mark right now, right? Are we treating the right patient with the immunotherapies? we have ⁓ several collaborations in discussion right now. And we do hope that by integrating genomic analysis that we can.

help determine the different population responders or non-responders and help stratify patients that way upfront. that way, we kind of treat the best possible predicted responders, right?

MJ (43:21)
I have to say, like, we are also so lucky to have these options now

Dr. Guannan Wang (43:25)
Absolutely, yeah.

MJ (43:28)
access

to the number of target drugs we have now, my residency didn't have it. It was Palladia, Kinnivet, and maybe a little bit of Imatinib, maybe that was it. Absolutely that was it. And zero genomic testing. And we had, the only immunotherapy we had was the Oncept melanoma immunotherapy.

Dr. Guannan Wang (43:33)
Mm-hmm. Yeah.

Mm-hmm. Yeah. Yeah.

MJ (43:54)
And now we are so lucky to have these options. Yeah, they come with a lot of unknowns, but it's so nice to have other options because as oncologists, we were beating our heads against the wall, so tired of these cases dying from just the standard repertoire of drugs that we couldn't get to work anymore because they were so resistant. So while there's so much criticism about using novel drugs that we don't have data for, it's like we're so lucky to have it. And unless you try, we're not going to get anywhere.

Dr. Guannan Wang (44:01)
Absolutely, yeah.

Mm-hmm.

And exactly.

MJ (44:25)
And it's

always been that way. Like we have to remember, like, what about just using Vin christine 35, 40 years ago? We didn't know anything. Same exact situation. And we, and all the oncologists before me worked hard. They figured it out. And now it's no one even thinks twice. So it's going to come someday, but we, it's about trying.

Dr. Guannan Wang (44:35)
Mm-hmm.

Yeah, are our options if we don't explore these novel newer therapy approaches or testings? Because a lot of the diseases, their treatment, the needles haven't been moved for quite some time.

MJ (45:08)
Yeah, here.

Dr. Guannan Wang (45:09)
Yeah, we are

MJ (45:09)
Here.

Dr. Guannan Wang (45:10)
basically spinning with the same ineffective treatment for these patients that you know that will fail. So try something new. ⁓ And the gathering data in the process is a big belief we have, and we are working towards that. Yeah,

That brings me to my last set of questions. ⁓ What changes or advancements would you like to see in this space? And in particular, what do you like to see us doing as a genomic diagnostic service that can help facilitate or lift some of the pain points that you experience?

MJ (46:02)
I think continuing to support trying to get data and research, that helps everybody. Bringing people together to explore the space and try to refine what we know is great. And accessibility, having accessibility to trying to run a genetic panel, profile it, that accessibility helps be able to get that done easily.

Dr. Guannan Wang (46:23)
Yeah.

Yeah.

MJ (46:30)
facilitating ordering in the test getting it done getting results back ⁓ that helps a lot So

Dr. Guannan Wang (46:35)
Mm-hmm.

Okay. Sorry. So by accessibility, you don't mean drugs. That's also a big thing, but you mean accessibility to genomic testing. Yeah. Yeah. Okay. So like a...

MJ (46:46)
Yeah, So it comes

with knowledge, so people knowing it's out there. ⁓ Knowing how your test is different than those companies before you. ⁓ The knowledge of how to order, you know, genetic tumor profiling and facilitating the smooth use of it. Because during clinical practice days are busy. You know, you need to get stuff done quickly because there's a lot of demands.

Dr. Guannan Wang (46:55)
Yes.

Okay.

Yes.

MJ (47:16)
And so not having hangups and ordering testing, stuff like that.

Dr. Guannan Wang (47:20)
Absolutely. Yeah, I've definitely had some ideas around that And for the whole space. right now, what what what I know and hear is, we need more data

Again, it takes a village, so together. Sounds good. Yeah. Do you have any questions for me before we end?

MJ (47:46)
Um, not really, you know, we talk a lot and all of us other oncologists talk a lot. Um, so not really at the moment, you know, I like that the test is available and it's out there. It's adding information or conversation pieces that we've never had before. Um, which, you know, spurs, you know, innovation as well as all our thought processes on trying to be better and do better with our patients. Um, so I think that's great.

Dr. Guannan Wang (47:49)
We've talked often. We've talked. Yeah. Yeah.

Sounds good. Yeah. It's you guys that are keeping me in shape. we need to do it. We need to do good, good, work. High quality work. Yeah. Sounds good. OK. All right. Thank you so much for the conversation. truly enjoyed it. ⁓ Yeah. And can't wait to getting good data out there and ⁓ show that this work matters, that this work.

MJ (48:19)
Thank

problem.

Dr. Guannan Wang (48:45)
outperforms ⁓ conventional therapy. And then the ultimate goal really is to advance cancer care and improve outcomes for our pets. Sounds good. Thank you so much. Absolutely. Yeah.

MJ (49:02)
Great, no problem, thanks for having me. Take care.