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Investigating Breast Cancer: Exploring the Many Intersections of Health Equity in Latin America
Dr. Jeffrey Weitzel delves into historical, cultural, and anthropological roots, of disparities in breast cancer prevention and outcomes
While genetic testing and counseling for breast cancer has been available in the U.S. for many years, accessing these services in Mexico and the rest of Latin America is more challenging due to limited resources. This disparity is particularly concerning because hereditary breast cancer has been found to be a serious problem in this population of women.
Leading genetics researcher and oncologist, Dr. Jeffrey Weitzel, has devoted his career to decreasing these barriers. He led a groundbreaking study that revealed BRCA mutations may be present in 25 percent of U.S. Hispanic women, leading to calls for increased genetic testing and counseling.
Dr. Weitzel, a BCRF investigator since 2013, is director of the Clinical Cancer Genetics Program and professor of oncology and population sciences at the Beckman Research Institute at City of Hope. Dr. Weitzel is pioneering low-cost genetic screening materials and training doctors and nurses working with underserved populations in Peru, Colombia, and Mexico.
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Read the transcript below:
Chris Riback: Dr. Weitzel, thank you for joining me I appreciate your time.
Dr. Jeffrey Weitzel: My great pleasure.
Chris Riback: There are so many places a conversation with you could go and I certainly hope that we get to go to all of those places or at least most of them. I'd like to start with your work that centers on improving access to genetic screening and breast cancer prevention in Latin America and Mexico. Let's start perhaps with a laying of the geographical land. How big is the screening and prevention problem in Latin America and Mexico?
Dr. Jeffrey Weitzel: I don't think we have to go beyond our own borders to get some sense of that as well. Really, our project is about, started at its heart, to address disparities. I'm an oncologist and a geneticist so this onco-genetics realm. Certainly there are many BCRF projects that relate to the causes of breast cancer. People come to mind like Dr. Mary-Claire King and others who are just absolutely stellar leaders in identifying hereditary forms of breast cancer.
While it's not the most common cause of breast cancer it is perhaps the most impactful. The risks are so extraordinary that people really deserve to be identified and given guidance as to how to take care of their risks. So, over 20 years, it's been over 20 years that we've been able to do commercial gene testing for breast cancer pre-disposition that there are still groups that are left out in the United States.
This really goes to my own back yard. I'm living in Los Angeles and we have a very rich Hispanic fabric. A lot of people with ancestry that might originate in Latin America. This goes back to the year 2000 and to one of my dear colleagues. If you don't mind, I'll tell you a story.
Chris Riback: Please.
Dr. Jeffrey Weitzel: Dr. Feldman was the chair of oncology at one of our safety-net hospitals. This is one of the LA County hospitals. 89 percent of their indigent service population is Hispanic and or has Spanish language as even their first language. She came to me when we were at a breast cancer retreat talking about science and she said, "We're dying out here. I have 32-year-old women coming in with easily palpable stage-three breast cancers, and they have a family history of breast cancer. Why weren't they identified, given access to genetics and the opportunity for prevention."
This is something that's so obvious. We know the story. We know what hereditary breast cancer looks like but these people weren't getting access. So, I said well, let's look at that. We literally created an infrastructure right off the bat. We're going to open a free clinic, we're going to provide the care but we still have to figure out how to get the testing done because in those days the test cost 4,000 dollars for two genes. Medicaid did not provide coverage for testing.
First, we had to say okay, what do we need to do special for these individuals so that we can make them feel comfortable. If you build it, will they come? If they come, will they learn? If they learn, will they do the right thing? If they do the right thing will they be free of cancer and live longer.
Chris Riback: Was that conversation the inspiration for you for your groundbreaking study that revealed the BRCA mutations may be present in 25 percent of US Hispanic women? Is that what drove you to do that research?
Dr. Jeffrey Weitzel: This is the thing, when you go to do the right thing, sometimes you learn other stuff. So, again from a friendship level we started this program to address a disparity. I'm honored that I also have Conquer Cancer professorship in breast cancer disparities in part because of this legacy. But we first published on the beliefs and interest in risk-assessment in Latino cohorts we said, if you build it will they come? We literally put that in the title. We started the clinic and said, are people coming in? Are they learning? And they were.
By hook or by crook we got funding and created our own funding to try and get testing done and in the process we discovered that, wow, these people had a high prevalence of mutations, this is in our study, just at the county hospital, which we published on in 2005. Further, we saw the same mutation repeatedly, which suggested a population level impact of history, anthropology, and epidemiology.
I'll tell you more about that story in a moment, but we, kind of, through the backdoor, learned the epidemiology and that's because nobody else was taking care of these patients. So what happened in the intervals, I have a large research network. This is something I've built over 25 years. I have 39 sites in the US and now we have 7 in Latin America. We're all running the same protocol, which is everybody we see for risk assessment we enroll and we study.
The 2013 paper that you're talking about, which at that point was published in the Journal of Clinical Oncology which is a high-level journal because it was a novel observation of 746 individuals, all of whom had breast cancer, presumably at a young age they met the criteria for testing and we got testing and it represented mostly Mexicans and Latin Americans and Central Americans based on our service area.
Chris Riback: Was it that 52 percent of them had the same mutation? I might be getting the fact wrong. What was the data there?
Dr. Jeffrey Weitzel: Of all the women with breast cancer 25 percent had a mutation. Of those mutations we found that there were two specific mutations in BRCA1 that had counted for a large proportion of cases and then multiple other mutations were seen. One of the things we discovered, because this was work I did again, on this initial cohort from the county hospital. First we found a bunch of mutations, then were new technologies coming along which was to look for specific mutations that couldn't be detected by just sequencing.
They're called large genomic rearrangements. So, big dilutions. Ironically, you can find a misspelling in the gene very easily with sequencing but if a whole chapter is missing, you don't see that, because everybody's got two copies. One copy is normal. One copy is not. You're just reading through and you think they're all normal but they're actually just completely missing that stuff.
It turns out that we were one of the first observations of a large genomic rearrangement, so a very specific type of mutation that was repeating in this population, had never been reported in Spain or any other country. So, we surmised that this was what we call a founder mutation. Any geographically or culturally isolated population can have this.
We further went and found out that not only was this frequent in the population, it looked like it was in Mexico. We found it once in Venezuela but it turns out that individual was Mexican. It turned out to be exclusive from people who originated in Mexico, and it was frequent. We did what we call haplotyping to determine how old the mutation was, kind of like carbon dating, and we found out it was 1,500 years old.
This long predated the colonial Hispanic influences. So the colonial influence of the Spaniards, et cetera, and really reflected origin in an indigenous population, indigenous American population likely in central Mexico.
Chris Riback: Not brought from Europe.
Dr. Jeffrey Weitzel: That's right. Now we found a lot of other mutations that were frequent. So the other one that was a very interesting observation we first published in 2005, one of the first times it was documented, was multi-generational Catholics, we found the 185delAG mutation of BRCA1 which is a known Jewish founder mutation. What we published on then, in 2005, was that they shared the same chromosome as my Jewish patients from West LA.
This shows an ancestral origin and that links it immediately to history and to anthropology. This is where I get just completely excited because we start talking about the impact of history and humankind and the consequences of diasporas. Think the Spanish Inquisition, 500 years ago, It's about 500 years ago this year. They basically caused a mass disposition of Sephardic Jews, so Spanish Jews, who moved to Portugal and then to the new world.
We're able to establish that there was a much larger diaspora that was of conversos, people that converted to Catholicism to survive than had been anticipated. That mutation and this founder mutation that we found in the indigenous population were the two most common mutations in the whole cohort. So, that was really illuminating and it helped me understand the impact of world history, and not surprisingly we saw a bunch of Spanish mutations too. There are other mutations that are common in Spaniards that are seen in this population.
One last population this represented, and again bringing together our world history view is, there was an African founder, and that reflects the impact of the slave trade. Especially in Central America and in Mexico on the gulf coast, because remember that was where a lot of the slave trade entered. We saw exactly what you'd expect for the admixture, the type of blend of cultures and ancestries that you see in Mexico. Again, I learned a lot about ancestry, anthropology, and epidemiology by trying to do the right thing. That is, take care of people who have no access to care.
Chris Riback: I was just going to say, you're raising one of the most fascinating parts of these conversations for me is the intersections. So often the intersections I come across are from oncologists who are studying or have worked in one type of cancer and from working in one type of cancer, lung cancer, stomach cancer, and other areas they take those findings and apply them in other areas of study and that mix has not stopped fascinating me.
What I'm hearing from you is, you're not a historian by study, and you're not an anthropologist by study, but is the fact that you are an oncologist and a geneticist, was that mix of your background part of what enabled you to really go forward on the type of investigation that you did there?
Dr. Jeffrey Weitzel: Yes, absolutely. I think that geneticists follow lineages and sometimes those lineages go way back. That's a natural interest on that side. The oncology side of me is all about, what's the problem? What do we need to help with? Where are we having a problem that we need to take care of people?
So, you're right. I'm sort of a junior anthropologist as a result of this. Really, I've read the books. I'm starting to read the books and the things that relate to these historical angles and then it actually provokes new scientific questions. You look at these ancestries but what was important at the time, let me just add one other thing, is remember we were talking about disparities in the access to care and the absolute limitation because of the economics.
The other thing we tried to do is we said, okay 75 percent of the patients who have a mutation have one of them that we've determined were on our shortlist. They were recurrent. They're historical, ancestral. We already knew these genes didn't mutate frequently, meaning new mutations aren't quite found that open. We said, can we do a cheaper test.
I actually turned around and created in my laboratory, I like to call it the pragmatic research, which is can I get testing done cheaper for my patients without having to spend $4,000 a test? And we did. We created then a platform that uses mass-spectroscopy, a $20 test that picked off 75 percent of the true mutations. That allowed me, even in my county hospital population in the US, before Medicaid started paying, we were able to figure out the 10 or 15 percent who are carriers based on this very cheap test. Turned around and converted it with a commercial test at a cheap cost to now have a tool for the whole family.
We were leveraging science to be pragmatic and literally translate directly into access to care based on knowledge of epidemiology. What's happened since then is that we started to raise that flag and really push that theme, that don't leave anybody out, any population that looks like it has hereditary breast cancer probably does. How do you take care of these people? We need people who are trained in genetics and oncology, so we married this to what I will call our, we have an award-winning doctor training program. So doctor, nurse, and genetic counselor training program.
Chris Riback: Is this the cancer genomics education program with Dr. Blazer?
Dr. Jeffrey Weitzel: You've got it. Dr. Blazer.
Chris Riback: So please go ahead.
Dr. Jeffrey Weitzel: So Dr. Kathy Blazer was a genetic counselor. She was one of the first genetic counselors that I hired when I got my first education grant back in 1997. She was obviously quite young when I hired her. She's Dr. Blazer because along the way we had gotten really involved in, really brought our education program because we realized post-medical school training, and even fellowship training of oncologists was completely deficient in understanding how to apply genomics and cancer.
That's become even more so the case. I'm sure you've had other podcasts where you've talked about precision medicine, so this whole intersection of genomics and oncology is just so stimulating and so fascinating. People need that training that they didn't get. Not only that, but she championed what we call situated learning. We've taken practitioners who are in practice and use their own cases to help them learn and it turns out that it's the most profoundly effective way to train practitioners is to make it situated, it's relevant to their practice today, and use their own cases in that learning.
Suffice it to say we developed a program that's over 100 continuing medical education hours and involves a lot of immersed learning. She’s Dr. Blazer because she went and got her educational doctorate at UCLA, while she continued to work at City of Hope and has raised the bar even further on our program. I'm very honored that last year the American Society of Human Genetics recognized us as a team to award their education award.
Suffice it to say, we've taken this award-winning program and said, okay, how can we increase access to care, and how can we leverage this epidemiology. Because even though we continue to expand access to this care in the US. I will say there are still deficits in the underrepresented minority populations, and disparities there. Also, among Hispanics in the US. We have made a lot of progress there. We now have trainees in every state of the union and 26 countries.
How do we then take what we learned and maybe take it to Mexico? This is where, really BCRF, has been so instrumental. These things take a while to develop. We have to be patient. Even though we've been doing testing for 20 years in the US they still don't have a fundamental access to genetic cancer risk assessment in Mexico, Central America, and most of South America. This can be said also for, probably, Africa and a few other places.
We said, hey we're training people, but it doesn't do them any good to get trained if they don't have tools. So, I have a registry protocol, that allows return of results that are clinically actionable to the patients and the clinicians who are participating in this research. So, what we've done is created an implementation intervention so, there's a whole science of dissemination and implementation, I've had to learn multiple sciences beyond oncology and genetics to do research.
Behavioral research, will they show up? What are the social-cognitive aspects of Latinas preparing to undergo risk-assessment. I've learned so much from my colleagues and embraced my colleagues who are multi-disciplinary, it's so important. Again, genetic counselors are so key to that process.
In any event, we, embracing all these various specialties and things, and learning how to do dissemination and implementation which is really, how do you take this practice that you feel is medically important and will help to save lives, how do you get other people to adopt it and what are the barriers?
It's a whole study. They're the PIs of their own registry but they send the biopsy specimens to my laboratory at City of Hope where Joseph Hertzog and Danielle Castillo both work in my lab and they're just awesome. They do all this work.
They receive all the samples, we extract the DNA. Even though I didn't want to be a service lab. I have no intention of being one of the major commercial genetic testing laboratories. I realized, if we did it cheaply using a number of different tools, what we can now do, BRCA testing plus another 30 genes all for under $100 per case. That puts it into the realm of research funding, and into the realm of plausibility for these other countries if they can pick up the technology.
It's partly tech-transfer too. In the meantime we said, well you don't want to just give them the tool and tell them to go, test people, you want them to take care of them appropriately. So, we trained them in the course. They get the high-level training in cancer genomics and how to apply it in the clinic and they go back to their own setting, they create their own clinic and we help coach them on creating clinics, which is part of what dissemination and implementation is about.
By putting them in our registry we accomplish two things. We now, continue to grow the body of knowledge about epidemiology. So, what are the country-specific patterns that will help to convince their own health care administrators that it's important. And second, they're really giving that care to their patients and helping to find ways to take care of that risk when they find it.
I'll give you an example that is so pragmatic. Unfortunately, most of these people still have cancer when they're identified, we're not quite at the identifying the at-risk relatives, but if a woman at 35 years old or 40 years old comes in with breast cancer, at whatever stage... I will tell you the stage distribution in countries without good screening is dismal. It's like stage three. But, they have big families. And so, if we can identify the risk in that woman, she gets good care and survives, and we find out that because she is a BRCA carrier she has an extraordinary risk for ovarian cancer that could take her life. With almost no chance of early detection there.
That's an intervention, remove her ovaries and tubes out after the completion of childbearing that could save her life. Then, on top of that, we now have the anchor for that family, we do what's called cascade testing. Now we can go to her sisters. Even if we can't provide comprehensive care for everybody in that family, at least half of the individuals won't carry the mutation so we can give them reassurance that they're average risk. The other half we can focus what limited resources we have.
This is about allocation of limited resources in low and middle-income countries. If I looked at it, at a population level, how do we help in a bigger way? Our goals are nothing short of changing entire counties' plans for the care of high risk individuals at risk for breast and ovarian cancer. At the immediate level, I believe we are saving lives now by not waiting until genetic testing is somehow implemented by commercial firms at an adequately low price that the countries with such limited resources are willing to pick them up and integrate them.
We're really creating the infrastructure to implement these cares and getting immense experience for the people locally and for our general knowledge of epidemiology to help guide these directions. Again, the BCRF funds have been so important to be able to have the patients. We literally develop these programs one city at a time. We're in Mexico City, Guadalajara, Monterrey. We just opened up a clinic in Tuxtla which is in Chiapas.
Even in a poor country or a low and middle-income country, this is like the poorest.
Chris Riback: And historically there's been real danger there.
Dr. Jeffrey Weitzel: That's right. Real danger, and historically disparities even within that setting. The more indigenous people, and there's a lot of disparities. We're partnered there with Francisco Gutierrez and his clinics. He trained with us. We went and did a site visit back in January before COVID-19. He was a most gracious host but we got to see where they're going to do their work, we got them logistical support and we've already tested over 50 patients for his clinic.
That will serve people in Chiapas all the way down to Guatemala and into Oaxaca, so a very large area that they'll help to serve. We're also in Bogota, Columbia, Medellín, Columbia, and Lima, Peru. This is the nucleus of the network. I will tell you that overall supported by Breast Cancer Research Foundation. We've helped to test more than 4,000 women over the last five or six years. That means 4,000 families with access to care. At least 15 percent are carriers of a significant mutation that influences their care.
We're starting to create a legacy in terms of publications as well. We have one publication from 2014 on triple-negative breast cancer, and out of 190 women with triple-negative breast cancer we found that 27 percent had a mutation on our quick screen. We screened 190 women in two weeks for $5,000 and came up with 45 carriers that quickly.
You just can't do it on a scale when we're being nimble, we're doing what we can. We found out just recently, we got some really exciting data coming out that we're writing right now, so it's unpublished suggesting that there may be a difference between the mutations. That the mutation that's that founder mutation while it confers great risk, also may confer some survivor benefit if given chemotherapies. We're actually starting to get into the patho-biology of breast cancer, not just who's at risk but what are the outcomes? We're also studying what's the uptake of risk reduction surgery.
Do the women who we identify get access to the care? Remember this is all on the backs of those saints, those clinicians, at each of these sites. We said, we'll help you define the risk, but you've got to figure out how to take care of those patients. Rather than saying it all had to be lined up before we started we said, let's get this going and the natural experiment, which has been just amazing, is that when given the opportunity, we give the patient the information, let them be empowered. Give the doctors the information, let them be empowered. They find ways to work the system and get the care.
This has been really remarkable that they're going to figure out how to provide the care where they are and it's respect for cultural and situational circumstance. We aren't promoting US guidelines, we're promoting locally relevant guidelines in terms of the care that they provide.
I'm becoming more adept and understanding of all of these very important, I'll call them, cultural humility is I think the new word. Understanding how...
Chris Riback: Yes, it's a terrific phrase. In listening to you so many key ideas and such important concepts jump to me. When you say you've tested 4,000 folks. It goes beyond that. The cascade effect of what you're learning is all of a sudden, the folks within that testing environment who do discover that they have a genetic mutation, I know you already know this, you've just now positively affected at least with arming them with information about themselves, their whole families. Every member, sisters, granddaughters, nieces. The list goes on.
Dr. Jeffrey Weitzel: Absolutely.
Chris Riback: That's number one. Number two the thing that occurs to me, so tragic, I'm certain you feel the same way. You mention that so often in some of these locations in the US, in other places where there is disparity of care and disparity of access that the person who comes in, comes in because the risk identifier that has come up in her life is the actual cancer. You described it as so often they come in and it's stage-three cancer, they haven't been identified before that. Obviously that's tragic and sad and you wish to goodness that somehow you'd been able to identify them earlier.
That said, same thing, then they go through the process and all of a sudden you're now able to arm the rest of their families, yes maybe, you phrased it, maybe you'll be able to find some other type of cancer that they might have been, might have come across, or had ultimately. By doing this care you will have identified that. You mentioned ovarian cancer as an example.
Lastly, and this is kind of my question, one question is, please correct me if I'm not interpreting the lessons that you've been describing because I'm just trying to communicate back to you what I'm hearing in getting to hear the work and the study and impact that you've made. Going into this conversation, one of my main questions was, okay Doc you're worried about disparities, where do you begin. Is that a money question? Is that an access question? Is it a social question? Is it a health care professional question? Is it an education question? Is it a science question? When you talk about disparity what exactly does that mean, and what I'm hearing from you is, yes. It means all of that and that probably, is what defines one of your current research programs, the multi-modal approach to address these disparities. It really is multi-modal isn't it?
Dr. Jeffrey Weitzel: Absolutely. It's creating infrastructure, generating knowledge, being able to help influence health policy decisions, so a truly global profile. Right?
Chris Riback: Yes, yes, it's a public policy.
Dr. Jeffrey Weitzel: It's a public policy. Again, by demonstrating the impact. By going and not waiting for little pieces to come together, but to put it all together and allow my colleagues to take the lead. They really do take the lead. They're extraordinary in their efforts. We're publishing locally. We're publishing globally. The idea is that they will establish that the problem exists and that there's a pathway to some solutions.
We're laying the groundwork. One of our colleagues we were working with Alejandro Moja, he was the former director of the National Cancer Institute in Mexico City, and he was at one point or another also working as an agent of the Ministry of Health. One of his charges was to create a national cancer plan. We were able to at least, get his ear because he was one of our earliest collaborators, probably our biggest critic, but once convinced [he was] our staunchest ally.
I appreciate my friendship and my collegial relationship with him to date, but he had written in, to this national cancer plan, allowed us and my partners in Mexico, to help write a component of the plan that started to integrate the concept of genetic risk assessment and the need for scale-up. To be able to take the lessons that we're learning from the BCRF project, expand them, and now apply them to other parts of the country beyond the major population centers.
I think we're already seeing the path we need to take. It's also sobering, I'll tell you. We went there in January, had a physician round table and all the same things were still there. What's even worse was at the time, because of political changes, and we know that well in the US as well, that things change. Support for different programs change. They were in the process dismantling their safety net program called Seguro Popular which threatens our program so we actually talked about starting a social movement.
I've got to tell you it's so inspiring to see them standing staunchly to support their patients and those families and realizing that they've got tools that can make a difference and finding a way. Just finding a way. As they say, nature will find a way. Humankind will find a way. If you are respectful and understand that.
Chris Riback: If humankind will find a way, and you may have just answered the question that was going through my mind, which is, listening to you, it is beyond obvious that you are inspired. It's beyond obvious that you are enthusiastic. Are you optimistic?
Dr. Jeffrey Weitzel: I am passionate and I believe, yes, you can't do this kind of work without being an optimist. If I had been a fatalist we never would have started. We would have said there's too many barriers. In fact, we did some focus groups and things and things. There was a fairly, concern about, there's so many elements working against the integration of this care but we put a wedge in there.
You put the wedge in, which is knowledge, the teaching, the training, and then you let them be inspired and find a way. Again, we just started building tool and putting them together and hence the multi-modal intervention. The recognition that it's the registry because I have to do the testing in my lab now. Eventually that's not going to be the case, it'll be available commercially but cheaply and good quality. They'll already have in place the structures for the follow-up care. Again, it's not just getting the risk assessment done it's what do you do with them once you know they have risk. It's so inspiring to just follow my colleagues.
I give them the tools they're the ones who are really doing the hard work. It's easy enough for me, well it's not easy to write grants. We write grants, we sit back, it's not an ivory tower. I get out into the field. I do travel. We do site visits at these sites because we want to see what they're up against. We want to see what they've done. We come in, not like an audit. It's a friendly audit. Here's what you've done. Boy, these other sites in Peru they got over this barrier by adopting this. So, we help them adopt those practices and share it among this group and we have a cohesive group of people who recognize common goal. They're in multiple different countries and we're innovating together.
We publish together. We innovate together. I try to never stop learning and listening. I tend to talk too much. I get that all the time. But I do listen. My absolutely spectacular colleagues in Mexico, Dr. Yanin Chavarri Guerra in Mexico City Dr. Cynthia Villarreal Garza in Monterrey, they're some of my longest-standing colleagues and partners and I think they are brilliant. They are the future of oncology and prevention in Mexico––absolutely so. Julio Abogadas who's in Peru at the National Cancer Institute in Peru, a breast surgeon. Again, the future of prevention there along with Pamela Amorra.
That's where I get my inspiration and I think it helps me understand our impact well beyond the walls of the City of Hope. I mentioned also, here's something interesting. We're trying to help them through strategic allocation of limited resources. So at the end of the day if you're just a healthcare policy wonk, we have a limited amount of money and so many needs, how do you do this? I would tell you that there's a big drumbeat for can we get breast cancer screening for all women?
I don't want to offend anybody, but for many women they might be a 1 in 10 chance at most, maybe less, we're being able to stratify that more, but the BRCA carrier's an 8 out of 10. If I have only a certain amount of money to apply for screening and people are not getting regular screening, only 19 percent of women are getting breast cancer screening in Mexico despite the fact that it's technically a covered benefit. As a basic limitation there, if I could only screen one set of people. It's when Willy Sutton was asked, why do you rob banks in the 1940s.
Chris Riback: I know why. That's where the money is.
Dr. Jeffrey Weitzel: That's where the money is. Okay. The same applies here. If you apply the strategic allocation of limited resources. If you can cheaply identify those at highest risk you'll make the biggest impact with the least amount of money quickest there. I'm certain when I look at the uptick of the risk reduction removal of the tubes and ovaries, and the other side, mastectomies that are being done as prevention for some of these BRCA carriers with breast cancer, I'm confident that we've already prevented a bunch of ovarian cancers and probably quite a number of breast cancers.
This is prevention in the moment while we're still working on the implementation, and that's exciting. Think about this, is that they're teaching us how to get limited resources to work for a population, we can take that home and start to address disparities in the US and in low resource settings. It's reverse-engineering. It isn't that it's just a one-way street where we're just bringing stuff to them. We're learning from them and I hope to bring that to disparities in the US.
Chris Riback: I am certain that you are. I knew coming into this conversation that you are recognized as a world-class oncologist and geneticist what I didn't know and what I've learned is you've got a bunch of other titles, historian, anthropologist, sociologist and I would dare say a potential for a novelist because not only do you tell a great story but there's a remarkable story that you've uncovered. There's something multi-cultural and extraordinary there. Thank you. Thank you for the work that you do and thank you for taking the time to tell me about it.
Dr. Jeffrey Weitzel: Well, thank you for your interest. I'm so pleased that you would take an interest and willing to help to share this. I'm always in great debt to the Breast Cancer Research Foundation. I've been a long-standing scholar with them. I'm so grateful that they've had the patience and understand the mission. They're one of the few organizations in the world that's truly global. They have global impact. I just can't say enough positive about that and how important their funding is.
I think they are the largest public or private funders of breast cancer research in the world and I truly see a global understanding on their part. Everything from absolute basic biology to what I would call pragmatic translation. I'm probably from the middle of that curve on over to pragmatic translation. Really honored to be one of their scholars, so I can't say enough for my gratitude for their support.
Chris Riback: That's wonderful. Thank you.