Dr. Verstovsek:

And you know yourself that things change over time, so patients we know very well can change from ET and PV to myelofibrosis but not just because fibrosis is going higher on the scale.  There are other factors that we mentioned, the spleen, the anemia, the symptoms that have to be present for one to say that there is a transformation. 

There are cases of ET patients, the high platelets that acquire higher red blood cells, ET going to PV.  Not that the patient has two diseases at the same time but that the biology of the disease after 10 or 15 years has changed, and now the patient requires phlebotomy, bloodletting, to decrease their red cell blood count.  So it's not that simple.  There are multiple factors.  Fibrosis is paramount to look at, but it's not the critical one.  

Dr. Bueso?Ramos:

Exactly.  So the reason why you have all these collections of samples that we've talked about at the beginning is because multiple tools can say now the molecular JAK2 amount has increased, and that may be switching the biology of the disease to a p. vera kind of clinical presentation that he can actually monitor by the change in the molecular markers too, in addition to the assessment of the bone marrow. 

Andrew Schorr:

So a lot of patients have been writing in who are pretty knowledgeable.  They say, well, is there an international standard?  So you have that.  Is it always achievable like by people getting the right samples?  Not always, and maybe a significant percent of the time unfortunately not.  You need a team working together to look at the whole picture, the genetics, what you have on the samples, etc., right?  And then you need sort of the wisdom of specialists to make sense of it, right? 

Dr. Verstovsek:

That's right. 

Dr. Bueso?Ramos:

Pretty much you summarized. 

Andrew Schorr:

Yeah. 

Dr. Bueso?Ramos:

Now, there is a detail, there is an effort from the pathology clinical community to strictly and specifically detail exactly how the bone marrow should be reported and what specific components—a checklist, if you wish, right?  When you're leaving to the airport, you have a checklist.  Do I have my this, do I have my passport, right?  Well, you need a specific checklist for this disease, for this group of diseases, and it has to be strictly followed and completed.  That way you can actually have a reproducible data set, and there are many efforts ongoing to try to do that.  

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