Derek Maetzold: CEO of Castle Biosciences

Derek Maetzold, CEO of Castle Biosciences shares his thoughts with BioBoss host John Simboli about leadership in biopharma and how Castle is leveraging its expertise in cancer genomics and the use of artificial intelligence to improve patient outcomes.

Transcript

John Simboli  

Today I'm speaking with Derek Maetzold, founder, president, and CEO of Castle Biosciences, headquartered in Friendswood, Texas. Welcome to BioBoss, Derek.

Derek Maetzold  

Thank you, John. I appreciate the opportunity to talk about the Castle story as we see fit here,

John Simboli  

What led you to your role as founder and CEO? How did you get here?

Derek Maetzold  

I spent most of my career, all of my career prior to Castle, within the pharmaceutical biotechnology industry working for four companies over 24 years; two what I would call biotechnology companies, and two large pharmaceutical companies. They've all gotten acquired, by the way, since I left them, not because of me. And the last one moved me from New Jersey down to Houston in the early 2003 time period. And that was to really set up and run commercialization for a small biotechnology company that was developing a therapeutic to help treat patients afflicted with pulmonary arterial hypertension. And over the course of a couple of years I was with them, we were able to garner European approval, Canadian approval, Australian approval, but we never quite got over the FDA hump. And so we de risked that company; ended up of being a purchase in 2008, I guess, by Pfizer. And at that point, in time, I had an opportunity to sit back maybe and just do a recheck on what I wanted to spend the next part of my life doing from an avocation perspective. And what I think is interesting to me, personally, is, I think there are many avocations, one can choose to build a career around, I hope that those of us who work in healthcare kind of migrate towards the healthcare marketplace or industry because they care about wanting to move patients from point A to point B, just improving care, improving outcomes. And that could be a nurse, that could be a physician, that could be somebody working in the pharmaceutical or diagnostic industry. And I firmly believe that if we have a core of that, then we'll, hopefully, focus on doing what will advance care for patients. And if we do that, I have a belief that if you run the other parts of your business properly, you can build a successful business, not the other way around. So that was a sort of core belief, I still hold, and even when we look at hiring people into Castle today, we try and look for people who have that sort of inner drive of not wanting to be successful. But wanting to actually help move treatment forward, and be successful because of that outcome. That's a great place to be at. 

Derek Maetzold  

So in the 2007-2008 time period, when we were looking at selling, that last company I was with, I had a chance to go and sit back and say, Well, what do we want to do with the rest of our life, my wife and I? Do we want to pick up and move back to either coast, which is more of the hotbed than Houston is regarding working within the pharmaceutical or biotechnology world? Or do we really like the home we now call Texas and want to build something around here? And if you know anything about the Houston biotechnology marketplace, there aren't a whole lot of commercialized companies. And in any space, yes, there's a lot of healthcare industry in the Texas Medical Center and kind of ancillary around that, but not really, in terms of private industry. And one of the things that has always attracted me is sort of the harnessing of the Human Genome Project. When that kind of got wrapped up in the late 1990s, early 2000s and you were seeing, in certain disease states, wonderful advances, what we kind of call, colloquially, you know, personalized medicine or precision medicine. And the classic example, which we kind of modeled Castle after was a company called Genomic Health who had developed an assay or a test, a molecular test, which measured the RNA or the gene expression in breast cancer tissue, and was able to demonstrate that you could safely let women who were diagnosed with a certain kind of breast cancer consider not undergoing five or 10 years of follow-up chemotherapy because their risk of recurrence was so low that the toxicities of that chemotherapy actually outweigh the risk of recurrence. G great advance and great use of this sort of Human Genome Project unfolding to move care forward. And that's attractive to me. I mean, one, is that you're really doing exactly why we're in this industry, I think, and we looked around a Castle at our situation. So you know, I don't think it's likely that I could raise capital, develop a company that would do what, be the fifth or sixth company to develop a breast cancer test? That sounds like, one, I can't believe that we're that smart to develop a better test and therefore not really adding great value. And number two, is where can we make a difference? And what we found was that, unfortunately, and this is true of many parts of medicine, I think, if you're diagnosed with a rare disease or in this case, a rare cancer, the patient certainly cares about what's going on with them, their family cares, I would think they're their primary caregiver or their medical oncologist cares. But there's not a whole lot of industrial caring going on, because you can't make a business around that. If you built a business for breast cancer, you can't step back and support a business for a cancer of two, three, four thousand patients a year. You know, 300,000 versus 2000. The infrastructure is just different. And what we developed was an early business plan saying, Well, if we actually start Castle Biosciences, focused on people diagnosed with these rare or less frequent cancers. But we knowingly start that, can we build a business that is built around small cancers as opposed to large cancers and fit things back in? 

Derek Maetzold  

So he started out in that direction. And again, paralleling saying how do we actually get a hold of assays or tests that work, that help change treatment decision making, in people diagnosed with low-frequency cancers? And our answer was, well, there are people who care in academic centers. NIH funds, a lot of research in these areas. There are interesting tests out there that have been published and if you happen to be living close to a certain academic center across the US, you might even gain access because proximity-wise, you're already seeking your care there. I take an example of our uveal melanoma test which we in-licensed from Washington University in St. Louis, I guess in late 2009. That was an assay for people with uveal melanoma, that we can get into as you'd like to during this interview process, where it was really developed, validated, a multicenter study was undertaken with NIH funding. The data turned out beautifully in terms of the decisions it was going to help drive from a patient care standpoint. But as the trial was winding down, because there's only 2000 patients a year in the U.S. diagnosed with uveal melanoma, there was really no appetite for even Washington University's clinical diagnostic lab to make the test available clinically. Well, why is that? Because they were thinking about serving the 100 or so patients that were diagnosed in St. Louis, not the 2000 across the U.S. And so we looked at that technology and said this is an example of a well-developed test, that could have a real impact on de-escalating care in patients diagnosed with this condition. If we make it available nationally, it still is a very rare cancer, but it serves a great patient mission. We believed if physicians began adopting our test, then we would be able to be paid successfully, and we could have a nice business that would serve a great unmet need that nobody else would go and pick up and run with. So that's an example of what we believed we should go after. And kind of chapter one of Castle was just that. So we believed that we could kind of identify a dozen, or so, good tests that were developed in the academic centers across the U.S., in-licensing those, complete the rest of the validation work, make them available, we could serve a fantastic patient need. And we knew that two or three of them wouldn't turn out to have nearly the clinical impact that we thought. That's OK, we have nine left. But we figured we'd kind of get there over time. So that was chapter one of the company, was to really say, let's kind of scale the company small, stay small and really serve this unmet population of patients diagnosed with rare cancers Who we felt we could easily serve with a small group in the company and be successful. 

Derek Maetzold  

Now along the way, of course, things change, right? So around late 2010, we asked the question of saying you know this issue in uveal melanoma, which is melanoma of the uveal tissues of the eye, some people call it ocular melanoma, in some cases colloquially. That's a condition when people are diagnosed by a retina physician, typically speaking, they have no indication that the melanoma has spread beyond the eye. It looks like it's contained to the eye, there's no evidence of metastasis based on imaging or any other symptoms. And the treatment for the eye is very effective, about 95-97% cure rate if you radiate the eye, or in some cases, enucleate, which is  toremove it. That sounds great, doesn't it? But the issue is at about three years later, about half the patients who had no evidence of metastatic disease outside the eye actually metastasize. And a 50% chance of metastasis is high-risk cancer, no matter what you want to call that. And so the result of that, correctly so, was that if you can't get much better than a 50% risk of metastasis, then we assume every patient is high risk and you kind of push them down to what, medical oncology. You choose to image them, you know, three to four times a year to pick up metastases early, you might do surgical procedures, you might get them in clinical trials, all because they could be the 50% that is going to metastasize. But the other 50% are being really overtreated. They're going to, you know, succumb to a stroke or something else over time, but they don't know who they are. And so what this test at Washington University did was it was able to take that out of 100 people, we use a simple system called class, easy to think about, and we have a class one on the class two, which is the binary outcomes and we have a kind of a 1A, a 1B and a two in uveal melanoma. And if you have a class 1A test result, which is a result from the tumor tissue of your eye cancer, that's a low-risk result. What's that mean? Well in multiple studies that means about 96, 97, 98% of the time, you'll be recurrence-free at five years. No spread. So no test is perfect. But it's a 2 or 3% chance that we're wrong. Does that patient want to go forward and be seen by medical oncologists four times a year? Does that patient want to go into clinical trials? Maybe they do, but they have a choice now. But the vast majority of those patients take a breath and say OK, nothing's perfect, we're going to be vigilant, but we can go back to living our life, which is much different than the people who have a class 2 result, where they have roughly an 85% chance of metastasizing. And that stratification is what all cancers actually are treated against. You know, most cancers treatment plans are based upon the progression of disease. If you have a low progression, you do less things or nothing. If you have a high progression you interven. And so we are able to take kind of a 50-50 coin toss and have strong separation. 

Derek Maetzold  

In 2010, after we made available our uveal melanoma test, we thought, you know, there is another thing called melanoma, which is the skin or cutaneous melanoma. And I wonder if the same question exists there. And it was interesting because if you look at cutaneous melanoma, that's a much larger disease state, we think about 130,000 patients a year diagnosed, and it has had a well-developed staging system. So in cancer what that means is you typically take clinical factors, sometimes age but most of the time what you see on the cancer itself, and pathology factors seen under the microscope. So how thick is it? Does it have other features? And you group people based upon those outcomes. In stage 4 disease, in all cancers that means it's metastasized distantly. So if I have a melanoma on my forearm, a distant metastasis would be melanoma in my lung, it's spread to my lung or my brain. Stage 1 disease, on the other end of that equation, is a very small melanoma that's limited to where it is on the skin. Stage 2 is a little bit thicker, but still on the skin, and stage 3 means it's gone to your lymph node system. So in melanoma, we said, well, that's interesting. It looks like they got a better staging system in cutaneous than uveal. Maybe there's no question to be asked. But we sort of turned the graph sideways and said, well, gee, that's true on a population basis. But what's curious is that over two-thirds of the patients who go on to die from melanoma, before there were effective therapies, are those people who, you thought, had a low risk of progression; two-thirds. Now it's not because as a group, they have a higher risk of progression. I mean, staging does group by progression, but it's because there's so many people in the low-risk category, we sort of forget about the fact that as a group, they're low risk, but as a population that metastasizes of the majority of patients, and we felt very strongly that if we could take the same gene expression profile approach, you know, understanding what that tumor is telling us about aggressive biology, that we can hopefully find a signature in the cutaneous melanoma world, like we had in the uveal melanoma world, that will then help bifurcate care so that people were again moving from population-based medicine down to personalized and more precise medicine. And that's what is the early chapter of Castle

John Simboli  

When you first envisioned the startup part of this, that you described for me just now, did it make any sense—did you consider at all taking it—because you have connections and experience in the larger pharmaceutical world? Had you thought at all about taking it to a large company and saying OK, there's an infrastructure in place to help me to build this thing? Or was that just not realistic, made no sense?

Derek Maetzold  

Not realistic for where we thought we were going to. I think one of the opportunities, even in melanoma, which is interesting, you know, 130,000 afflicted patients per year sounds like a big marketplace, but if you have a company that thinks big, as breast cancer, prostate cancer, lung cancer, melanoma is small. And so that part of it is a little unrealistic that you've got a company, now let's take Genomic Health as an example, the breast cancer company. If we were to knock on their doors and say, hey, we've got five tests here that cover 25,000 patients overall, I think one, they would say that's very nice, we'll talk you when you have about 300,000 patients covered. So the numbers don't quite work out from that standpoint. Now, a different question, a different answer to a question that you didn't quite get to, was early on, some of the decisions with our investors and ourselves was to say, cancer is treated based upon the risk of recurrence or progression. But you have treatments for cancer. And you had, at that point in time, and, you know, or 2000s, in early 2010 decade, a lot of these targeted therapies coming out, you know, if you have a mutation in gene A, my drug, my drug works against that mutation, or in that patient population. Why don't you think about partnering with a pharmaceutical company, for example, where you would develop what we call companion diagnostic tests. So you know, you have a condition, and you can use one of the tests from Castle to select which drug to use. And we looked at that for a while. And actually one of the assays that we in-licensed and made available commercially, not only could stratify low risk and high risk of recurrence. But at least it had been seen to suggest that it could also help you identify who should go on longer-term therapy with a drug called Temodar for primary brain tumors, and who, maybe, shouldn't, i.e. they wouldn't respond because their outcome was just recalcitrant. And that sounded interesting to us. And this test happened to be already inserted into two phase 3 studies. One of them was looking at kind of standard dose of Temodar and triple dose and the other one was looking at first line of therapy and the same disease. And we said, Wow, this sounds like a winner. We can go in there with a test that's been validated well, assuming the results of this test work out well. We could help direct therapies. That sounds great, intellectually. What we also saw, though, was to say, Well, what if that doesn't quite turn out to be a rosy picture? What if the trials fail? What if our test doesn't help to differentiate responders? It turned out that both those trials failed. Now for the detriment of patient care, that means that those therapies didn't help people overall. To the detriment of Castle, it meant man, if we hadn't had a couple of other tests available, that could have been the end of our employee base. And when we saw that first negative trial, one of the active choices we made was to not ever put the company's employees and the company in a position we're going to be relying on somebody else's success to actually build an important business. And so we sort of backed off of thinking that was a great business plan and rather said, let's focus on medical conditions that have unmet clinical needs, where people are being undertreated significantly, or overtreated. Which you could chargingly called mistreated. But that sounds very charge-y, by the way. And let's focus on improving that care. And if later, it turns out that we can actually help within a high-risk group, help select therapy A or therapy B, that's icing. But the cake is to really impact patient decision making first,

John Simboli  

This must have been quite a transition from working at a pre-existing structure to creating a structure from scratch. What is that experience like compared to what you thought it might be like?

Derek Maetzold  

Yes, that's interesting, I think my entire adult life, maybe my childhood, I've always been more attracted towards building things, figuring answers out to questions as opposed to maintaining, and that doesn't mean that people who are great at maintaining, administering are any less valuable than I am. It's just a different driver. And part of that, in my 24 years in the pharmaceutical industry, if I look at what did I migrate towards position-wise, company-wise, was really, where's the opportunity to really create and build something? Is it a therapeutic, which is sitting in phase 2, in phase 3, so you have a chance to really help craft how that product is talked about, how the message is communicated, how the publications are written, to really maximize good outcomes or patient care? that excites me. When it came to Castle. I think a couple of things that were successful in how we approached the business was to say, myself and my two early employees, Toby Juvenal, who is here in Houston, and Kristen Oelschlager, was out in Phoenix with a laboratory, none of us had any experience in diagnostics. Plenty of experience in healthcare, but zero in diagnostics. And so what does it mean to us? Well, it meant to say I"m not sure how much capital we could raise. We certainly had a bit of a runway, but we also knew the runway could run out. And what we decided to do was to kind of build a business plan that we thought would focus on being successful, on the one hand, assuming our assumptions were correct, but on the other hand, it would also de-risk the chance of catastrophic failure. So what does that mean, for example? Given we hadn't worked in diagnostics or worked in laboratory settings, we had a choice, do we want to take some of our limited capital? And do what? Find a location, buy instruments, find technologists to work the instruments, find a medical director to oversee the laboratory, and then hope we actually generate orders and samples to be processed, reports to be issued? Or do we say maybe we should actually, within the legal framework, find a laboratory that we could contract with on basically a piecework basis? So maybe we might drop the instruments there. But given that we don't even know how to spell the word CLIA of CLIA laboratory, why learn that? Let's find people that we can trust who do that for a living. And if we can arrange at a variable cost structure, then, one, if we under exceed our forecast tremendously, we don't have a whole lot of cost in the laboratory. If we over exceed it, let's make sure they can staff up and meet our needs. And so we approached areas of the business that we were uncomfortable with our expertise on, to say, How do I not, you know, we're going to stumble, number one, everybody does, we're going to hopefully learn from our lessons and have some bruised knees. But let's not fall on the knife. And that's it, you never get up. And so we took that approach with our laboratory early on. We took that approach with medical billing, you know, we had all been aware of the pharmaceutical distribution and reimbursement category, but nothing about procedures and test services. And so we thought, man, that sounds like a black box of just too much time spent in the areas we don't understand. So we went out and identified, at that point in time there were only two or three players nationally who were serving startup labs like us, and they would basically do a whole outsource billing department. And so we said, that sounds pretty good. What happens if we don't have anything for you to bill? You don't pay us, we only get paid on what we bill and get paid for. Again, another way to kind of reduce our fixed costs down. So if our business plan was off, it wasn't going to kind of crush the company. And so we did that with a few areas like that. And we thought, Well, what do we know about ourselves? Or what do we think we know? Well, we think we know how to communicate to clinicians about the value of what, products and products could be a therapy or could be a test. And so we focused our efforts on really identifying what we felt were high unmet clinical needs, seeing if a test helps solve that for a doctor, and then communicating, educating our customers about the value of the test. And then once we got that order in, then we let the sort of experts that wasn't us develop that. So that's how we kind of started out early on, managing risk to make sure we didn't necessarily hit a road bump that we couldn't survive from.

John Simboli  

Can you remember being whatever age it was for you, eight, nine, ten, something like that, when you were trying to figure out what it was probably your parents expected you to be or wanted you to be, begin to have a picture of it? For some people, it was identifying with a character on TV on something they saw in a book. Did you have anything like that? Did it have anything to do with how your life turned out or what you're doing now?

Derek Maetzold  

It's interesting, the honest intellectual answer is that I probably was migrating even at a young age towards something in healthcare. Now, I would have thought back then it was the doctor because that's all I would think about back then at that age, not the industry at all, but being a direct healthcare provider. However, nobody in my family on either side of my parents has ever been a nurse, physician, direct health care provider or in the industry. On the flip side of that, though, my probably most influential relative was my maternal grandfather and grandmother. And they were entrepreneurs through and through. And so when I was shipped from Virginia to the Dakotas every summer, from the age of six or seven through about 15, I thought why am I being cursed like this as a young child, and I turn around saying this because they wanted me to develop their values. But kind of watching that entrepreneurial attitude and just you know, you can't rely on somebody else to do it for you. You can work with other people to do it better. But you've got to take responsibility, accountability and just pick up and do it. And you're going to fail a lot when you're going to succeed a lot and sometimes you succeed better working with people and sometimes it's a one-person job. But I think kind of those two expectations was sort of thinking about healthcare, I think, or being a physician early on, I think is a truism and then kind of combine that with I think was fantastic formative education by my maternal grandparents. This resulted in, I think, the way I am today.

John Simboli  

It sounds like you kind of ended up near where you started 

Derek Maetzold  

Pretty close. Yeah, yeah, it was interesting. I went through undergraduate education, kind of in biology, but really spent all my interesting time in physiology. And figured I'd go to get an MD and a Ph.D. and a master's degree or whatever that looked like. And then I realized probably while I like that thinking I like that creativeness. I really don't like to see sick people. So can I stay one stage behind that as a direct person and have an influence? And that led me down this course here. Now, what's interesting, when we look to hire people who are clinicians in the company or even interact with some of our advisors, one of the conversations we might have after a beer or a glass of wine is sort of, you know, how do you view your impact on human care? So I'm talking to one of our surgical customers, I mean, their impact, largely speaking, is just on the patients they see in their career. 2, 3, 4, 5000 humans they are interacting with. If we're successful at Castle, we affect hundreds of 1000s of people. Nothing is better than the other one, it's just a different kind of impact that one can have in the marketplace. And so when we interview people who want to come work with us who are in the healthcare industry, somewhere, nurses for our clinical research group, or physicians for our medical group, one of the things that we kind of, not poke them negatively, poke them honestly say, you know, think about that opportunity here. I mean, right, now you're sort of an N of 1, you impact that patient in front of you. And that has to happen, we need you. But if you want to come to this side of the fence, the impact you can have is you can impact hundreds of 1000s of people one time. And that's a responsibility to do it right and do it well and do it honestly, and ethically and, and that's exciting. And if you can kind of be okay, stepping away from the patient care that's giving you warm and fuzzies, to saying Well, I'm just developing a test or I'm just overseeing publications. But those will be used to impact many, many more patients. And if you can kind of transfer that necessary, warm and fuzzy that you get out of a patient interaction, to this part of it, you'll be successful and transitioning over.

John Simboli  

When people ask and you probably answer this question five times a day, who is Castle Biosciences, what's your, your concise description?

Derek Maetzold  

So if they're in the industry, or know healthcare, what we do at Castle Biosciences is to develop tests for high unmet clinical needs that will change or improve a physician's decision-making in front of their patient. Today, what that means is that we're focusing on really transforming the management of people with dermatological skin cancers, cutaneous melanoma and squamous cell carcinoma. patients who've had a biopsy taken where you don't know if it's melanoma or not, that's our core product profile today. And the information that we deliver through our laboratory reports has a direct impact and how a physician directs care. That's kind of who we are in a nutshell today.

John Simboli  

In what ways is your R&D effort an expression of the vision you have for the company? 

Derek Maetzold  

It's a good question. So we're still quite young. We're still quite small. What we talk about publicly since last year, as I say, we have these three commercially available tests in the skin cancer space, primarily used for people diagnosed with early-stage skin cancer. So what does that mean? It doesn't mean oncology, it means dermatology. And so as a company, we have kind of one commercial structure, one educational structure, which 80% or so of the effort is focused on helping to make dermatologists and their nurse practitioners and physician assistants more aware of what our test could do to improve their patient care decision-making process. Because of that, sort of strength and reputation, and also our expertise in our R&D group and working with skin cancer specialists, we have a series of pipeline programs that we initiated kind of earlier this year, and are still rolling out protocols now that focus predominantly on that same sort of customer call point. Now, why is that? It's not just because we know those people today is because we found significant disease states that have significant unmet clinical needs that we think we can solve through a molecular test that we would develop and if we're successful, then we can do what, leverage our reputation, drop it right in the same educational programs, the same sales bag, etc. We have announced one of those targets which is worthwhile talking about for a second here. And that is a pipeline program that's quite large, that might end up being about a 5000 patients study, which is aimed at what I would call inflammatory diseases of the skin. So what does that mean in practicality? There is a sort of range of inflammatory diseases or eczema-like syndromes, from psoriasis on the one end to atopic dermatitis on the other end. And many patients get adequate relief from topical agents, lotions and potions, to use kind of an internal word. But a number of people progress from kind of mild disease to moderate or severe disease. And typically speaking, to a dermatologist, that means they go from having an insufficient response to topical agents to wanting a systemic therapy. Now, most therapies are biological agents that are injectables, there are a couple of biological agents that are orals and there are more orals coming out downstream. And those therapies, if you look at sort of the more pristine phase 3 studies used for FDA approval, you see efficacy, sometimes of 80%, 90% relief from symptoms. That's that sounds fantastic, right? What a great relief to somebody who has moderate to severe psoriasis, and has an 80% response rate. And that just sounds like a gift. And if that was true, that'd be great. But what we see in the marketplace, is that on average, I think it's 70 or 80% of people go through three biologics before they get to the fourth one that actually works enough where they're comfortable with that. Now, if they work 80% of the time, why do 80% of the people switch four times? There's something going on there. And it's not cost. It's not side effects. It's just not the right drug for that patient at that time. And so we looked at this and said, Is there any data in the marketplace that, in the public domain, you know, published studies here now that would suggest that a non-invasive tool, or maybe you'd go ahead and take a scraping of that psoriatic plaque or that eczema-like atopic dermatitis, and look at the RNA of that inflammatory condition. Would that, you know, perhaps tease out or lead you down to a drug response? And it looks like there's enough data in the literature to say, the concept's there. We initiated work earlier this year to say, Well, does the concept work in our hands? And yes, we can go ahead and use our approach to kind of get skin scrapings off these patients. And we can at least see viable measurements of genes being expressed, sometimes over, sometimes under, so we think we have a technical approach here that will make a difference. We're launching a large study where we're going to essentially develop a test which we believe will help predict which patient will respond to which therapy regardless of a psoriatic or atopic dermatitis indication for the patient. There's a whole inflammatory spectrum. Now, why is it since some of those drugs may end up getting closer and closer, blurring the line of diagnoses? We think we'll be technically successful at the end of the day. We don't know how good of a test we're going to have, for example, I think combined, there may be 15 systemic therapies between psoriasis, atopic dermatitis, today, there'll be a few more coming out here in the next couple of years, based upon FDA approval turn time. And I don't know if we're going to find a series of signatures in one test that can say, I can tell a patient who's going to respond 80% of the time to drug 1, 2, 3, 4, 5—that'd be one outcome. That'd be wonderful, I think. Or we may find that we find groups of drugs. So maybe I respond to drugs, 1-4, highly likely but drugs 5-8,  20% chance. OK, I know what to avoid, don't have a guaranteed outcome. So I think that's exciting, to me, because at this point in time, from a patient care standpoint, when they've gone from this topical is not quite cutting it to I need some relief. And they make that leap to saying Do you want to inject yourself and you know, get over the fear of a needle and all those mindset changes, it'd be wonderful to have that patient respond to the first drug that they get, as opposed to having them try four drugs to get to the right one. That's great patient care. Now, from a healthcare standpoint, what's it also mean? Most of these therapies from a sort of cost standpoint are front-loaded. So the first quarter of a therapy is usually the most of it in the first year. And people are usually on a therapy for kind of 8-12 weeks. So almost the first quarter before they would say, you know what, we're not getting a response, let's switch. If we can go ahead and help jump forward, you know, not having month 12 be when you get your right drug, but month 1, that's a lot of healthcare extraction dollars. So to me, this is a wonderful opportunity to not only advance patient care by addressing a huge unmet clinical need but improving patient satisfaction and reducing healthcare costs. That's a great outcome. 

Derek Maetzold  

So we're excited about that program. No guarantee we have right now, but that's one of the pipeline programs we're doing. And on top of that, what does that mean? Within dermatology, most clinicians who diagnosed melanoma and squamous cell carcinoma of the skin are the same ones who treat psoriasis and atopic derm. So if we walk in there a couple of years from now, I think we're targeting, right now, the end of 2025 as probably the likely outcome. It could come earlier. It could come later. We can say hey, thank you for the business. Thank you for listening to us and incorporating our tests for skin cancer. I've got something exciting now for another dermatological condition. We talk about that. My sense is that we'll be welcomed fairly easily. If we continue to do the right thing for our physicians, which is to speak honestly and not overreach on the data, then I think we can walk into a very rapid uptake from a test standpoint, which means we've served greatly because of the reputation we've built within this disease space of dermatology. So that's an example of where we think we're going to go. Now we might venture outside of dermatology over time, but at least for right now, our programs starting this year is to say, hey, let's leverage where we know the disease and the doctors. And then if we need to go beyond that later in the decade, so be it. 

John Simboli  

Derek, thanks for speaking with me today.

Derek Maetzold  

Thank you, John. It's been wonderful to interact with you and to have your audience here the Castle story