 It's 9 AM. Good morning everybody. Thank you all for coming and spending a day with us today. We want this day to be productive and hopeful and helpful to all of you. We have a day lined up with a lot of speakers. Most of them are my colleagues here at Stanford. By the way, my name is Sandy Srinivas. I'm a GU medical oncologist. I've been here at Stanford for about 22 years now and I specialize in urology oncology. We see patients with kidney bladder and prostate cancer. I'm going to have my colleagues here at Stanford talk about various aspects of providing care for patients with kidney cancer. We've been doing this meeting now for almost 12 years and it's all done through the kidney cancer association. So we happen to just partner with them to be able to do this for patients in the Bay Area. It used to be up at San Francisco in Japantown and I think in the last three years we decided that Stanford might be an easier place for people to come to than drive to the city. So we host this every year and really the goal of this is to provide education, show you where we are with this disease and what's new and what's upcoming. But I think really the purpose is also for you to feel comfortable. There's really no question which is stupid. This is a day just for you to get your thoughts and your questions answered and really to share your stories with amongst yourself with us and it's really that's what this day is for. In the past people have felt a lot of comfort just coming into this meeting learning about what is available and what's new and upcoming in kidney cancer. So that's what we are going to do. I'm going to start off by just doing a little bit by way of introduction but that's just the beginning and we'll talk a lot more about each aspects of kidney cancer, the surgical aspects, the medical aspects and I'm going to talk a lot about genomics and personalized medicine. So I would just encourage each of you don't hold back, you know really this is about how we can help clarify questions, concerns, anxiety, fears. There's really nothing that's off the table for today. So let me start by just giving you a very brief introduction. So I'll first start off with a picture of the kidney. So people think that every tumor that arises in the kidney is kidney cancer but I'll just show you that when we talk about kidney cancer it's really those that arise in the cortex. So the outer circle is what kidney cancer really is and within kidney cancer there are various subtypes and we'll talk about that as well but there are a lot of other cancers that can happen like for instance in the center that's where urine is made and the type of cancer that you can get from that is called ureothelial cancer. So anything that starts in the center of the kidney that's where urin is made goes through the urinary tubes called the ureter and then into the bladder. So we see ureothelial cancers or bladder type of cancers happen in the center of the kidney. Then there are other cancers like lymphoma. So Schanford is a very big institution that's world renowned for lymphoma which can really happen in lymph nodes but because we are a referral center we see a lot of patients who have tumor in their kidney that ends up being a lymphoma. So the point of this slide is really to tell you that not all tumors that start in the kidney are necessarily kidney cancer so especially for people coming from the outside it's really important we look at the location of where the tumor started to give us some ideas to whether it's really a tumor that originated from the cortex or the outer lining of the kidney is what kidney cancer is and that's what we are going to be talking about the whole day today. Stop me at any time okay really I think that's the best way we are going to get comfortable going through these slides. So how big a problem is this? So kidney cancer is not a common cancer but common enough to make it to the top 10 cancers in both men and women. You can see compared to common cancers like prostate cancer and breast cancer which affects close to 250,000 people a year kidney cancer accounts for about 5% of the cancers in men and about 3% in women so it's around 27 to about 48,000 per year and certainly unfortunately there are patients who it still accounts for the top 10 death that can happen from this disease so clearly we have a lot of work cut out for us in terms of what we want to accomplish with this disease. For the most for the majority of patients kidney cancer is still diagnosed at an early stage so this slide shows you that 45% of patients were diagnosed are diagnosed with localized disease meaning that their cancer is contained in the kidney and will undergo a surgical removal. Another 25% we call as locally advanced I'll show you the staging of kidney cancer in a minute but that just means that the tumor has gone from the kidney and is invading either the blood vessels the kidney the renal vein or the inferior vena cava surrounding the kidney and that's about 25% of patients again for these two groups surgery is the first treatment that you would do and is still associated with a good cure rate 30% of patients at diagnosis unfortunately have disease that may have left the kidney and it really comes down to the anatomic location of where the kidney is so it's located in a place where if you don't have blood in your urine this is a disease that you're not going to pick up very frequently so if you have blood that's certainly something that you're not going to ignore so people seek medical attention but most of the time it's like a pregnant uterus you can have you can have a be pregnant and that not be shown for up to six months in people so kidney is located in a location in our body that really doesn't show for a long period of time so these 30% of patients where their first diagnosis is usually by either a spot in their lung they go to the emergency room for something totally different and they find a large mass in the kidney so a third of patients even today present with metastatic disease we can talk a little bit about screening that's being done in other cancers and why screening is really not offered in kidney cancer because it's not a you know you have to have from a from a health perspective from a health care for economic perspective it's not a large enough percent for us to use like mammography for breast cancer so there's really not a great tool that you have for screening and CT scans are associated with a certain level of radiation so there's a lot of concern about just offering screening for every patient which is a shame because clearly cancers that are detected early can be cured but I think we have to get to a point where there is a better tool to screen for kidney cancer so screening is really not standard today for for every patient to just look to see if we can pick up these tumors early in fact I don't know if Dr Chung will talk about it but there are a large number of patients who whose cancers are found incidentally so they come for abdominal pain maybe for a gallstone and as they get a CT scan in the emergency room a small tumor is detected in the kidney for those patients we actually just watch some of them because those tumors are very very slow growing and it takes many years before these tumors can really be detected I think we are going to talk a little bit about the genomics so there is an hereditary condition called VHL so if for patients who are diagnosed with kidney cancer less than age 40 so that's not a normal age for kidney cancer the average age is in the 60s so if you have if you're diagnosed at age 40 there is something that's predisposed to you to develop this cancer so the National Cancer Institute now recommends that patients who are diagnosed less than age 40 have a genetic test to see if there's something that's predisposing you to develop this so if that's the case then perhaps your children or the kids would have to be screened at an earlier age so there is the syndrome called one Hippolynda of syndrome where it's not just kidney cancer but there are other cancers that people are vulnerable to such as brain tumors so as we have a genetics clinic up here that we send patients to and they do a screening and they also come up with a recommendation about what would be good for us to screen for you know are you at risk for getting colon tumors other tumors but I think that's where we are headed in terms of as we acquire more knowledge yeah slides the presentation well you know this is this is being recorded so it will be in the kidney cancer association website I'll ask them if they will have a copy of our presentation available to all of you who are here today yes yeah people have we haven't gotten that far but we know a little bit about the growth pattern so people know how long it takes for the kidney tumor to grow each year and it's relatively slow growing but unfortunately you know as you learn today kidney cancer is so heterogeneous meaning that there are so many different patterns that what we think I mean and we are unable to lump them all together in one bucket so there are patients where the tumor growth is extremely slow and on the other hand there are some very rapidly growing tumors and they are all not the same so we are lumping them all today as kidney cancer but I think as our knowledge increases we are going to be putting them into different pies that we'll probably learn a little bit different so to you to answer your question I think we know a little bit about the growth pattern and that's why patients tumors which are extremely small are actually just watched because we know that tumors that are less than three centimeters their risk of leaving the kidney and causing metastasis is very low so it's not uncommon today that if you were to have multiple medical problems and you have a small tumor that's detected we would just watch you with a scan every six months because we know that the growth pattern is really slow growing that it's very safe for us to watch you and that tumor is may not cause a problem in your lifetime if you have other medical problems that are more pressing okay so here is the staging guidelines you know so all patients need to know this when you have a diagnosis of kidney or any cancer the first thing we do is what's the extent of the cancer so the American Cancer Society there is a big staging system called AJCC this is a common language that all cancer doctors across the country and across the world speak the same language so that we know what the staging system is and that's what we do for kidney cancer so it's stage one is if it's confined to the kidney and it takes into account something called TNM and what it really stands for is the T stands for the tumor and that's really what's what's the size within the kidney and then the N stands for lymph nodes so nodal metastasis is what N stands for and M is for metastasis so you'll always have to know what is the TNM stage and then after you get that they sort of lump you into stage one two three and four so stage one are small tumors that are less than seven centimeters and in fact today we break it down even more into T1A and T1B where tumors that are less than four centimeters are considered T1A and four to seven would be T1B. T2 tumors or stage two is when you have a tumor that's between seven and 10 centimeters is T2A and T2B is those that are greater than 10 centimeters but you still have no evidence of spread to the vena cava or to the lymph nodes or there's no widespread meds and those are considered stage two. Stage three you're now beginning to see involvement of the blood vessel so if there is in you see the tumor that's big and it's gone into the renal vein or into the vena cava which is a big blood vessel channel that brings blood from the lower part of your body to your heart that would be considered stage three and stage four is if there is any spread to lymph nodes outside the kidney area if they're spread to lung, liver, bone and brain are all lumped as stage four disease. So knowing where you are in this is extremely important and I would certainly urge you to check for your individual one so once we have kidney cancer we want to then know what is the histologic subtype so as we are beginning to understand I would say even in 2017 I think we are pretty crude about our knowledge and what we know compared to cancers like lung cancer where they know they can separate a patient with lung cancer into so many different molecular subtypes I think in kidney cancer we are still working our way towards figuring that out but right now it's somewhat classified based on what the pathologist looks under the microscope so the most common cell type is the first one which is called clear cell kidney cancer that's what happens in almost 75 percent of patients have this subtype called clear cell kidney cancer the other cell type is called papillary so there's papillary type one and there's papillary type two and then there are less common subtypes like chromophobe and oncocytoma so it's helpful to know this because A you know the outcomes are very different today our treatments we treat them all the same especially with medical therapy we treat them the same today but I think that's changing probably in the next three years there'll be different treatments that we would do for papillary type one versus papillary type two versus clear cell and then the surgical treatment is also a little bit different where there would be more inclined perhaps to watch an oncocytoma compared to a surgical removal I would still say there's a lot of work left in figuring out exactly these subtypes but I think this is the beginning so just very briefly on background because I know you're going we are going to spend a whole talk dedicated to treatments medical treatment surgical treatment I'm just going to give you a little bit of background so that you know what to look for for the rest of the day so again majority our clear cell 75% our clear cell kidney cancer in the past you know maybe in the 10 years prior to today we had very little that we could offer patients with kidney cancer and there used to be a drug called interferon which we don't even use today that's what we had for patients with kidney cancer and I think the last 10 years there's been a remarkable improvement with almost 10 to 11 drugs that we have today that we can treat patients with kidney cancer and each of these have been associated with longevity but I think the search continues because till we really end up curing kidney cancer I think we can stop but there's definitely been a lot of improvement and we are grateful both as providers and for our patients for the ability that we have to cause prolongation of life today I think you know we use these targeted drugs but clearly the next step in the advancement in this field has really been the emergence of immunotherapy you're going to hear a lot about that today and it's really what these drugs help allow your own body to fight the cancer there's been great progress made in diseases like leukemias where they are able to take your immune cells out of your body completely re-engineer it and send it back into your body to fight these cancer cells and leukemias which were completely fatal even up to two years ago now the cure rate is close to 80%. So I think it's remarkable and I think that's where the hope is that there will be similar things because all of us have an immune system there's really no reason why that immune system can be put to work for each of us so really the hope rests on immunotherapy while we are very grateful for the drugs that we have today which have resulted in prolongation of life I think the hope is to have something that will allow for a cure and I think immunotherapy holds a lot of promise and we learn from other hematologic cancers are much less complex compared to solid tumors because there it's really one abnormality that they have here we need to get down to the understanding of the disease where it's not just one pathway there are so many things that result in causing the cancer so really re-engineering that is somewhat of a challenge but the good news is that there's work being done so here is the progress that's been made in RCC so starting in 1992 was when we had a first drug called intraleukin 2 or I listed there as high dose IL2 it's really an immunotherapy it's a drug that's challenging to give patients end up being in the intensive care unit they are really sick and we have a 5% chance of a cure when we give this drug and it's really a drug that's not applicable to a lot of people because as I said in the beginning this is a disease that happened in the 60s and 70s and giving patients these sort of drugs you need normal kidney function you need normal heart function you need normal liver function all of your systems have to be pristine for us to be able to give you this drug so it's really not applicable to a lot of patients and then starting 2005 the understanding of the biology of kidney cancer has just led to a whole host of new drugs that you can see starting in 2005 we had Surafnib 2006 a drug called Sunitnib got approved 2007 we had a new class of drugs called mTOR inhibitors Temserolimus is an intravenous um mTOR inhibitor in 2008 we had a drug called Bevacissimab which was approved 2009 there was another oral mTOR inhibitor called Everolimus 2010 we had a drug called Pozopinib that was approved 2012 Axitinib which is another oral tyrosine kinase inhibitor and in 2015 we had the first immunotherapy drug called Nivolumab approved 2016 was another year where we had two additional drugs one called Cabozantinib and another drug called Lenvatinib so this is amazing progress to have in 10 years really to have 10 different drugs and I think this list will continue you know the next wave of trials is really looking at combination of drugs and you're going to hear more about those as the day goes by so this is how kidney cancer looks like in 2017 the drug therapy we have immunotherapy with intraleukin-2 interferon and old drug which we don't use anymore and Nivolumab is our choice for immunotherapy that we have today there are these whole class of VEGF inhibitors Sunitnib, Sauraphinib, Pozopinib, Axitinib, Bevacissimab, Cabozantinib and Lenvatinib plus Everolimus and then this class of drugs called mTOR inhibitors so it's really this is a complex slide we will probably go into a little bit more detail in one of our talks but you can see that this is how kidney cancer understanding the biology of kidney cancer has just led to this explosion of many drugs and we hope that list continues so we have a lot of things that we want to know but our goal for you today is to share some of these questions so what's the appropriate surgical management is there a role of kidney removal in patients whose disease had spread elsewhere and we're going to have Dr. Chung talk to you today about that what happens everybody is curious you know we have two kidneys but everybody most people are going to have that kidney removed what happens to kidney function after you lose one kidney and how important is that going to be Dr. Leppert is one of our urologic surgeons he's going to talk a little bit about that one of my junior colleagues up here Dr. Sumit Shah he's going to talk a little bit about immunotherapy and what that promise holds and what is what are we doing at Stanford that you may have access to and then I have one of my star fellows Brian Dietrich he's going to talk about how do we pick between these 10 drugs what is appropriate for us to give you for first line what do we do when one treatment fails how do we pick the next line of therapy and then Alice Phan who many of you may know is a colleague of mine in medical oncology her lab and her research is going to be how can we tell when these drugs are working she's going to share some of her work and help us understand those questions a lot of it is about genomics you know it's all the new era is about personalized medicine so to help us understand this language Alex Elysian who's one of our senior fellows he's going to talk a little bit about genomics and how that pertains to kidney cancer I'll come back and briefly talk about patients who have their kidney removed is there any role of preventive therapy so we do this in breast cancer we do this in colon cancer what's new in kidney cancer how can we not even deal with this disease and is there any role of giving treatment in a preventive fashion and finally I have our social worker Jordan talk to us a little bit for a patient forum this is your day today so we want you to be engaged and Jordan is going to help us have a conversation with all of us so I think I'll stop there there'll be a lot of room for questions during the day but I just wanted to give you a flavor of what's coming so if you're good I think I spent 30 minutes so I'm going to have Dr Chung so Ben Chung is a urologic surgeon so he's one of our surgeons he's the director of the laparoscopic kidney program here at Stanford the robotic program Dr Chung is an associate professor of urology he's been here at Stanford been for 10 years 11 and counting so it's our pleasure to have Dr Chung here today we thank him for spending his morning with us on a Saturday and I would urge all of you to ask any question of surgical that you have feel free again you know don't hesitate the day would be a success if each of you are engaged and have questions that you can have clarified