 So I'm going to bring this patient conference to an end by hopefully talking about both opportunities and challenges in what all of you care about and what I and others care about and that is, can we cure kidney cancer? So a bunch of us got together by invitation, there's a group in Washington called the Angiogenesis Foundation. This is a foundation that is a 501c3 corporation that was founded entirely on understanding and supporting research that targets blood vessels. And we got together, there were about a dozen of us from around the world and we went through an exercise that I thought was helpful, productive and enlightening and really to look at the critical pathways forward in the treatment of kidney cancer. And I know you have some of this in a handout, the handouts were not blown up large enough for you to see as you'll see in a moment, but you'll be able to get these online. So what are the key points? Well we've approved seven agents, most of them targeting angiogenesis or pathway associated with angiogenesis since December 2005, almost coming up on a decade that has produced a true paradigm shift over the last number of years. And I think you've seen that today, both those of you in the audience that have participated in these trials, participated in the successes and are also relying on these drugs to continue your lives. But there's really some very large challenges. One of the challenges in kidney cancer is the leadership. If you asked yourself who are the spokespersons for leading the effort in the fight against kidney cancer, there are no national leaders that have been given the gavel to really drive this conversation for all of us. So more independent leadership that critically advocates for better data and better drugs. Why is that? Because realistically the support is insufficient for kidney cancer research. And when you ask the question how many dollars, federal dollars, or philanthropic dollars are spent on an annual basis to support some of the diseases called cancer, lung cancer, breast cancer, colorectal cancer, prostate cancer, there are several orders of magnitude greater than the number of dollars available for kidney cancer research. There is a critical need for both basic and translational research to address some unanswered questions. We cannot fall into the habit of saying, well, if something was discovered in another disease, maybe it will work in kidney cancer. And what's taught us over the last decade when we've approved seven drugs over less than a decade is that a better understanding of the biology of kidney cancer drives the research and successes for kidney cancer patients. So we need to understand the biology of kidney cancer. What's a biomarker? A biomarker is is there something in the blood or on a scan or measurable by a test that can identify kidney cancer early. Everybody in the audience knows that if you're a woman over a certain age, you get your mammograms once a year or every other year. If you're a male over a certain age, you go to the doctor and you have a digital rectal examination and you have a PSA test. If you're a person who's had a history of smoking, you go to your doctor and we now have evidence that's profound after a $50 million trial that says that high resolution CT scans are beneficial for the early diagnosis of lung cancer that can lead to a 20% increase in cures of patients at risk. There is no such biomarker for kidney cancer. There are also no biomarkers for therapeutic efficacy. You've heard across the day that there's a lot of toxicity associated with the things that many of you have received. There's a lot of toxicity that's continuing to affect you. It would be nice if we could actually pick out who are the people that are more likely to benefit or suffer from the side effects associated with the drug so that we could tailor the treatments to those patients. I was just at a meeting and gave a conference in somewhere, I think it was San Francisco, where I spoke to Japanese urologists and that was going to go back to Japan where the Japanese urologist community, which are the ones that actually give therapy for kidney cancer, spoke to the nature of the side effects in Japanese patients that are really quite different than the side effects associated with what we talk about in the United States. That's called pharmacogenomics. Pharmacogenomics is really the study of the difference between different genetic people and how they tolerate drugs and how best to deliver it for both benefit and safety. And lastly, head-to-head comparisons. It's okay to develop seven drugs, but as you saw when Dr. Paul pointed to the two buckets, the bucket A, which is the VEGF bucket, and the bucket B, which is the mTOR bucket. The reality is that there's really only two sets of drugs. Some of them have different names. Some of them have many different types, but they're really only two sets of drugs. And one of the things that you would want us to ask and I wanted to answer is what makes drug A different than drug B? Is it better? Do it first? What's right for me? How should I use it? And oftentimes there's inadequate data in the literature for us to be able to make those recommendations because those questions have not been asked and answered. So what we did is we used actually a management tool that is often used in big business. And this management tool is you look at a situation analysis, you define the state of kidney cancer therapy or anything that you're looking at. You look at emerging kidney cancer therapies. You look at the future state in mapping the challenges. What is the future state? What are the obstacles and challenges for achieving the future state? And how does one prioritize? And for any of you that are in the business world, you're familiar with these management strategies about almost any problem or project or product that you would ever consider. How do you develop solutions? How are their leadership issues? Are there strategies? In our case, clinical strategies, biomarkers for therapeutic efficacy and defining patient centered values, i.e. don't just think about it from the perspective of developing drugs, but think about it from the perspective of developing things that people will want to enhance their life. Very nice talk by my colleague at City of Hope, Matt Lascalza, which really solidified in a very short period of time, we can't forget that we have to define the patient-centered values. And lastly, you generate that into action, develop a research agenda, an action agenda and commitments, and then you identify the resources to put behind that to succeed. So this is what we spent the day kind of in our regular clothes. And it seems like a complex, and there will be many slides like this, it seems like a complex way of approaching problems, but actually it's very solution oriented. So for example, if one wants to look at the desired future state and discuss it, you look at the desired future state, for us it was in five years. And you identify the priorities, research, prevention, treatment, effective drugs, priorities. I think the one thing that was dramatic, and I think we would all agree in this room as at the end of the day, we want to make sure that the questions that are being asked and the dollars that are being expended are leading to the things that you would want. Well, what you would want is you would want something called complete responses or no evidence of disease and long term survival. Because industry loses track of what you want. Because there's a lot in between, and pardon my English, there's a lot in between where you can make a ton of money and not get to the end point. And what we need to be sure is that we as advocates for this disease advocate for the end points that are of value, which is cure. So what are some of the barriers in prioritization? Well, there is inadequate funding for basic research, clinical trials and advocacy. Sitting in the audience is one of my patients, Barry Hoven, who started a foundation called Cureit, the purpose of which is to raise money for laboratory and translational research in kidney cancer and is giving out awards to the American Association of Cancer Research. It's going to be through funding of basic research, clinical trials and advocacy that get us to the next step. Undefined mechanisms of tumor biology. I am struck by over 30 years of dealing with this disease that the home runs are not always easy, but they're there. And it's kind of like in the baseball analogy, you have to wait for the right pitch to hit the home run and not every pitch that comes in is going to be a home run ball. Well you have to identify what's the matter or the manner of the right pitch and how you go after the science associated with the right ball that you want to try and hit out of the park. You can't wait for, no one hits a home run if the ball doesn't get to the plate. You have to get that information to try and hit that ball and search for that cure. There's been a significant disincentive to develop better agents. So the market is a problem. We have seven drugs that are making a lot of money for some companies. What's the incentive to develop the eighth drug? And it's not like new cars where there's another car coming out or another model coming out every year. So what we need to do is we need to make sure that we're on the path of making sure the kidney cancer is advocated for so that a decade from now we don't look back at the last decade and said, yeah but the decade before you developed seven drugs and in the last decade we developed, we developed nothing. Because remember between 1992 and 2005, how many years is that, 13 years, there were no drugs developed in kidney cancer. Not because we didn't try, but there were no drugs developed. Want to make clinical trials available to more and more people? We want to align incentives, sometimes incentives are misaligned or the incentives for the patient, the same as the incentives for the physician, the same as the incentives for government, the same as the incentives for the pharmaceutical industry. Many of us are worried about incremental change. I think that most of you in the audience would say, if I have an opportunity to participate in a trial that has a modest benefit for me, is that as important as participating in a trial that is a paradigm shift where I have the opportunity to reach one of those barriers that's associated with long-term control of my disease? And in oncology, especially in 2014 where the federal dollar available for research is decreasing, it is absolutely critical that we use every one of those dollars in a valuable way. We struggle for fragmentation of delivery of care and quality of care. I mean, you're here today, all of you are seeing your doctors and I'm hopeful that all your doctors are as familiar with the data as you are now, but most cancer doctors in the community see four or five kidney cancer patients a year. I see 20 a week. Do you think the level of care is the same for a doctor who sees four or five a year and one who sees 20 a week? So my view of kidney cancer care, it should be focused and centered around centers of excellence. You should see the people, like the people that we talked about today, because they're the experts who are able to give you not only today's therapy, but tomorrow's options. Scientific researchers can't allow industry to drive the clinical agenda and I think you can imagine that the industry agenda and the questions that they ask and answer are driven by things that are important to industry. And if they help you, God bless, but they're not always aligned. And we have to make sure that all of our voices are heard so that industry knows exactly what are the end points that we want for ourselves and our patients. We need to develop guidelines for therapy to make sure that they're followed, especially when a physician who may not be an expert in this disease sees a patient who has kidney cancer. And this is what the barriers look like and there are many of them and you'll be able to see these online and they're very granular. This is the leadership challenge and there are substantial amounts of leadership challenge. I'm not getting any younger, many of the people that are associated with my generation of kidney cancer scientists are not any younger. We hope that the Dr. Paul's of the world will continue to thrive over the next decade and generations because we need leadership in this area to lead to future cures. We have to remember who we serve. We serve you. We don't serve our institution. We don't serve industry. We don't serve the federal government. We serve as the person who we sit in a room and talk to them about a life-threatening disease and we have to make sure that the patient-centered value associated with the delivery of care for kidney cancer patients is not lost in the process of development. Lastly, we have to make sure that centers of excellence in community oncology practice are aligned. I talk all over the world and the questions that I get now as compared to a decade ago are more sophisticated, but many of the questions that I get are still pretty naive, which means that we haven't penetrated with information across all of the domains across the country so that people actually know how to take care of the individual kidney cancer patient. And lastly, where do we want to get to? We want to get to a paradigm shift, a paradigm shift meaning that instead of me walking into a room talking about current therapy, it's a paradigm shift where we walk into a room and talk about emerging technology that might lead to an endpoint that is very different than what we deal with in 2014. Will vaccines be that opportunity? Maybe. Will checkpoint inhibitors be that opportunity? Possibly, but we can't just stop with those targets. We have to continue to discover, put resources behind it, and be creative. I wanted to leave you not so much from the perspective of CEDARS, but from the perspective of how to deliver care. These are the clinical trials that we have at CEDARS for patients with kidney cancer. I don't need to go through that, but in every one of your visits, in every one of your conversations with your doctors, you should ask the following question. I know what I'm receiving now and I'm happy to be receiving it and benefiting. What else is going to be available for me should this stop working? And if that person has that available or access to know what is available, you're in the right place. If the person says to you, I have no clue, you might want to revisit exactly where you're receiving your care. So with that in mind, I thank you all for coming. We have a few moments before we all go to other things. I thank Nancy for establishing and setting this up, as always. Let's all give Nancy a hand. I thank the Kidney Cancer Association for its advocacy across the country and the world in support of kidney cancer patients. And it's nice to see you all again. Take care.