 Thank you. It's such a pleasure to be here this morning. It's really difficult when I have to follow rock stars like Dr. George and Dr. Malalski, so hang in there with me. I'm not such a rock star. So I'm honored to be here. Like Dr. Rathmell said, I'm a nurse practitioner. I wear two hats, so I work in urology, so with patients who've had surgery for kidney cancer, and also medical oncology, so patients who are taking medicine for kidney cancer. So I'm all over the place. That's why I have a lot of gray hairs and bags underneath my eyes, but thankfully I love what I do, and it's actually, it's a joy to see it to be here with all of you today. So the medications we're going to focus on today are the ones that we prescribe most commonly for kidney cancer. So I'm not going to talk about IL-2, not going to talk about interferon, because we don't use those as much. So we're going to talk about the targeted agents. These drugs can have pretty significant side effects. There are some that are much more common than others, so I'm only going to touch on the common ones, okay, because we can spend an entire day talking about all of the different side effects and how to best manage them. So in 20 minutes, I'm going to try and squeeze as much in as I can. So things I'm going to try and touch on are why do these side effects occur? You're going to love the slide that I have for that. It'll make a lot of sense. What are the most common side effects, and then what are the treatment options for these side effects? So before I even touch on that, just as a caveat, we all, so as oncology providers, manage these side effects all very differently, even kind of within our own group, we manage stuff differently. There's no really right or wrong way to do this. It's very much like when you're picking a treatment for the cancer, how you manage the subsequent side effects is also not a perfect science. So we individualize these things based on a lot of different factors, just to kind of throw that out there. All right, when the side effects of this medication kick in, you'll forget what was wrong in the first place. So that's what we try to not have happen. We don't want things to get to the point where it's so bad that you don't even know why you're coming to see us anymore. So this is just a little blurb about why these side effects happen. So to kind of break it down just a little bit. So class effects, and what that basically means is when the medicine inhibits a certain receptor that we know plays a role in a specific process. So like VEGF, we know that that plays a role in making new blood vessels. So when we give you drugs that go kind of interfering and mucking around with that, that's why we can get a side effect like high blood pressure, which I'll touch on. And then off-target effects. So when we give you a medicine that inhibits unintended targets that we didn't mean to, but we can't just based on them, we can't help it just based on the mechanism of that particular drug. So I think my next slide is going to clear all this up why these medications have all these side effects. Oh, no, it's my next slide. Sorry. So what, right? Some side effects are predictable and some side effects are not predictable. We do a bunch of things before we start, even start these medicines because of the potential toxicity. So a lot of you have probably had more blood drawn than you ever thought you'd ever have. We take a lot of tests to check for liver function and kidney function and all other kinds of stuff. Heart ultrasounds to make sure your heart's strong enough to take the medicines. And we monitor blood pressure. Sometimes we have to fix stuff before we start you want a medicine to make sure we keep you safe. All right, I think my next slide explains all of this brilliantly. So that's why these medicines cause side effects, right? That clears it up brilliantly. Right? Anybody have questions about this slide? No, I can move on. Okay, so so so that's why we have side effects. Brilliant. So these are just this is just a list of the medicines I'm gonna that I'm gonna go over that because these are the ones that we prescribe the most. Okay. Is anyone tired? I know I am. I'm leading on the podium. It's kind of embarrassing. I'm feeling like, I think Dr. George is tired. So fatigue is probably the number one, at least in my practice, kind of number one thing that folks tell me about as far as side effects from these medications. So that manifests itself as these are just different words that people used to describe the feeling of being tired. Okay, so fatigue is the self perception of tiredness. So feeling sluggish, slow, tired, dragged out, heavy, all those kinds of things, which is definitely not me on a Monday morning. And that's not me on a Monday morning. That's not a self portrait. So that's how a lot of folks feel on these medicines. So different ways to to manage fatigue. It's, this is tough, because there's not a magic pill, you know, for a lot of the other side effects that these medications can cause, we can try medicines to help with the side effect that the other medicines are causing. It's so important to conserve your energy. And I know that that sounds, some of these things are going to sound really simple and kind of duh, kind of moments, but a lot of folks who have cancer and who are taking cancer therapy, have a difficult time, asking for help, and kind of scaling things back so that they want to be able to do, and have things that are still everything 100% in their control. But when you're taking these medications, fatigue is definitely is definitely one of the biggest side effects. So these are just little tips on how do you conserve your energy. So setting priorities, asking for help. People want to help you. Okay, a lot of caregivers and family members and neighbors and friends also feel a little bit helpless in these situations. So if by asking someone to take your dog for a walk or go to the store for you, that's good kind of for the whole caregiver circle as well. Plan activities when you're rested. So what I try and tell folks is, when you wake up in the morning, if there's something that you'd really like to do, do it then. But don't try and squeeze all of your activities into this two, three hour window because you're going to weigh yourself out. So it's all about kind of timing things that are important to you. Defer non essential tasks. So I can't tell you what that what those things are, but things that that are just don't have to be scratched off the to do list and doing one thing at a time. So I'm a hypocrite. When I take a nap, which is rare, it usually turns into a full night's sleep from five o'clock until five the next morning. But napping if you nap, it's kind of embarrassing. If you nap for more than an hour, it really can interfere with kind of your normal sleep wake pattern. Also napping between five and seven at night can really mess you up for the nighttime as well. So earlier in the day and sudden alarm to kind of get you up after half an hour, 45 minutes. And I do realize these things are easier said than done. Okay. And then distraction. So there's there's some evidence that things like playing games or music or reading, things like that can can help with fatigue. Exercise. So I now have an exercise plan for all of you after today, we're all going to go to Dr. George's house and get on his rolling machine. So I'm thrilled that he brought that up because now we all have somewhere to go. So exercise has absolutely the most data to support that it's the most helpful thing with fatigue. And I know that it seems counterintuitive because how in the world can you get up and exercise when you're so tired? That's why I showed you different little tips to help conserve energy first. Because if you conserve your energy, then you have a little more up to exercise. And I'm not talking about going to run a marathon, because then I would be a hypocrite. But anything that gets your heart rate up a little bit, it you can go for a walk around the block. You can do there's if those of you that have computers and internet home, find some YouTube videos, do some yoga, it doesn't have to be anything extensive. But this is why so it really in a nutshell helps your ability to function. It increases muscle strength, flexibility. It's good for your heart, which is good in turn for all those other things. And it helps with your mood too, because you can be fatigued for a lot of other reasons other than just because you're taking one of these medicines. So good sleep hygiene. I preach this a lot. So what that means is having a good nighttime routine. So going to bed at the same time every night, waking up at the same time in the morning, comfortable room temperature, making sure it's dark. Every single one of my patients laughs when I say this, but the only things you're allowed to do in the bed are sleeping and have sex. Okay, so no reading, no TV, no iPad, no phone, because all of those things keep your brain active long after you're asleep. So that can interfere with getting into that deep sleep that we all need so much and avoiding stimulates. So those of us who drink caffeine up until the time we go to bed. Other things, so CBT is cognitive behavioral therapy, massage, acupuncture, some prescription sleep medicine, if it gets to the point where you need something like that, those things can help in low doses. Okay, other things. So two things that are important, especially with these medications, is that there are some labs that can be abnormal because of these medicines that we as your providers need to be checking every time we see you. So every time I see a patient with advanced kidney cancer who's taking one of these medications, these are two of the things that, of all the hundred tubes we take for a visit, these are two of the things we check. So these medicines can alter the function of your thyroid. So if your thyroid, if you become hypothyroid, that can lead to profound fatigue. And it would be, it's amazing how when we correct that with a pill, how much better you actually end up feeling. So next time you see your provider, ask them if they're checking your thyroid. They might be, and they might, you might just not know, because if it's normal, then we just kind of check it off our list. Anemia, so that's just one of the labs to check to see if you need a blood transfusion and things like that, because that can make you feel tired if you're anemic. Ah, these pictures are really, this, I don't know, I was doing this like one o'clock this morning, so I apologize for the ridiculous cartoons. But this is someone who has a bellyache because of diarrhea. So I decided not to put in like an actual picture of diarrhea, because that would be a little bit, right? I mean, they exist, I googled it. But that, that would be, that would be a little bit crude and it's right before lunch. So diarrhea is incredibly unpleasant and it can be a significant quality of life issue, because people are afraid to leave the house. So this is something that can be modified a lot of times with some pretty easy diet changes. So low residue food, eating small bland things that are high in protein, and this brat diet that you all may or may not have heard about at some point, and that you can see what the acronym there is for, but why those things are important, because they help absorb the fluid that are in your bowel to lessen the frequency and amount of diarrhea and get you back to kind of normal pleasant bowel functioning. It's crucial that if you are having diarrhea to drink as much fluid as you possibly can, because severe diarrhea can lead to dehydration, which can lead to all other kinds. These things just kind of snowball one another, as you can tell, which is why we can have a whole day talking about them. So two to three liters a day, that's a lot of fluid. So a lot of people just have them carry around your favorite water bottle and fill it up as you go. Of course there are medications, so the easiest one is Loparamide, which is the modium, which you can grab over the counter. You this is just kind of the schedule for how you do that. You start with two pills after your first liquid stool, then one after each max eight pills a day. Then if it gets severe, there are prescription diarrhea medications that your provider can prescribe for you. If it gets really severe and you're dehydrated and you're very sick from this, then we would have to bring you into the hospital to correct things like giving you fluid and giving you really powerful medicines for this, but we try and avoid getting to that point. I know I'm talking fast, I'm sorry. If anyone wants these slides and I'll be here through lunch if anyone wants to talk to me, this is really slow. So basically this is kind of a duh thing, but if you're having diarrhea, stop your stool softeners and laxatives. A lot of times we forget to tell people that, and I know it seems kind of like an aha thing, but it's important to make sure that we're not giving you medicines that are actually making the problem worse. I don't know why it just splashed. Okay, so there are some unpleasant pictures that are coming up here, but these are different types of rashes that can happen with some of these medications. Ouch. So one of the most common is this acne form rash. So that is the gentleman with his back there and then the back of the legs here. If you can see that it's kind of it's kind of faint. I'm actually just saw a lady a couple weeks ago who had that very appearance. Oops, wrong way. Back to diarrhea. That's not what we want to do. So that rash can appear generally it's on the face, upper chest and on the back. It kind of goes mild moderate to severe and we don't really do anything about it until it becomes bothersome. So if it interferes with your day-to-day activities or you're itching all the time, then there are stuff that that we can give you. So there are medications, there are creams and then I'll kind of go through in another slide. Ah, there it is. So how to prevent this? Keeping your skin kind of nice and healthy throughout all of this. Wearing sunscreen even when it is cold, if your face is going to be exposed, if you're going to be out making sure you have a light sunscreen on. Good skin hygiene, so just making sure you're keeping everything nice and clean. If it gets to the point where it bothers you and you want medicines for it, there are you know oral and histamines to help with itching us and then we can provide you with prescriptions for different types of creams, too. So the hand-foot syndrome is, I forget how to go back, but it was those like kind of hard callus-looking type pictures on the palms of the hands and soles of the feet. So these really kind of happen on areas of friction and pressure on those. So if you can kind of see this table, it's a little bit difficult to see, but again kind of a grading scale and we use that to kind of figure out how severe these things are. But tips to kind of help prevent this. So if you're taking one of the medications that can that can cause this, using thick kind of alcohol-free emollient creams, avoiding things that are of extreme temperatures like very hot showers, avoiding pressure, so jogging, jumping, hand tools. So if you're in the business where you make a lot of stuff and you're holding things a lot, so hand tools and things like that, don't go barefoot and wearing thick cotton kind of supportive socks. Treatment for this, if it occurs, our prescription creams, we have a lot of stuff that we kind of use and then pain medication that you can take as pills if it gets to be severe. So probably everyone in this room has had one of these. So even those of us who don't have kidney cancer taking these medications. So this is kind of what we think about as a canker sore, but you can get these mouth sores. They're shallow, kind of punched out lesions. They can happen in the cracks of your mouth and kind of down here in your lip and on the sides of your tongue. So to prevent these types of things, good oral hygiene, so keeping your mouth clean. Make, for those of you who were dentures and surely no one in here is old enough to be wearing dentures yet. Make sure they fit well because if they don't fit well and they're constantly moving around that can really irritate your gum line and make you more susceptible to kind of having these problems in your mouth. And I like something that's simple and cheap which is a warm salt water rinse after after meals. As far as treatment, again you know we can take out our prescription pad and write you some stuff. So there's mouth washes and there's steroid creams that you can put directly on the lesion, lidocaine which is a numbing jelly and then if it gets to be severe there are pain medicines pills. I know that this seems kind of like an aha moment but if you get these things just make sure you stay away from this stuff because they can really exacerbate the pain and make it take longer for these things to heal. So things like very hot and very cold things, coarse fried foods and anything was citrus in it and especially mouthwash. Over-the-counter mouthwash with alcohol in it. So if you like to kind of use a mouthwash in the morning I think there are several brands that make one that's alcohol-free and that won't hurt. Isn't that cute? So this is your heart checking its blood pressure which doesn't make a whole lot of sense to me. So high blood pressure. So if you have high blood pressure, lots of folks have high blood pressure even before we start these medications. So it's really important that we as your providers make sure that your blood pressure is under good control before we give you a medicine that can that can make it even higher. What I like to do is give my patients a blood pressure log to take and keep at home and every day for the first two weeks that they're on one of these medications is to keep a list of the time they take their blood pressure, what it is and then to alert us if there's anything abnormal. Ideal target is 140 over 90 or less which can be very challenging to get to. We treat this pretty aggressively and there's a whole host of blood pressure medications that we use that work differently to control blood pressure. Speed demon here. So in conclusion everyone tolerates these medications very very differently. Be open and honest with your provider so that we can help you. When I start someone on a new medicine I see them back in two weeks to see how they're doing. If that's not possible then I do it over the phone because I know folks travel but that's to get an idea of if they're having any of these side effects kind of up front because like other folks have alluded to that that kind of first cycle on a new drug can be the toughest and then I see folks at least once a month if not if not more often than that if necessary. If the side effects are severe in spite of us treating them as aggressively as we can your provider may need to decrease the dose of the medicine that you're taking or give you a treatment break. Okay because we always have to risk the continuing to push forward with therapy while keeping you safe. Okay and good side effect management will improve your quality of life and good palliative care should be incorporated into into all of your cancer care at all stages. Thanks. He helped me. He did. He snored the whole time.