 Hello, I'd like to thank the KCA and NYU for hosting this event today And what I'd like to do is ask the panelists took the speakers to come back up to the front We're gonna start some questions So again, we have William Hwang who was the surgeon who spoke Robert Altar one of the medical oncologist Janice Dutcher and Jeff Shea And I'll start off with a few questions One question to the surgeon is what do you do and you mentioned the surveillance for patients with some of these small tumors Is your approach similar in a patient for example, who's 20 years old with a small three centimeter under three centimeter tumor Versus someone who may be in their 70s or 80s So that's an excellent question. I think as a surgeon when we see patients who come to us with a small tumor We have to really take a look at two things and this is the discussion I have with them Not just a tumor, but also the patient themselves. So, you know, it's unrealistic to think that a patient with who's only in their 20s or 30s Would want to follow their tumor for the next 20 30 years waiting for it to grow And so often someone like that will tell them well, you really should have this treated But this is not an urgent issue And we can address this when it's appropriate for you, but that's frequently for most people almost immediately I think for older patients who find out that they have this in the setting of a lot of other medical conditions They often take more importance than this tiny little kidney tumor and we'll probably You know follow them every six months or so or follow them with imaging that they're getting image for for other reasons and only if there's A demonstrable change in their tumor will we then say you should probably consider having these treatments So it's on an individual basis that that we follow tumors and by no means What was I suggesting that in someone who's completely healthy and someone who has a normal life expectancy that we would necessarily watch But I think a good example is I had a lady who was pregnant And so during her pregnancy she had an ultrasound and found a kidney tumor and we certainly waited till after she delivered before treating her Okay, thank you and some of the questions on high-dose interleukin so Janice you talked a little bit about the the treatment and patients have asked often You know how many cycles can I get can I get treated you know come in five days ten five? Do I come back again? How often can you repeat these treatments? Well, I Tend either so you can repeat the cycles depending on the toxicity that people had previously What I always tell people is your body remembers because it isn't immune-activating drugs So your reaction to it the second time is going to be greater than the first time so the first week The second week you get usually fewer doses and then the clinical trials say after three months you repeat it But I tend to watch How things go before I will give another cycle and see because there are people that I've only been able to give One two-week cycle to and then they had other issues I want a woman developed a rotator cuff injury, which is pro-inflammatory And I couldn't give her more I'll to and over the course of a year Oliver London I just went away without any more treatment because the body remembers and she still had this immune reaction going other people Will give more frequently and try to get like four cycles in and over the course of the year It really depends on each individual person and I think Bob would agree because he gives a lot of I'll too as well That it's different for different people. I don't First of all, we learn from Jan We try to buy by the god-mines So I like to give you the five those of their five days of therapy obviously And again, the great thing about the toxicities that they are in particular in person So I give them not the nine day break. I've given the 16 day breaks. I have come in two weeks later Then I wait for four weeks scan them and see how they do I'd like to write on each individual course of therapy if they do well Then we like to sort of promote a stable disease or better Discussing patient potential benefit of doing it again I find the maximum of the courses I've given is four courses Which is a lot of toxicity Again as one is towering therapy last we stopped giving So I believe with Jan a lot of times that therapy is just stopped and the patient's benefit still evolves and beneficial and we can get a lot of duration of time between Coming off IO2 until you need to initiate the next therapy. So again once it's great years is Fantastic Do you see that I'd also like to say I have actually given boosters booster courses like people have gotten a course of IO2 Things got better and they were stable and go on and on and on and then maybe something starts to grow again And I've given it again and they've knocked it down again So I think you know a lot of us as he said we don't just do what the book says We kind of vary it with the patient and kind of experiment a little bit along the way With success The two kind of gases they are talking about the IO2 and the ferro which one Which kind of gas you like Which side of them? Yeah, you know the bookini is in IO2 and the ferro right so you want to do combination those are all gases right one is The old product oh stepping on the gas. Yeah. Yeah, that's from you. You from you The gas the gas, okay um Well, you get higher response rate with IO2 There were there are old data that bond presented with high very high doses of interferon where there are complete responders I just that the problem with interferon is you have to keep giving it You know, it's three times a week forever or for however long you can tolerate it Whereas is IO2 it's short and sweet. Yeah, you're in the hospital. You have toxicity, but when it's over you're done You know you walk away from it So I I'm I've always been and I'm probably always will be proponent of IO2 because I just think it's it's easy The person goes back to a normal life You know interfere on this like having the flu forever people lose 30 pounds. I mean, it's very tough How do you manage um toxicities with these newer agents like the tkis and and uh Suthent vasopinib everlimus m-tors do you do you start patients on full doses initially? Um, you know, I've seen a couple of patients that have come in and they were started on a full dose They had some toxicity and now they're off that drug onto the next drug What do you recommend for patients? So, um, that's for the oncologist on the panel. I keep the patient who has a disease So you have to know who your patient is first. Um I you know We're seeing this disease happening in younger patients. So you believe that they're More able to tolerate side effects that I probably give them the standard doses as recommended based upon the data that's been presented And I think the data that's been presented is how we should all uh apply our therapies The one variant would be that with that will be with suthent or suthent Which as a standard dose given the typical 28 days and 14 days off have been significantly toxic patients young and old And I've adjusted the therapies to rather do the 28 days around 14 days off the 14 days in around seven days off And there's data to allow us to believe that that is as powerful Actually better tolerated as well as as effective. So That's the only change I've done. I really try to treat patients with the recommended doses Accepted patients function performance as or at least of them as a 75 dose and escalate up Um, I believe that it's easy to treat a patient and accept the dose and accept toxicity Um, when the focus is the cancer, but I like to have my patient believe the focus should be them And then we can take care of the cancer at the same time So for them to tolerate dose and if we feel something tolerated very well, we can try to escalate it up Without the impact that they believe that the most max dose is going to be the one dose that's going to be effective So I'd rather tell I tell my patients you are walking the marathon So to sort of take a day by day to eventually get to a finish line Is much better than to do all your energy up front and bad side effects of the therapy Then you have to sort of scale back So I have no problem starting at a moderate dose and escalate to a full dose based upon the tolerability But on patients who have a good functional performance that is a good treatment full dose I just like to say that after Going through the clinical trials with these drugs at full doses When I treat people off study, I actually tend to start low and build up Because I just have found so many people will bolt from the toxicity if they have a really bad hand flicks and room are really bad hypertension They don't want to be on the drug anymore and we saw that a lot in the adjuvant trial because It you know had a different motivational level but There's data now from canada and from europe of a two week on One week off schedule for student at nibb and I think is far better tolerated and that you can give up full dose But if I'm going to do the four week on two Two weeks off I tend to start One week at one dose and build up the next week and then build up because I just think the goal is to keep people on the drug Like you said a marathon and I think however you can do it to keep people's You know on treatment and doing well The best way the better way to do it I mean there are some data suggesting 50s better than 37.5, but You know most people can't stay on 50. I I think Very few people can stay on 50 for a long period of time So I think the goal is to keep people on the drug keeps them stable keeps the disease under control And that has to be done in a way that they can continue to live their lives Just I have to tell you one anecdote which was a fellow that was taking seraphimib for a while And he had terrible diarrhea with it And he was a golfer And he basically said if I can't golf I don't live So he basically you know and people take oral drugs. They do what they want to do. They don't necessarily tell you So he would just stop the drug Stop it in the night stop it in the morning go out and golf and then started again You know, I mean you gotta be able to live What about you? I tend to start either Depends on the patient so depends on the patient depends on depends on their Other conditions that they may have blood pressure or so forth I tend to start at an intermediate dose and work my way up Rarely do I start full dose And work my way down and then it also depends on also Different ethnicities. So, uh, you know What I've anecdotally in my in my practice, uh, I've seen that patients of asian descent don't tolerate These tyrosine kinase inhibitors so well. So I started a lower dose and worked my way up Um, so you it's art of medicine. Yeah, so Only half a day a week. So I don't see that But uh, but I do I you know, I do love my patients. So I pay attention So the the idea is this I think it depends. So for from an elderly patient In the for isomac 70s 80s You don't want to get a full dose because you're You are going to knock down their performance there. They'll do the miserable So you can start with to me like for those patients. I really start with very low You know, like was over there was our 200 to see where they tolerate 400 maybe not come to 600 really go up to that You know, so so it really depends on who the patient you are seeing if it's a very very young patient Like 40 some years old I want to give you the most benefit. So I keep in like full dose like 50 and to see whether you can tolerate And to see whether it is really working. If it not if it's working as great And maybe if he's having trouble tolerating, I can start to reduce it So that you can do either way But I think it's very important to see what the patient wants and what the patient really expects Um, and again, if you're dealing with clear cell kidney cancer, that's what we most deal with That is Super important Even the patient with succumbate or whatever they progress To lift them up or to dope them They slow down their disease So we can see that they progress based on radiographically, of course, but they feel better But the formula is really taken off. Boom. It's gone. So that that's you have to understand the disease That's what the mechanism is important. It's not because they take out other things It's just because they on top of they learn something else. So that's your treatment always in your mind So James in your half day clinic, you know, they're not become a little bit very long Yeah, they're they're long half days. I like to talk to too long So I don't know I think I'm like But no, it's fine. It's fine. That's not painful because the day that I enjoy it So I know that we are still, uh, you know, we we still treat patients Same size fits all, you know, we're giving everyone the same agents What can patients do to learn more about the genomics or metabolomics of their disease? Yeah, so so I would say that don't don't try to learn it Because even even think about if you ask your doctor, no, none of them know If you can ask them, do they know about it? You can spend $10,000 to sequence it Do they know it? Do they know how to deal with it? No, they don't So basically it's a waste at this moment that if you know, so to me, it's really People need to really try to learn more. You know, of course, I'm not saying spend don't spend the money You should spend the money and the time is more important than money They just spend it and then get all the data then we start to learn what's really going on And the best way to learn it It's as I said that you know, how long you want to survey your patients like you want to survey 20 years Whatever if that makes sense if you take, you know, we have a study that was very nice that if you take a tumor And you sequence like five or six regions And then combine them and just sequence once and you find it if you don't find any bad You know, like bad one or safety to mutation I don't think you'd follow your patient that frequent couple two years. Maybe it's sufficient But if they have some other mutation like bad one mutation or steady two mutation, then you have to be very careful about it Okay, so that's the way you just think about it. And if we don't you have Clear cell is very simple. Clear cell is just VHL disease on top of they are something else And that's the part we started to learn what are the g maybe at play and that's what where the convergence is And then if you treated two drugs or three drugs Blocking a different, you know, you know converge they have different conversion point If you find out those conversion point on a very specific disease, maybe you can get rid of it Because if you're doing one you block into one this or easily get to another way to converge a second point So the easiest way is just, you know block two or three you think and do that Um, successfully you may actually get rid of disease before like every chance to develop resistance But it takes time to try to understand how it's actually involved. Every disease is a bit different Even every individual patient is different So so and then nowadays you do sequencing and the sequencing Yeah, it depends where you sequence you sequence the primary is not going to be the same as the sequence the metastasis So if I if you guys anyone want to sequence your tumor and if you have metastatic disease sequence the metastasis Don't waste your time on sequencing the primary because that's Let me not be the cone actually cause your problem. That's just part of the game So anyway, so I don't I don't think this is a very good answer The problem is really it spends so much money and really don't you know And you mean things like foundation medicine these types of Yes, no, no, no the idea is basically they need a very very big number and really really clinical annotated And really try to understand which disease is doing what and then what we call a worker is Novartis is kind of one of the things where we can do that is basically a big clinical trial Um, and then we collect all the DNA We collect everything because the the regular DNA is easier to analyze is DNA does not You know so stable millions years, you know, that's why you can sequence dinosaurs There's no what kind of DNA they had and that you by sequencing that you can try to kind of not correlate clinical response And they can figure out who will do well who will not do well who will respond to who will not And based on that in the future you should be able to collect The patient who have that kind of patient and should be treated one way We're going to see some of that information over the next few years from the adjuvant trial Or from several of the adjuvant trials because I think they've all collected tissue And the the the one that was sponsored by the nci the ecog Akron cooperative group multi-center group They actually allowed clear cell with other histologic Types, so there's going to be a lot of information, but I think you know what what we're saying here It's just not ready for primetime Yeah, you know, it's interesting because what you're saying also goes all the way down to the disease state that I see Which is localized kidney tumors people People often say well, you know what? Why are you operating on me? Shouldn't you biopsy this shouldn't you see what it is before you take it out? And the problem is that unlike some other cancers biopsy isn't really telling us that much yet And we are not good And we don't have enough information from a biopsy at this point to really say to you Oh, well, this is a two centimeter tumor. You can watch it for the rest of your life This is a two centimeter tumor and this is going to rapidly progress and metastasize So until we have that ability, you know, we we we sort of use really Rhythm entry instruments. How big is it? You know, is it anywhere else? Things like that. So It's interesting and I think also with the follow-up imaging for patients who are theoretically free of disease You want to be able to tease out who's going to recur? And who's going to need additional therapy until You know, we're more advanced with uh, figuring that out It's just one size fits all you image everybody and you image everybody regularly and you spend the healthcare dollars on that So I can keep asking a million questions, but I'm going to go ahead and open it to the audience If anyone has any questions Anything that doesn't have to be related to what we've talked about anything with kidney cancer or cancer in general Maybe I should sit there. I will ask questions Well here actually since uh Let me ask a question as a surgeon. I'm not a medical oncologist. Obviously with all these different tkis now What is what do most people use as their first, uh, drug of choice now that You know Is there a favorite amongst you or is it sort of uh, and what do you do to choose? So I would have to say for me, uh I separate the standard therapies Uh and the clinical trials I try to encourage patients to enroll in clinical trials, especially since a lot of the new Immunotherapies are available only via clinical trials. I'll try to encourage patients to Seek out clinical trials other either at my institution or other institutions many of these clinical trials with the checkpoint inhibitors that the panelists spoke about are Comparison studies so they have The checkpoint inhibitor nevolumab for example versus one of the standards su-tent Or the checkpoint inhibitor versus another standard. So you have an opportunity Uh to get a drug that may you know may or may not be better than the actual standard Short of a clinical trial of patients unable to go on a clinical trial depends on you know as as uh, dr. Alter talked about the the prognostic factors of that patient. So Uh in a patient who has poor risk disease, you know unwell person I I tend to choose temsarylimus In a patient with good or intermediate risk again, this is It's one size kind of fits all I'm using one of the tkis of either votrient or or su-tent so, uh depends on the the the patient so I can give you some Depends a lot on the patient and what they do. So I've had uh, for example some Athletes or musicians who are very concerned about the hand foot syndrome the painful calluses that may That occur more often in patients that take su-tentative. So in that case, I would use the votrient instead Conversely in patients for example, who I know have abnormal liver function test abnormalities or Issues with their liver. We tend to see more abnormalities in in those liver studies In patients who take votrient. So I would stray away from that So it varies any any patient with a non-clear cell. I'm talking about clinical trials So that's how that's how I choose So, okay. So, uh, almost two years ago, uh, there was a clinical trial that compared the two common drugs the two active drugs that we use for queer cell kidney cancer that was Votrient opazotinib and su-tent or su-nitinib and fearful of the toxicity of su-tent There was a drug votrient that got after you improved and they went right on to a clinical trial comparing the Challenger that being votrient to the chanting that being su-tent and A lot of centers were involved as a international study And the data pretty much showed that the drugs were similar in how effective they were against the patient But the tolerability of votrient was Superior Based upon that There still is habit for me where a lot of physicians believe that su-tent was the end opioid drug where therapies were Again, we've been using this drug since early 2006 with very good results and based upon the Responses patients have had it's very hard to sort of knock off the chanting coming in with a newer drug We always take the patients quality by functional goals when it comes down to therapy A lot of times votrient would be an excellent option to patients because the tolerability is Against deemed to be superior enough based upon a clinical trial There's also another study was a patient survey where actually patients were exposed to both drugs in different sequences and patients Gave a diary and they submitted their thoughts. What was the better agent again? They were not knowing what they were taking And the patients by 71 to 20 percent margin believe that votrient was a better tolerated drug So taking that into account. I like to have these therapies as you know, there's the patient and there's the disease And patients who have volume of disease that I believe needs shrinkage Faster, I think as soon as soon as a better drug to stop But again, we have learned to adapt the dosing of it to make it much more tolerable Because that was not presented on the actually that was not represented on the clinical trial compared to drugs So I would say we've soon ended up as a great drug to use for patients volumes of disease patients We're trying to adapt more towards their Quality of life and the recognition that we're trying to slow down the disease or stabilize the disease that the judge has said Stay with disease is an accomplishment that we try to achieve as medical oncologists Patients of course want shrinkage and disappearance. So we always again have to explain the goals, but I tend to look at the patient again If the patient has good functional performance status and they have bulky disease I think that a drug that can reduce that is important The patients who have not threatened disease and I believe this is again that walking the marathon approach I think votrient's an excellent option Okay, I would also say that a lot it depends on where you're being treated if you're treating it Being treated in a place that has a lot of kidney cancer And the staff and the doctors the nursing staff and the doctors are very familiar with the drug You know, you're going to get A lot of help taking the drug if you're not in a place where that's the case But your physician is feels comfortable giving this drug It's more important that you get the drug that that physician knows the best Because it's you know, a lot this is outpatient treatment There's a lot of coaching that goes on The nursing staff have to be tuned in and you have to feel comfortable that you can call somebody Whenever you need to because there are things that come up along the way So I think familiarity with the drug and the toxicities and the management is key to giving the drug successfully And to taking the drug successfully On the part of the patient So I I think again that you need to know what you're comfortable doing I will say in that my only quibble with that study that was the comparison was that the quality of life Questionnaires were timed to hit suit and at its worst That's the four weeks before the break So I I'll be a little skeptical about that But but otherwise, um, I I understand the data and I still um I've actually had more success with cement than I have had with water So I think we all have it's the it's the blind men in the elephant We all have a piece of the picture and you know, again, it's our comfort zone in terms of what we ask patients to do Is it better to I think clinical trials If you can access to a big clinical center clinical trial will be the way to go because Now all the clinical trials had to had compared to standard In the past clinical trial is like, you know, we don't have this we don't have that as we don't know where it works It's why we're just sorry everything But now the clinical trial at least in kidney cancer. They are all very very reasonably designed And we really need to and we really understand what's really going on That's why a lot of treatment the face one the phase three trials or From line trial is always the other Talk about you to pair a suit and Which you know some of the trials suit and was pd1 suit and was pd1 plus amastin And he thinks like that and those are the you building the composition of immunotherapy and try to figure out What's really going on if don't have the excess I would still depends on how you How fast your disease progressed you really don't want to wait. I have some patients with oh, I'm slow When you go to a break of the other places and the other thing you have to understand Continue when kids bigger they continue to evolve So you don't want to get it too big because you want to evolve they will acquire some other bad mutation And that's when they take off when they take off you are dealing with different monster Well, there are people where it doesn't take off. Yes. Yes. Yes, but there's so the small ones This one the small one you monitor that if they only one centimeter, you know I have some patients that I don't treat for two years because their disease just don't do anything But you have to understand 10 years 10 years. Yeah, but you have to understand the biology Well, that you know what I would say is get two points on the curve at least and see how fascinating Especially somebody that is late recurrence where you know that things have been quiet for a long period of time There are other people where every scan it's a little bit bigger It's a little bit bigger. Well, you know, and there's some people who are in the next scan It's a lot bigger. Well, those people are not going to respond to immunotherapy at least not up front You may have to calm it down with the tki shrink it as Bob was saying And make sure that it's under control and then consider giving me immunotherapy The sequencing is still tricky. I mean we still don't understand it yet I mean there were data Early on that if you gave interleukin right after tki you would have some toxicities that were unexpected But part of that was that gave it a little too soon after the tki You need to take a couple of months break and then you can go on with the immunotherapy So What I always tell people you're going to need all of the drugs once you start on drugs You're going to need all of the drugs. So just you know, but we don't really Truthfully know the best sequence and so it's still judgment. It's still what we call clinical judgment Somebody's going slowly and they've had a long hiatus I would go with immunotherapy if somebody's got disease that came back in six months You could try immunotherapy or you could say well, maybe we should just go in with the targeted tki But you know, there's no and and you know worrying about the mutations because once they start to grow They really can grow. That's another that's another subcategory is I guess the big thing is it's not all one disease And each individual person is going to have their own pattern and what we do as a doctor is try to figure out what the pattern is So we can give you the best what what about in that patient? That has that long hiatus 2001 nephrectomy And then now has you know, 2015 Small lung nodules. Maybe the biggest is two centimeters a small right renal mass They've already had a partial nephrectomy by the way in 2008 What do you do for that patient? Do you go in? Resect? Do we ablate? Do we start treating? normal you know I So there's a couple things that have been proven in retrospective studies to make a difference I think some of the things that you brought out are very important to look at One is what was the duration of time between which The person developed a recurrence and so, you know We've had success in patients who have Six seven years and they develop a solitary recurrence and just removing it And I have a few patients where literally every three or four years I go back in and take a little something else out But that's uh, that's the biology of disease. It's not really us being successful surgeons or clinicians treating them successfully It's really that this is how their disease sort of putters along If you're talking about someone who has lung nets and then a renal lesion as well It you know the more disease burden there is in multiple places the less enthusiastic I am to try to go and pluck everything out or send them to an orthopedic oncologist or send them to a Uh, you know a brain might be different. You'd obviously treat that but you know, it really depends on how long it took to come back And I think what the the volume of diseases And again, also the one thing also is to get multiple points So, you know, you see one thing six six months or six years later And then you scan them again after three months just to watch it and now it's everywhere clearly going in to take that out would be a bad idea So I I sort of take the a little bit more aggressive approaching in terms of surgery because I at this moment I believe if you have limited disease Surgery may be the only bad thing you have at this moment unless we really develop some way to cure the disease If the promotion of the patient is very very well if you're limited the surgeon is very very competent So that's why where you get your surgery done and where do you get it's done? It's very very important lots of some of my patients that I you know Have this recurrence It's just like some other patient we talked about that That had disease like 10 years ago now Lymphono recurrence Plus lung recurrence maybe And the question is whether you want what do you want to do it? So it really depends on the patient What you know, what will how aggressive they want their performance status they have and where they want to get So the patient I've had the two of them or three of them just operated And they're fine. So so it really depends on On the course, you know, and of course you have some patients operate no matter how we operate three months later something Those are patients that that's not going to be a very good surgical tender if they just recurred like after three months Yes Again So the question is is Is it detrimental to take one sequence versus the other or taking a certain sequence Will prevent you from being able to get another drug? So I would imagine something like maybe like if you get a tki and then an mTOR Like synitinib and then avrolimus does this mean that you and you progress on the synitinib Does this mean you can't come back to another drug within the family of synitinib? So I it doesn't limit as far as we know it doesn't limit the your ability to get other or or You so patients can respond and can develop stable disease and one of our panels later today Will talk to you. He's on his seventh agent Some of which have been tki some of which have been mTORs some of which have been experimental drugs And has been on the current drug for many years now Similar drug to the initial drug that he started on but on the other hand if you Disease that's been stable or quiet and then develop metastatic disease Again with that lung hiatus my preference my bias is to give immunotherapy Because you've demonstrated a long period of time and then you have disease that's not growing quickly My concern was starting with the tki and then going to an mTOR is that every time you change It usually means there's been something changing with the disease depending on what your threshold is To change drugs and a person might miss their opportunity to get at least get I'll do at this point in time Because performance status is key to tolerating the drug and to responding to the drug. It means your immune system is still cooking Now that may or may not be the situation with the checkpoint inhibitors We don't know because a lot of those people have had prior treatment We don't know whether the performance status is much of an issue But you know file two it seems to be sort of a Surrogate for being in good immunological shape And just back to your patient, you know one thing that might be a consideration that that situation that you hypothesized I would be nervous about doing more surgery on a kidney that's already had a partial nephrectomy When they have other sites of disease, but they might be a candidate for something like cryo Or rfa to the kidney and systemic treatment for the lung nodules, and I still would prefer And their data actually that's what I want to say there's data in animals and I think now Brendan curtey in Portland is doing a study of Radiation basically serving as an antigen release And then giving interleukin two afterwards as sort of a vaccination and then hydrocyle two In animals it's it has a profound effect. It really is a remarkable effect on tumor shrinkage We don't have any data To the tumor well to the kidney Yes, so That's that's not a rule by by any means and I think it has a lot to do with the comfort of the surgeon Um, you know, there's you may have heard the word vhl passed out multiple times You know these people who have vhl syndrome will develop kidney tumors repeatedly throughout their lives, right and so Uh, many of them end up getting their kidneys operated on three or four or five times in the same kidney. So Uh, a lot of it has to do with where the recurrence is located, for instance, and also with, um With the comfort level of the surgeon, but it's not a rule that once you've operated on it that you won't have it I think the issue Is if it's your only kidney The likelihood that something could go awry during A repeat or redo partial refractomy Is greater and the possibility that you end up losing the entire kidney is higher And in that case that could leave you possibly with no kidneys and dialysis which for some people may be a situation That's worse than having you know, a solitary or a small growing tumor Now we are looking into other alternatives rather than removing it or going in and cutting it out Oblating it freezing it and you know The use of that is very different than what I was describing in my talk about Someone who has two functioning kidneys and a small real mass You know, your your particular situation is different. You know, you had a recurrence You already had an operation on it and in that case ablating it may be very reasonable But that's really up to the comfort level of the surgeon and also I think part of it's where the tumor recurrence is located And also what that, you know, the person's kidney function is is going to come come into play here Yes And I just want to say I'm not going to cut everybody off. We'll take one more question now and we'll break for lunch And then um, there The session after lunch There will be lots of opportunity for questions. Okay. Yes Well, uh, you know, one thing to keep in mind is that we don't screen for kidney cancer Okay, so, uh, you know, and that's a whole other topic, but To screen You really have to fulfill certain criteria and one is not just finding every cancer but also meaning and making a meaningful Difference by screening and also having treatments that are acceptable and doesn't result in more harm than Good, I think, you know, you always hear about that news about breasts and prostate and perhaps the downsides of screening But with kidney cancer the bottom lines we don't screen and I think that Because of how frequently people are imaged nowadays It's it's almost like a pseudo screening. They're they're actually being screened without knowing it We do screen for people who have hereditary diseases that may You know predispose them to kidney cancer, but it's not a disease that we screen So there's really nothing that we are interested in doing right now To try to find kidney cancer if that makes any sense I think having having said that I would encourage Everyone here and your family members to see their doctors at least once a year have complete blood counts Have your analysis looking for blood in the urine. These are simple tests that can be done That can detect these uh malignancies as well You know in 1980 they did a study for patients We developed lung cancer They thought they would want to be ideal to screen both smokers And get them x-rays and they calculated that the amount of x-rays Uh, it would take to find one lung cancer is 170,000 x-rays And they said it was probably not financially worth it Well, just recently they approved on patients who have smoking to do cat scans and screened lung cancer I've just discussed that the oncology means this past year so 30 years later they find that screening the right patient population may be beneficial There are so many different risk factors for kidney cancer and so vast But there was also Numerous factors and no risk factors who could get kidney cancer for no reason whatsoever So who is the right person to screen and I give Dr. Molina You know the simple urine test may detect a small microscopic Trace of blood in the urine that you would never see for years upon years But the doctor may find it so that will probably be the best screening And a routine Dr. Cenk about these ones here Thank you