 So, you were talking about the immuno-RAT process and that there's a clinical trial coming up. I think Dr. Tykoti and I talked about that earlier this week. What are the criteria that need to be established to be involved with something like that? Yeah, the trial is still in development, so I think there are negotiations to be done with all the other branches. I think right now we have a trial open already for patients with melanoma hoping to expand that to a greater population. There are also patients who are not technically on the clinical trial, but in the right setting we vocationally, because you're allowed to receive radiation when you're receiving your therapy. You don't have to be on a clinical trial for that. We just want to make sure that the setting is correct because that's kind of the effect that you're going to have. So, there wouldn't be a conflict if you're currently on a clinical trial for the nevolumab and to be involved in something like that. So, there can be, it depends on, so if you're currently on a clinical trial, the trial that you're on usually has specifications for what you are and are not allowed to receive. Some allow radiation, some do not, some require a washout period, like you can get radiative and you have to be treated for, you know, two or four weeks or something. It also sounds like nevolumab is saying exactly what you're receiving is technically a standard of care right now, clinically, for the right patient population. Okay, thank you. Is there a difference between proton therapy and radiation therapy, or are they one or the same? I debated putting a slide of how proton therapy on there. I think it's a kind of radiation, but it works a little differently in that regular radiation travels through your body. So, in turn, one side comes out the other side, which is why for the radio surgery I was stating that you have to use a lot of different beams so that they converge on a spot. Proton radiation goes in your body and does not come out the other side. And so, there are definitely clinical scenarios where that's a huge advantage. When I think of it, I usually think of it in terms of treating a lot of kinds of pediatric brain tumors, especially for some kinds of child cancers where we treat not only the brain, but we treat their entire spine going down the back. And so, with regular radiation, what happens is we shoot a beam of radiation from the back, but it exits out the front. So, you treat all the organs in front of the spine. So, heart, lungs, liver, not too much kidney, stomach, bowel. Proton radiation, it goes in the back and it just stops. And so, you don't treat all those organs in front. In kidney cancer, we have not been excited about using proton radiation because we've already tested the kind of low dose every day kind of radiation, which is most likely what proton radiation will be used for. And it was proven to be very questionable kind of cancer control benefit, whereas it was toxic. Proton radiation is going to be less toxic, but if it's not helping your cancer, then why would you want to receive it? Whereas for most other spots of kidney cancer treatment right now, we do more of that radio surgery that I talked about. And that is not really applicable to use proton radiation. So, I debated talking about it really not, but it's not, we're not really using it for any cancer. I have a question. First of all, full disclosure, I am Pookie's neighbor, but I don't think I'm the guy that said she wasn't a real doctor. I have two risk factor questions I'd like to ask. I noticed one of the early slides, Aspen was up there as a risk factor. I do take low dose aspirin. And a second risk factor question would be if someone could speak to contrast when used on CT scans. So in terms of the chronic analgesic abuse, I can't speak to threshold doses, but I would say per package use of over the counter agents is totally fine. These would be patients doing strange, very high dose, long tributes, and the association there, it's a pretty uncommon phenomenon. But if you search the literature and really dig hard for associations out there, so I wouldn't worry about routine aspirin use. Contrast agents for CT imaging, we don't have radiologists here. We're wearing more bounds, toxic injury to the kidneys and pairing kidney function, more so than that being some sort of cancer risk factor. So, you come out the other side from the front to be surgery often having mildly abnormal kidney function. And Dr. Musinski will take that on after the lunch break in terms of speaking to about long term kidney function and trajectory of your kidneys. So we do worry about impaired kidney function of the contrast, but not really directly cancer, carcinogen point of view. I have a question, it's a very function, right? Okay, we'll try it again. Well, since you're there now, I wondered, you just briefly mentioned that you don't really recommend Omega 3 supplements like fish oil and things like that. Why? I wondered why, yeah. Well, because really the only thing that fish oil supplements have been shown to do is to reduce triglycerides. And they've been shown to increase risks of aggressive prostate cancer from some of our researchers here at the Fred Hutch. They've been shown to cause chemo resistance for some drugs, some of the platinum drugs during treatment. And also the source of fish oil, who knows where it's coming from, from what fish in what waters polluted or not. So I personally and my colleagues at SCCA, we really recommend getting Omega 3 fatty acids through food. Versus supplements. I just don't think the data is strong enough to support a lot of fish oil, flax oil supplements. In general, they're not, well, they're not harmful unless you take a lot of them, I mean, then they're blood thinners. And many of the supplements have blood thinning properties. So I'm not a supplement believer. I'm a food first type of a person. And I say that because the data just doesn't bear out the use of supplements. Okay, I guess this is for the panel. For metastatic cancer, which at this point I don't think I have. How do you determine the calculus or the pairing of the new drugs that will come into trial? I mean, is there data that it seems like as you describe it, it was more like random, let's try this one with this one and we get a trial. What is the evidence to try a different drug than the pairing of those? Does that make sense? Yeah, that's a great question. There's not any sort of overarching guidance or structure that would prioritize and create a hierarchy about trials. It's dominated by commercially owned compounds. And so some of the pairing, a lot of the pairing is pragmatic. A company has a new compound development. They have an old compound that works for disease. And they're gonna look at A plus B from their own holdings. There is scientific insights and a lot of what's done, hopefully is done for well thought out scientific endpoints. But there is a pragmatism of commercial agents that has also come into play. So, yeah, I showed you a slide of three very similar clinical trials. Do you really need three studies to scientifically address whether bringing an immune checkpoint drug into first therapy is smart? No, you probably don't. But you have competing companies that own similar compounds that all want a piece of the pie. So there's not like a quarterback that's doing regression analysis that will show you some type of analytics of why two mates is just pure business. So no, there's no, the NCI NIH does not have some kind of overarching authority. They do have their hands in certain types of trials. There are cooperative networks that participate in some clinical research trials, but a large part of what's available is driven by free markets, pharmaceutical enterprise. We'd like to think we apply a filter about if we bring it to the clinic and we think it has scientific merit and value to the patients. So it's not completely free for all that we're forced to open studies that we think are stupid or not helpful. So we try and make things available that we believe in and think are helpful. But from a comprehensive kind of research utilization and cost point of view, I mean, there isn't a czar that decides what's going to be done and what won't be. I guess I have two questions. My husband has stage four cancer. I was kidding, removed metastasis to his lungs and his lower spine. At what point do you, and he has a subversive low back pain, what point do you consider radiation therapy to be the appropriate treatment? And then I also have a question for Linda. What is your knowledge about turkey tail? Some curious your view on that. Thank you. So I think, you know, when I see a patient to talk about possibly doing radiation for metastatic disease, my goal is that I should hope that I'm going to help more than I'm going to harm them. And so, you know, for patients, if they're pain in the mild and it's not affecting their function like walking, and it's well managed by pain medication, for example, then I might say, you know, this is what I expect are the side effects of doing the radiation, but you seem happy. So I don't necessarily know that I'm going to make you a lot happier with the treatment. And so why bother doing that? But usually when patients come to me, you know, they are more bothered by the pain. They're starting to have more mobility issues from the pain. And then I think, you know, it's just a matter of looking at the lesions. Like I said, what exactly are the side effects treating it and then having a conversation? And so as far as the turkey tail mushroom, which is Corellus mushroom, all mushrooms have beta-glucans, which are, they have positive impact on our immune system. And I know that turkey tail mushroom is often prescribed by naturopaths in the area. It has been shown to enhance some of the chemotherapy impacts of certain drugs, which I can't recall specifically, which they are right now. I don't think there's any real danger to it. I think that in general, mushrooms, because they are plants, they have a lot of these anti-inflammatory compounds. And specifically, it's the beta-glucans that improve our immune system. And again, that's kind of the role of nutrition is to support us as an organism so that we can help contain cancer cells. My question is regarding long-term surveillance in a very young patient. So specifically, a radiation exposure over a lifetime. So we've done MRIs, routine ultrasounds, and a chest x-ray. But the concern for us would be the chest x-ray isn't the same as the CT regarding kind of the lungs, keeping an eye on those. So we get this question a lot about the risks of surveillance. And I do use a lot of MRIs in younger men and women, especially stratified by the intensity and the surveillance rate required. So for example, someone with a low-risk kidney cancer, which would be a stage one kidney cancer that's been completely removed, that patient probably needs two cross-sectional imaging studies. And if those are fine, they may not need anything else thereafter. But if someone has a higher risk cancer, say, for example, a kidney cancer that's spread to the adrenal gland, and we remove those, there's no other cancer deposits in that patient's body, but they're at very high risk for it coming back. That patient may get scans every three months for a couple of years. And so I kind of think about that. If it's just going to be two CT scans and I'm confident that patient has a pretty strong chance of being cured, then I would not hesitate to do a CT scan. In general, we know that CT scans in the chest are better than chest x-rays for lung surveillance. But again, the sort of marginal benefit in someone with a lower-risk kidney cancer is probably low. And I would probably just do a chest x-ray in someone where their cancer has more aggressive features than I would have a low threshold to do a chest CT. If we're stage three. I would get a chest CT. And I've never had a problem with insurance coverage. Any other questions?