recovery Monday at least for now is their life after recovery what does it look like what comes next it is Monday this is episode 33 of recovery Monday so let's go through that now and I'm gonna put the chat up on the screen like I usually do as you guys pop in just let me know that everything is working as you can see slightly different setup today I'm just tired of sitting in the office so new MacBook that allows me to do this with a new camera and everything so hopefully it's working so just let me know that everything is working that you can hear me that you can see me all good thanks be appreciate it I needed to actually needed a new MacBook to be able to do this my old one could not encode the audio the video fast enough so and it's beautiful out and this is where I want to be so this is where we're gonna be for the next 20 30 minutes let's see what happens I'll just let everybody kind of kind of stream in here usual suspects I'm sure everybody just let me know where you're coming from let me know how you're doing thank you GBG I appreciate it YouTube is here Facebook is here I'll remind you that if you're coming from the Facebook group I won't be able to see your name I'll only see Facebook user but that's not new hello Katya how are you Kendra is here I just will remind everybody pretty quickly that every week or for the last 33 weeks or so this is the last chapter in this book we have been doing lessons right out of this book the anxious truth this is my anxiety panic and agoraphobia recovery guide so if you do not have this book and you want to go back through and read along and go back and listen to all the old videos you can check this out on my website at the anxious truth calm that's where all my other stuff is too so let's get cooking here this is always a big question people want to know like hey are you fully recovered and what does it look like what is what is recovery actually look like when it happens so we're gonna talk about that today there's a lot of really good stuff I think this is this was probably the most uplifting part of the book that I wrote when I wrote it was my favorite part it's a very short little chapter at the end but yeah kind of give you a glimpse of what it looks like and what you can look forward to and and all that kind of good stuff so hey everybody Jersey is here st. Louis is here the UK is here what up Jason how you doing I am inspiring your son well thank you those are very kind words and I'm happy that I'm able to do that in some way I will try to continue if I can so this week we are on the very last chapter of the anxious truth this is chapter 6 there are no lessons in it it's one little short chapter and it is called see it what's next so this chapter is all about essentially like where are you now now that you've gone through this whole book now you may be working on your recovery plan now that you're actually actively engaged in the process what do you have to look forward to so I'm gonna read a little bit out of this because I think it's you know there's not a lot to read and I think what I wrote sort of says it when I set out to write write this book my goal was to take you from sort of lost and anxious and confused and afraid and discouraged to empowered knowledgeable understanding and maybe inspired or emboldened to actually move forward you didn't none of this was your fault if you're in a hole right now you didn't decide to go there you know so yeah it's a let's see hang on moves cat away from the touchscreen his tails making it up and down it could be me rattling this table to I don't know I can't tell I don't know if I have image stabilization in the camera so anyway if it's the cat you know so my goal in writing the anxious truth was to take you from that point to get you to the point where you're not lost anymore you're not confused you're not Claire we've called it be willed you're not discouraged you don't feel lost or helpless like you have some idea of how you got to where you are today what the nature of the actual problem is what the nature of the solution is how to make a plan to go toward recovery how to execute that plan how to start moving forward so that was really my goal my hope would be that when somebody gets done reading this book that's where they would wind up so as you move down the road and get further along the recovery process those are the things that I think you have to look forward to you don't feel lost you don't feel confused you don't feel like things happen to you randomly you don't feel like you're being attacked by some external force that you can't control you have some idea of what's going on you have you have an idea of the mechanics of this you have an understanding of the concepts of an anxiety disorder and the concepts of recovery and those things become portable and they stay with you long past your last panic attack long past your agoraphobia and there are things that will come with you throughout the rest of your life as we go through this journey and that's one of the things that I want to talk about today for sure great the sun is moving which is going to change the exposure so I'm making this up as I go along here let's hope I want to lean forward a little bit let's see so what I talked about here is what comes next what can you expect as you execute your recovery plan is it really possible to live free from fear and what will your new life look like and the answer to that is yeah it is possible to live free from irrational fear so let me be clear about this this is not about like oh when you're fully recovered you'll never be anxious again or you'll never be afraid again that's not true and that would be completely unrealistic wouldn't be fair for me to promise you that you may experience anxiety you may be an experienced things like panic you may have intrusive thoughts sometimes you may be afraid and uncomfortable sometimes it just won't rule your life anymore so if I were to have a panic attack right now which is certainly possible I would want to but I might I could have a panic attack today it would come it would go be over in 1015 minutes I'd feel shitty for another hour or so afterwards I'm sure and then it would be done it would be over I wouldn't have to think about it anymore that's what it looks like that's what recovery looks like you are living a life free from irrational fear you're no longer being dictated to by your fear all the time it doesn't drag you up and down the street anymore recovery is really about having built a new healthy normal relationship to things like anxiety panic and fear that's what we're after here that is a full life for a human being we do not get to walk on the planet free of anxiety or fear always being happy thrilled and totally comfortable and content all the time that's that's not what life is that's not the human condition so we just want to get back to being fully human the healthiest way that we can be and that's what that sort of looks like one of the things that happens along the way is there's so many ups and downs right so to quote my one of my favorite movies a lot of ups a lot of lot of ins a lot of outs a lot of what have you right so that's what they said in the big Lebowski there's a lot of stuff that goes along with the recovery process there are a lot of experiences there are a lot of lessons they can learn there are ups there are downs there are all those things and there are lessons in there patience and persistence you learn new I'm going to read some of what I wrote here you will learn new ways to view the world things that seem like threats to you now will be easy to dismiss when you are done that is so important the things that you feel are important and terrifying and must be addressed and and are impossible to deal with and you know you can't control will not seem like threats to you anymore so that's what life after recovery looks like that's what comes next you'll build confidence you'll discover your inner sense of competence competence comes before confidence by the way nobody goes through this process without gaining an appreciation for how strong and able they really are and that is true you might think of yourself as weak or unable or or whatever but it's not true you are you actually are and then in the end the hard days and there will be hard days hard days will teach you for compassion for yourself how to be patient how to let yourself off the hook how to not beat yourself up these are all really important things you learn those things but in the end when you learn to be compassionate with yourself you learn to be compassionate with other people too so there are so many really great benefits that come out of this process there are no benefits to an anxiety disorder I'm not that guy I'm never going to tell you that I may have to muck with my exposure just a little bit here because the sun is going to be a little bit brighter but yeah there's there's self compassion that comes out of this there's patience there's an understanding of how strong you are how capable you are there's a sense of competence there's a sense of confidence that comes along with that and you get to be a little bit more compassionate and a little bit more patient a little bit more understanding of other people whether they're going through similar problems or just life in general so these are the things you have to look forward to and one of the things that I say all the time I wrote this process and the process of solving it can feel like walking through fire it may be but there is gold forged in those fires and I write that from my heart in my own personal experience and I say it all the time there was gold forged in those fires and yes I was on fire I was in the fire I was walking through it but in the end there was gold forged in there and it mattered but here's probably the biggest thing for today I think most people will say okay yeah that all sounds great but Drew is it really possible to actually recover and the answer is a hundred percent yes but people will feel like they'll say is it really possible to live a life free of this misplaced fear or is recovery just a pipe dream I hear that all the time is this just a pipe dream this is never going to happen for me right and I understand that when you are struggling it seems like recovery is not possible and I think everybody who's been through this has felt that from time to time it happens like I don't know is this ever going to get better but the bottom line is that yes it can get better I would not have invested the many many many many hours of my life that I have in this subject if it were not possible I did it I watch all of you guys do it there are people in this video right now in the comment section that are doing it some of which have actually done it and might call themselves fully recovered yes it is a hundred percent possible it's not only possible but it's it's actually doable it's not this crazy long shot even though right now you might think that it is a complete long shot but it is not once you start to understand and apply the concepts and do the work and learn the lessons and uncover that strength and that competency and that confidence then yeah yeah it actually is possible it's not only possible it's almost inevitable as crazy as that sounds and I know that right now you're judging that based on but I feel so badly right now but I feel so bad and all I want to do is never feel like this again and it doesn't seem possible to feel good again but I want you to understand the difference between feeling better and getting better which is something that I read in David Burns book uh feeling good he wrote a book about depression and he talks about that all the time there's a difference between feeling better which is what you want right now and getting better which is really where you're headed in recovery when we get better we get better at forming that relationship with anxiety and fear and panic and vulnerability and all of those things the intrusive thoughts we build new relationships with them somebody asked is recovery never having anxiety or intrusive thoughts no that's not recovered it could be it's very possible but when you build this new relationship I know it seems completely far into you it's like trying to explain the color red to somebody who can't see but trust me as you go through and you discover these things and you have these experiences again and again again you start to understand that oh that's right if I see this a different way if I relate to this behavior really in a different way it can never be the same again it can never be the same again if I have a panic attack today that panic attack cannot be the same panic attack that it was in 2005 it can't it's impossible it can physiologically feel the same I can have the same scary thoughts I can have the same fear but it is not the same experience that is critically important that's the difference between feeling better and getting better if I have a panic attack right now it would not it would look the same and feel the same but it would be a completely different experience than I used to have change exposure again I guess it's getting sunnier and sunnier as we go sorry guys hopefully this is working out the other thing that I would say about is recovery possible is not only is it possible but it's just it's not just people who read my books or listen to the podcast or people in the facebook group or whatever this is not new stuff this way of approaching these disorders the way we talk about it the way I write about it the way I talk about it in my podcast the questions you guys asked these things are all pretty well proven at this point this is not a thing that I invented I didn't come up with this I didn't invent any of it to be totally honest with you I just appear to be really good at teaching it and talking about it but this is stuff that we have been working on for decades and decades and decades starting in the very beginning of behaviorism and behavioral theory and cognitive theory and combining those two and sort of the old school CBT which was really very effective but now we're even better at it with the more third wave therapies that are targeted toward the particular problems that we're addressing in this community yeah this is not just me it's not just oh I got better and Ingville got better and Bethany got better and the admins and jews facebook got better like people that never heard of me get better this way every single day every every every single day where you're not I didn't make this up this is not new okay this is not new so that's kind of what that looks like so in the end I asked the question so what does life look like after recovery and I'm just going to read this for me because it's really like the last couple of paragraphs in the book what will life look like after recovery so I wrote without all that misplaced misplaced fear there is no avoidance there is no need to retreat or escape there are no safety rituals no special requirements to get you through a day you won't get through days you will live them that's what it looks like in a post for your life you will experience human emotions without being afraid of them after recovery where you will you will find yourself be able to plan and set a course for yourself without being obsessed or paralyzed by worry your sense of internal direction will grow and get stronger this is the ability to make choices and trust yourself without endless doubt and questioning you're craving for external guidance and validation begins to fall away knowing that you are capable of doing life on any terms you will act more confidently and assuredly than you ever imagined possible that's what life starts to look like after recovery trust me on this there will be challenges for sure but in the end I address that there will be challenges of growth achievement and satisfaction but you will no longer be challenged to simply exist and survive your ability to accurately and objectively obsessed challenges and threats will surprise you right now you have no reasonable ability to assess challenges and threats everything is a threat everything is a danger everything is an emergency to you right now it won't be like that anymore like emergencies become very clear I know when an emergency is right now and trust me there are very few of them in life even though back in 2010 you know in 2008 and 2005 and 1999 my life was one giant continuous emergency now I have very few emergencies a much bigger life with much fewer emergencies I want you to chew on that for a little while that's another that's another thing that life looks like after that and then in the end you know people often wonder how do you how can I get the old me back and I wrote about this here and I can speak to that personally this is something that I used to pine for all the time all I wanted to do was get the old me back I wanted the old Drew back but in the end most people who go down this road will say well I didn't necessarily get the old me back I got a better version of me back I'm not saying you're broken and need to be improved or fixed or made better or anything like that everybody is valuable in every state that they're in but the lessons that this process taught me I am I am a far more well-rounded person I am a better version of me than I was before I wanted non-anxious me back but I didn't get that person back I got a better version of him back and this is a thing that I hear echoed again and again and again in the community all I wanted to do was never feel anxious again and in the end that's what I wanted but that wasn't really what I needed and when I got what I needed I realized oh I'm way better than the old a non-anxious me used to be so keep that in mind as you pine for the days when you didn't panic or you didn't have intrusive thoughts that's not the point like learning to deal with these things in a more productive way a healthier way changes everything everything yeah just to comment here I feel like I'm more emotionally rounded it's it's nice it is nice it is nice I can tell you that I'm much I'm much more emotionally well-rounded now than I used to be for sure you know I was a little bit I was calling myself armor plated you guys have probably heard me talk about this before I was like coated in titanium nothing bothered me I never got anxious I don't know if that was true now then retrospect but I have a much much more enhanced ability to experience all of the emotions that come along with being a human being and I like that that's actually a good thing when I was at the worst of anxiety and the worst and in my most depressed you know times my emotions were my enemies I did not want to feel them I was not good at feeling them before I developed an anxiety disorder during they were off limits every emotion became fear but now I am very grateful for the fact that I get to access all of my humanity and all of those emotions even the ones that kind of suck like sadness is not a fun emotion but it is a it is a birthright it is the right of us as human beings to feel all of those things they all matter sadness even does have a place in life this morning I was reading a little bit about the difference between sadness and suffering we'll talk about that one day in one of these live streams but this is what happens like a better version of you a better well-rounded version of I can't I could go on the for hours about this stuff but the main thing that I really want to stress again in my own personal experience is my life is 10 times the size that it used to be what I was where you might be today but I have one tenth of the emergencies so you have to ask yourself well what is that all about so it's a much bigger life with far fewer emergencies urgent situations threats dangerous situations things that I have to really worry about be paralyzed how will I feel when I do that I make no decisions now based on how I feel and people who go down the path to recovery echo that sentiment I am no longer dictated to by how will I feel if I do a thing will this trigger me I don't care about triggers anymore triggers don't exist all right so that is chapter six of the book which is a short little chapter that gives you a glimpse and hopefully what is coming down the road as you get further down the path to recovery and we use that word you know recovery all the damn time tried to define it a little bit I know some people are not still not sure hey caterpillar get out of here what recovery looks like and in the beginning stages let me just acknowledge that it is normal to want to shoot at feeling better that's very normal it's okay it doesn't mean you're doing it wrong everybody starts but I just want this to go away and I just want to feel better everybody starts there it's okay but that's where you are right now over time that goal starts to change and evolve and get massaged a little bit and I don't know what's coming down the street because you might be able to hear it but yeah so it changes and we stop trying to feel better and we start working on actually getting better so hopefully this helps the caterpillar completely wants in on the on the video for sure so I will see if I take a couple of comments here as we go by the way the fact that we've done this for 33 weeks blows me away we didn't do it 33 weeks in a row we had to skip a few but 33 of these it's been a very enjoyable experience I'm happy that you guys came along for this ride so let's see if there are any questions and comments that I can answer here we already know that the cat was shaking Becky's screen Sylvia the wolf is just a great name I'm here for that oh Carol this makes me happy to see I've had more confidence since following your podcast let me just be clear about this though that that makes me happy and I'm very thank you for the kind words it's very nice of you to say that but I need to point out a thing you have more confidence not because you listen to my podcast you have more confidence because you listen to my podcast and that informs new actions you take the actions Carol and anybody who's listening you do things I just point you at the things to do and then you do them and that is where the confidence comes so my podcast doesn't give you any confidence at all you make your own confidence and that is the best so thank you for saying that I appreciate it uh so let's see here I'm gonna keep going I'm predictable lighting makes it more exciting I don't know it still looks like looks all right it's doable so far the autofocus is working I'm here for all this the technology is treating me good it's all right um oh this is good mickey thank you for saying this I'm a I will be a much better person after recovery my empathy is so much more now yeah it kind of is like it is really hard to go through these challenges and face them and move through them and navigate through them and not build a greater sense of compassion for other people and for empathy there's a certain level you know I'd like to think that I've always been a kind person I don't know maybe some people would argue with that but I would certainly say that I think I'm a far kinder and warmer person now than I used to be and that is all from having gone through this 100% um this is important I can't sorry that I can't see the name knowing the mechanics of second fear it's this is one of the reasons our second fear is for those of you who have read the Claire Weeks books she talks about first fear second fear it's an important concept in my world I talk about your reaction right it's never about what we do it's about not how we feel it's about how we react to how we feel reaction is the second fear that is so important this is one of the reasons why I've talked at length before and if you're in my facebook group you know I say this like it's far better to take advantage of resources like this book that we're talking about like my podcast like other books like folks like Josh and Kim and you know the usual suspects that I work with you know access that information and learn the concepts of recovery learn them and then apply them that is so much better than just asking oh well now I feel dizzy what do I do about that now I can't breathe what do I do about that now I feel like I'm having a scary thought what do I do about that learn the concepts educate yourself and then begin to apply them that is leads you to that lasting recovery and the big changes that I'm talking about today just asking how to deal with every bad feeling as you go it would lead you certainly to believe that this thing that this guy is talking about today is ridiculous I'm never going to get there but if all you do is ask for directions on the thing you're feeling right now and then ask for new directions on the thing you're feeling tomorrow then yes it would seem impossible to get to where I am and where we covered people on but it's not but it's not so let's see here Sean what up dude I made it on time today doing a bit better there's no there's no butts all right I dig it man let me put this on the screen I appreciate this brother I made it on time today doing a bit better and there's no butts even though I want to say that good job man for those of you who don't know Sean's working hard at this too and no buts is the thing I say all the time is there no you know no buts because you always want to say like okay but yes but there's always a but anxiety will always throw the but the exception to the rule oh I hear what you're saying drew but but what about when but what about when it feels like no there's no buts no but but doesn't doesn't get in there so let's see okay this is cool it takes time the brain has no choice but to change when I said before that recovery is almost inevitable like our brains are so incredibly adaptable and plastic and and changeable and they're amazing machines it's ridiculous like we got so lucky that we have them there's bad design sometimes they go a little bit off the rails there's no doubt about that but there's such amazing machines and such amazing inventions the brain is amazing that yeah it's almost inevitable when you feed your brain experiences and and behave differently and relate differently to the world around you it almost has no choice but to change it almost has no choice so there you go oh monica's here I'm living proof of recovery thank you monica I appreciate you popping in and saying that offering some encouragement it's always nice to hear from people who have gone down the road so let's see what we got here uh no no no no no um I'll put this up this is a tough one sometimes I can't I can't necessarily answer specific questions because they don't know you and I don't know the situation but if you get really high anxiety around types of people of what happened in the past is there weeks there would be good for you that's a it's a reasonable question I've talked about this I think I've made Instagram videos and posts on it I don't know if I've ever done a podcast episode but if I didn't I will not everything is a clear weeks problem not everything in the world is an exposure problem not everything is a floating and accepting problem it's important that we recognize that's not true especially Muhammad I don't know the specifics I can't I can't know the specifics we don't know you but um especially when you say things like anxiety around specific types of people the cause of things that have happened so I'm always super clear and saying if you are dealing with people who have harmed you literally harmed you or are harming you or have committed you know bad acts against you uh people that are legitimate threats to your safety whether that be emotional mental or physical that's not an exposure problem right so that's not an exposure problem if somebody has harmed you then that is not a float and accept problem at all some of the techniques that come along with that can be useful in working on those things but we never we never just say well we'll have to learn to accept dangerous and abusive situations I don't know if that helps answer your question my friend but it's it's always important that I say okay this is a good hyah good name hyah 139 uh first of all just a big shout out for getting to the dentist which is really great visits to the doctor and the dentist huge in this community everybody is afraid to go to the dentist most people hate the dentist anyway like dentist must have the worst complexes inferiority complex just nobody likes them but um this is great congratulations on getting to the dentist but I put it up on the screen because this isn't a program I guys you guys laugh at me when I say that this is definitely not a program you're not following the drew program like I said before I didn't invent any of this this is this is a pretty well worn methodology for dealing with an anxiety disorder I'm just teaching it and I seem to be good at teaching but thank you and I'm glad that you made it to the dentist it's really great um keep going let's see here the dentist sucks see everybody hates the dentist man hate it okay let's put this one up on the screen every time I have an anxious or bad day with thoughts I think I'm still unwell I'm not recovered uh we can't I can't tell you you're recovered or not recovered again because I don't know you but I think I'm still unwell recovery is really initially defined and what you do it's okay to think that you're unwell so in that situation especially in the early days um when you have an anxious thought or something scary happens or you're just having an anxious state a bad day if you well and you feel that you are unwell that you were in some sort of danger something is really wrong you always think that it's okay to think that we are moving toward recovery when we act differently toward that feeling right so it's okay to still think that something is really wrong what we really care about is the changes in what do I do with that feeling how do I act toward that feeling how do I react to that alarm in my brain that says oh something is really wrong this time so no having the thought doesn't mean you're not recovered it's what you do in response to that thought that defines your path toward a state we might call their quotes recovered hopefully that helps this is good I'll put this up on the screen I appreciate this man like mentioning the neuroplasticity neuroplasticity is a thing sometimes I'm a little bit reticent to to talk about that and throw those words out there because sometimes when people are suffering and they're just trying to feel better all I want to do is feel better we can get caught up in terms like neuroplasticity like it's some sort of magic thing neuroplasticity is an amazing thing that's what I was saying before like brains are amazing people who suffer strokes learn to walk again and talk again and feed themselves again because your brain is amazing you can just build new pathways and relearn things so neuroplasticity is one of the probably the biological basis underneath all this we feed our brains new experiences with different outcomes and new pathways are formed that's that's neuroplasticity and it is our it is our friend here it is our ally in this process the thing that sucks is that neuroplasticity also goes the other way it's the ability to learn and change but that same neuroplasticity is what gets us sometimes into the situation uh-oh I started interpreting my thoughts and my my physical sensations and my my emotions as a threat I interpret them as threats I learned to be afraid of them and then therefore I become continually afraid of them that's also unfortunately neuroplasticity but it happens but the same mechanism I think I wrote that in the ancient truth somewhere the same mechanism that got you there the neuroplasticity that got us into this mess we actually backs us out of the mess so it's a good thing that it exists all right scrolling down scrolling down scrolling down uh uh always got to put up a better focus they're always good when you grow in your capacity to feel feelings are no longer disasters and threats I can't add to that that's really really good and that's true I'll throw this up on the screen okay do I not practice anymore at the recovery that's a really good question that is an excellent question do I practice being recovered no I can't say that I say I have to practice dealing with anxiety anymore I don't but what I do do is I do have a set of habits and rituals and I don't know call it self-care so call it mental health maintenance physical health maintenance just the things that people do to be healthy I meditate I try to take breaks throughout my day I exercise on a regular basis I try to make time to do things that I enjoy I like to learn I like to learn new things like to read I like to watch videos about cool subjects that I find fascinating I like to play my guitars badly but um so is that practice yeah yeah that's that's those are just good life habits I don't do them specifically to feel good or to make sure that I stay recovered but I have taken those habits that I learned in recovery and I they look a little different now but yeah I I just engage in what I think is is good mental health and physical health hygiene and um yeah it helps a lot so no it's not not recovery practice but I do do those things maybe that helps this is huge Katya says a lot of people say they learned that they are capable of much more than they thought they were and it is so true at the heart of this is the idea that what you are feeling physically or that you what you are feeling thinking mentally or feeling emotionally is going to be air quotes too much this all comes down to it's too much and I can't handle it and my inability to handle it will lead to some disaster of some kind be a physical emotional breakdown meltdown psychotic break everybody thinks that it will be too much but it's never too much right so none of what you've ever felt has ever been too much and so when you have these experiences in this new light and reframe this different way this experience teaches me as opposed to this experience tortures me and must never be repeated you start to understand like oh yeah I've always handled it I didn't like the way it felt it wasn't ideally handled but it was always handled this this has never broken any of you anybody that's in this video right now has never been broken by by anxiety or fear it's really important oh Kat this is great this is the parlor with the price of profission right there I used to be sad my old self is gone but thank well thanks to you you're doing the hard work I'm starting to love the new me I'll tell you a really quick story about that a little bit of a personal story and I and I think I've I may have told this before once or twice I don't know I used to pine away being in the technical field that I was in in this ridiculous brain of mine I remember zillions of passwords zillions of lines of code I have a silly brain that way and so therefore I would never write anything down had no notes nothing was documented I would configure networks on the fly global networks in real time without testing shit in the lab like I was that guy and I missed that guy so much because I couldn't do that anymore when I was my brain was so occupied with fear and anxiety and all of those things that that ability began to erode I would forget passwords I would forget commands I had to start to write things down which felt like such a tremendous failure for me because I was never that guy and I remember it was over Thanksgiving weekend it was actually on the Paxil Progress website which doesn't exist anymore but I was an admin of Paxil Progress which was all about anti-depressant withdrawal thousands of thousands of members it was a very big website and we were upgrading I was an admin but I was also the technical geek so I was in charge of the servers and whatnot and we were upgrading one day it was Thanksgiving weekend and I was sitting in my office and we were upgrading the Paxil Progress site and forklifting it from one server to another and I had like six different terminal windows open and I was just just going back in between them not thinking about anything and it was a little bit poetic that I had the realization when I was working on that particular website that I was still that guy like I was still that guy but but here's the difference I was typing away like a crazy person and just jumping from window to window and I was on different routers on servers and I was installing software and I was doing everything that I needed to do without even thinking about it at really fast pace because that's the way I could work and it dawned on me that the guy that I missed so much was still there but I actually cried a little bit that's the that was the better version of that guy because the guy that I used to be would just finish the project and I give it a second thought and I'd appreciate the ability to do that not care and just move on to the next day but I realized that I was still that guy and it actually actually a little bit of a little emotional for a couple of months that was okay so there's a story for whatever okay let's scroll down nearly to the bottom here I nearly made Carol and nearly made you cry I'm crying in recovery Monday that's okay you're free to cry it's all right dude let's see here oh this is good let me let me answer this for Maureen real quick let's talk about this any comments and the void anxiety used to fill this is really good this is a good like what comes after recovery comment right there's a void and yeah there is as crazy as it sounds there is a void so it's funny you guys have seen me talk to Joe Ryan Joe Ryan.com he's been on my podcast he's actually on the podcast this coming week we have a really good episode coming up Joe and I've been buddies for a long time we had a conversation a couple of months ago where the term emotionally unemployed came up and we talked about like hey remember when like we have similar stories Joe and I and like all of a sudden my full-time job was no longer being an anxious person I didn't know I didn't know what to do with myself I remember calling my old therapist who I didn't have for very long and I called her for like a one-off session I said what do we do now what the hell do I do I didn't know what to do my I had been fired from my full job full-time job trying to not be anxious and she said I don't know go to Starbucks and have coffee I was like what like that sounds ridiculous she's like yeah I don't know go to the beach sit in sit in the sand for a little while so she just threw out ridiculous things or what I thought was ridiculous like how is that supposed to help me what is that what does that do but in the end she was right so there is a little bit of a hole when you no longer completely consumed all the time with how you feel and trying to not be anxious and trying to like navigate through all this stuff all of a sudden you have all kinds of extra cycles in your brain available and mental horsepower and emotional horsepower just time and my best advice to you Maureen and anybody who has this question is just start trying stuff again sometimes you don't know what you want to do and how you want to fill that and the best way to figure that out is to just start trying things sun is on me so let's try and get the exposure a little bit more there we go hopefully that's better so yeah just start trying shit that's the way I had to do it this is a common question why do we have to take one step forward and six steps back all the time dude those aren't steps back I'm not I would I would tell you that they're not steps back so your your thought is like oh well I feel I feel a certain way you know so I was feeling better and now I don't feel better anymore I'm feeling a thing I'm thinking things again so that's backwards no it's not like as long as you continue to work on how you react to how you feel then those are not six steps backward I mean I wish I could tell you that every single day is an improvement linearly and you just that's it and you're done and you recover quickly in three months it doesn't happen that way I can't tell you why but I don't be careful about six steps back you know and this is such a common thing we're talking about recovery looks like but I hear it all the time and it makes me a little bit crazy I'm back to square one I was doing so great I felt so good for two weeks and last night I had a panic attack and I'm back to square one six steps back that's not true that's not true oh you oh you feel things or you're thinking things humans think humans feel you're learning to do that again in a more productive sort of normalized way so take it take the practice right so it's important to say that and I think one of the reasons why it's not linear to be honest with you this is just as me postulating I have no evidence of this so take this as gospel but you know that that threat response anxiety is here to keep us safe it thinks it's keeping us safe that part of our brain that part of our functioning is designed to keep us safe from threats things that that could be problems for us so it would be a bad idea in terms of design and evolution or whatever you believe to design that to be easy to turn off we want a survival and threat threat detection mechanism to be fast to be brutally like efficient to be easy to turn on and to be hard to turn off and we made that response if that response was really easy to turn off we probably wouldn't be here we would have died out long ago saber-toothed tigers would rule the world anyway let's see Layla is here hey Layla good to see you my friend all right let's give a little shout out to Layla who's about to get her hair cut in college and I know that that is a big deal for you and I appreciate that you guys if you want to you should go follow uh Layla on instagram she is at letter cottage the letter cottage how could I not know this but Layla shares pretty openly about her anxiety stuff um and she's just a good person so go check out Layla on instagram so there you go I put the comment up twice sorry about that let's see here a couple a couple of last comments and we'll hit it after recovery do we still have yes let me throw this up on the screen really quick after recovery do we still have the flight flight freeze response that's part of being human yes we do it just it doesn't get triggered at inappropriate times the problem is that fight flight freeze response is on an absolute hair trigger right now everything becomes a trigger whereas in recovery like yeah I hope I still have a fight or flight response I really need it I like I like my flight or flight response I just don't need it all the damn time like I used to think I needed it all damn time so no we want that we we're not trying to engineer that engineer that out of your life it just becomes far less important because it rears its head far less often all right does that make sense lawyers have the worst complexes is that true maybe it is true I don't know um let's see I lelly I'm all I'm going to say is don't get so stuck on like is this recovered am I recovered now is this recovered is this proper recovery you might want it last week's recovery Monday we talked about that sometimes that paralysis that happens when you want to judge every single thing you do judging every thought you have every action you take is this recovery is this good is this right drop that drop that I feel like have to accept things I did today practice okay that's that's the process of recovery right so stop worrying about whether you are recovered and just work the process I did a podcast episode not too long ago about being process focused and not outcome focused so I would tell you to go check that out in a big way don't worry so much about the outcome just just stay focused on the process what you're describing there in that comment is exactly what the process of recovery looks like so keep going no no no no no let's see okay I'll throw this up real quick but then well let me just see how much I got there's probably no many more yeah we're at the end okay let me pop up one more time because I think this is probably an important one I cried it must be a recovery thing let's say stick with me here I just saw a comment about an actual dangerous situation where the hell was it I'm sorry let me scroll up scroll up scroll up here we go throw this one up real quick Horace how would you suggest dealing with high anxiety or near-panic when in dangerous situations like being in a train or a bus when a fight is about to break out or robbery is happening that is where recovery is not recovery that's where anxiety and fear actually are sort of purpose we want them so when I said before I want my flight flight and freeze response that's why I want them in that situation you would you have to make the best assessment you can like I even got to get out of here which is totally okay if there's a robbery going on in the restaurant that you're in and you can get yourself out of that then by all means do that like nobody is telling you that you're supposed to float and accept through literally actually dangerous situations like that if there's a fight happening next to you and guys are throwing punches at each other and you have no needs to be throwing those punches and get that get at it that's totally okay I think that's a confusing thing for a lot of people too that's somehow or other like the principles of recovery will apply to every aspect of life and they do not so if there are two dudes going at it with knives next to me next to you then by all means get the hell out of the way like that's okay that's when the actual healthy normal purpose of flight or flight matters so we want it to be there right all right so i'm scrolling down a little bit here and I think we're good let's see here that's recently messed up like yeah it's not working on that anxious okay this is good Kendra's gotten the this is the process versus outcome thing I used to be like yeah it's working I'm not anxious and then when you would get anxious like all of a sudden you declare a disaster right oh my god it's horrible it's horrible it's horrible but in the in the end when you become process focused you stop doing that you could be frustrated that you're feeling anxious today or feeling like you're having a bad day that's normal uh you just don't have to be afraid of that and call it disaster all right so yeah um all right I think I'm kind of pretty much out of comments here very good let's watch beaches and what about Bob I'm working on what about Bob I don't know that might happen it might never happen we'll see anyway guys that is it we are done we have finished this book I will remind you that all of the recovery Monday episodes stay on my youtube channel they're in a playlist called recovery Monday and if you don't have a copy of the anxious truth you want to get it just go to my website at the anxious truth.com and you can grab it and then you can go back and watch all of these videos again and you go through the book chapter by chapter so if you want to do that you're certainly welcome so what are we going to do after this I haven't decided yet but I think what we're going to do is we're going to do this book right does that backwards I think it might be backwards I can't tell my mirroring my video so I think we're going to do seven percent slower after this it's a much smaller book but I need a little bit of time to sort of break it down and see how we're going to go through lessons and seven percent slower but we will do that I think next week probably no live stream I have no classes next week I have a week off at school so I'm going to try not to do a live stream next week but I will make an announcement after that and we will do the first seven percent slower we'll do Q&As now and then I'm going to try and bring some of the crew back on from time to time you know the old crew and we'll do some Q&As with those folks and we'll keep it going I like the Monday live stream so I will figure out what it's going to be we'll definitely do seven percent slower and we'll sprinkle some other shit in there too so thank you guys for coming out and hanging out with me for 33 weeks we'll go figure out another 33 after this I guess anyway that's it see you guys later


It's my pleasure to introduce our next speaker, Alice Fan, who's an assistant professor of oncology and a colleague of mine in our medical oncology division. Alice came to Stanford. She did her medical oncology training here at Stanford. And we were, again, fortunate to have Alice be interested in kidney cancer research. And she's now part of our clinical faculty. Alice spends a big part of her time in her lab looking at how best to study kidney cancer and the various drugs that we use. So I think one of the questions were about how can we detect from our tumor cells which therapy is right for a given patient. So Alice is going to tell us about her work and how the technology that she's developed in order to be able to get some answers from very little tissue. So again, pleasure to introduce Alice. Thanks for coming on a Saturday afternoon and sharing your work with us. Thank you, Sandy, for inviting me. And it's so great to see everybody here. So it's my great pleasure to tell you today about a burning question in my mind and in many of your minds. How do we actually know if a treatment's working? We've heard a lot this morning about how can we predict from a biopsy, from our surgical specimen, from a drop of blood? How can we predict how long we're going to survive from our cancer or if it's likely to come back? But I'm going to ask another important complementary question, which is once we've actually chosen our therapy based on the best predictors, how do I actually know it's working? Another important complementary question, which is once we've actually chosen our therapy based on the best predictors, how do we diagnose with Sunny's talk this morning and how we can do surgery and how that's important? And a bit about choosing our first treatment. Well, for our patients and for many of you in the audience with advanced dramatic cancer, we know that this is a tough decision. We have a menu of treatment. Then we choose something, and then it tries to do something against the cancer cells. And then only eight to 12 weeks later, and you're tired of hearing this from me and Sandy, how long do I have to wait before we can see if it's working? We have to do a CT scan, but we have to wait eight to 12 weeks. That's when we measure the clinical response, and eventually we'll know if we've cured or relapsed. So just to go over a country recap, some of the things that we've talked about earlier, and then to launch into what I'm going to focus on. We know that a diagnosis, you want to go a standard evaluation, and that's determining your stage with CTs, imaging, in some cases an MRI, bone scan to see if it's gone to the bone. And then if it's advanced disease and you require systemic treatment while you would see the medical oncologist, me or Sandy, then we choose for you the best systemic treatment we can based on all the information that we have. In some cases, it's now increasingly involving additional tests that we get. But it's important to think, OK, well, what are these treatments that are the first ones? And Sumit just gave you a very beautiful overview of especially Neville about one of the newest ones. OK, well, what are these treatments? Oh, this is an old slide. It's supposed to be systemic therapy in 2016. And but you know it's important because in 2014, all we had were the ones in black. And in the past year, the three that I've added are the three in blue. But you know, if you think about it, we've heard a lot today about immunotherapy thanks to the fantastic talk that I've had before me. And you heard about Nevolomab and Avdevo being the newest immunotherapy that we have. And we also talked about mTOR inhibitors. These are inhibitors to a cell and an infinitor that are pills or given IV treatments that actually suppress tumor cell growth and survival signals in those cells. But if you look at this list, by far, the biggest category are pills and IV treatments that are inhibitors of blood vessel formation. And again, this is really important because even the last two that have been approved, Khabazantinib and Linnvatinib, these are inhibitors of blood vessel formation. And again, this is really important because even the last two that have been approved have been inhibited in Linnvatinib and Linnvatinib. I just talked about all these targets that we're trying to do with all these specialized therapies. How do we know that this targeted therapy is working? How do I know that you're tumor? I just talked about all these targets that we're trying to do with all these specialized therapies. So from the time of first treatment, we know that we're supposed to be inhibiting the blood vessel formation that feeds the tumor cells if we give you one of those seven. Or if we're giving you a nevolumab, we think we're supposed to be activating the immune system. But how are we measuring that? Right now, the standard of care is our CT scan. And these are diameter measurements. The problem with diameter measurements, even though that's our gold standard, this is the best we've got right now. But it's billions and billions of cells in every square millimeter of tumor. We think we're trying to hit cells in immune cells that are going in there or hit blood vessels that are in the tumor cells. But we don't have ways of measuring those yet. So this is what we're going to be talking about. Again, the standard reevaluation scan is measuring the size of tumors and how that's changed. But this is why for kidney cancer, that's not always the best way. And we're looking for better ways. So we know that a lot of our treatments don't necessarily shrink your tumors. For a tumor to shrink, there has to be a change in balance. Either the tumor cells are dying faster than they're growing, or they've all stopped growing and it's just not getting bigger. For it to actually shrink, something has to change in the balance. So just a diameter measurement of how big it is isn't telling us as much information as we really want to know for a change in the balance. And the other hard part is that it does take 8 to 12 weeks for a treatment to actually halt tumor growth. So by the time we can see it, we've done a measurement with a ruler. We've had to treat, and you've had to have all the side effects for 8 to 12 weeks before we can actually make that standard measurement. And to make things even tougher, we know that with nevolumab, you just heard that there's a small percent of tumors that actually look bigger at the first scan. And how can we figure out if that's bigger one that's going to shrink later because it's due to tumor cell infiltration with immune cells that are actually attacking the tumor cell, or if it's actually progression? So we have a lot of work to do to try and get better ways to immune the cell. And so I'm gonna tell you about what we're doing at Stanford as well as beyond. So a more direct approach would be let's measure not only the size and how things are changing based on a ruler measurement as beyond, but let's quantify how active the cancer pathways are in your tumor. We think we're knocking down these activity pathways. Let's see if we can prove that in you, and let's try and do it sooner than the cancer pathways are in your tumor. So I'm gonna spend quite a bit of time talking about the seven out of 10 targeted agents that actually suppress growth of blood vessels that feed the kidney tumors. So these are the seven listed here, Votrient, Cetan, Nexivar, Avastin, and Lida, and the two newest ones, Cabometix and Lenvina. And these suppress the growth of blood vessels that feed the kidney tumors. So you can imagine if you've got a tumor, imagine the tumor mouth is in green, and some normal tissue near it. Oh! So you can imagine if you've got a tumor, and if you've got normal tissue near it, the tumor mass, in order to keep growing bigger and bigger, it needs to get oxygen and blood. So you've gotta have growth of blood vessels that go into the tumor and feed it. So we know that kidney cancer is especially dependent on antigenesis, on this growth of blood vessels feeding it. So, and in fact, I don't know if you remember from Dr. Lepper's talk, he talked about the number one genomic hit that we see is in the VHL gene. That's the mutation that actually makes tumors really oxygen-hungry, and they want blood vessels to come feed them. So that's why one of the major targets in kidney cancer is suppressing the growth of blood vessels, suppressing antigenesis. And if these drugs are working, we know that in preclinical studies, you actually see less blood vessels, and the tumors may stabilize, or they may start to shrink, as they lose their oxygen and blood supply. Blood vessels, and the tumors may stabilize, but they may start to shrink. So how can we quantify antigenesis better than just a ruler measurement with our CT scans? Well, this is a special CT scan, called a dynamic profusion CT, and it's a special scan that we're set up to do here at Stanford, and we're studying if that can really help us measure these antigenesis factors better. The things that we're set up to measure are tumor blood flow, tumor blood volume, and how weak the blood vessels are. And it requires very special scanners and software, and we do have this at Stanford. Tumor blood volume, and how weak the blood vessels are. And the hypothesis is that if we're doing an antigenesis treatment, we should be decreasing the tumor blood flow, something that we can't measure with our scan scans. We should be decreasing the tumor blood volume in your tumors, and we should be decreasing the leakiness of vessels. We should be decreasing the tumor blood volume. So we do have a clinical trial that offers you this profusion CT imaging, and the way it works, and it's for patients that are getting any of these anti-angiogenesis inhibitors. We do a scan before you start your treatment, so we see how vascular it is before you start. And then after one week, we do the next scan. Now this is still research, so no matter what we find at one week, we can't make any clinical decisions. We still have to wait for that eight to 12 week scan to decide if it's working or not. But what we're hoping to see is a hint. At one week, if we can see decreased blood flow, decreased tumor volume, and decreased leakiness of vessels, hopefully that will predict what we actually see at 12 weeks with our standard scans, and a repeat profusion CT. So the goal of this study is to determine if blood vessel measurements, not just size, but blood vessel measurements, can change as early as one week. As we know in preclinical studies, things start to change within days, but right now a size measurement can't find it. So we wanna see if the one week measurement with a special profusion scan can predict the 12 week response. So this is very early, but we are offering this participation to any of our patients that are starting these drugs with better angiogenesis inhibitors. So this is very early. And in fact, I think I see a few patients who have actually been on the study. Any of our patients that are starting these drugs with better angiogenesis inhibitors. It is an additional CT scan, and it takes an extra 10 minutes for each one of these scans, so you do have to come back at one week and do this, and it's being run by myself with a radiologist, Dr. Ayak Maya, and you've probably met our study coordinator, Yori, who helps facilitating this. And it's being run by myself with a radiologist, Dr. Ayak Maya. Well that's not the only approach. There are other ways to try and figure this out. So some of you have probably had PET scans. PET scan, or standard PET scan, is when we inject radioactive sugar into you, and radioactive sugar is taken up by tissues that are very active, and dividing quickly or metabolically active. And radioactive sugar is taken up by tissues. The problem with the regular radioactive sugar PET scan is not all kidney cancers take up the radioactive sugar. So one of the radiologists at Stanford, Dr. Iaguru, has a new probe. It's called F18-RGDT peptide. This is a probe that specifically binds blood vessels and it's radioactive. So theoretically what it can do is, if we inject that instead of radioactive sugar, this probe, the RGD2 peptide, will go to all the blood vessels, especially the very antigenic and vascular blood vessels in your tumors. And we can measure, similar to the other study, before starting treatment, how much there is vascularity. And then after one week of treatment, how that vascularity has changed based on this radioactive probe. And then there's a third scan that's done 12 weeks after treatment. This is an example of the type of data we could get. This is a regular glucose FDG scan on a patient with lymphoma, because as I said, the regular scans don't necessarily light up the kidney cancer. And all the red spots, the hot spots, that's where there's active tumor based on the glucose scan. So what we're hoping is we can localize your tumor with this FDG-RGD2 peptide, sorry, the F18-RGD2 peptide, that we can see a similar picture of your kidney cancer. And after we start, again, these angiogenesis inhibitors as early as one week, we're hoping that the red stops glowing. And after we start again, we have had patients that have participated both on the perfusion CT scan, as well as the special PET scan study. So we have had patients that have- Well, how can we do this even more directly? I've just talked to you about several imaging studies, but wouldn't it be much more direct if we could see what's happening in your cells? That's what we want to know. Are the cells dying? Are they growing really fast? Are they slowing down? But wouldn't it be much more direct if we could see what's happening in your cells? Are there blood vessels? Are there immune cells in your tumor? Are they growing really fast? Are they slowing down? If we could even get these cells magically without having to do a big surgery to see what's happening and get a movie, what's happening once we start treatment, what should we even look at? Well, there have been a lot of efforts, and you hear a lot of stuff in the news about measuring changes in DNA, looking at mutations. Also, there's a lot of great research going on with RNA, and in fact, I think you're going to hear more in the next talk with Dr. Alchin about ways we're doing this for DNA. Also, there's a lot of great research on RNA. Well, what I'm focusing on are proteins, because if you think about it, DNA is like a blueprint for building a house. It tells you how things are going to be built, and then RNA is kind of the lumber that everything's made out of, but then it's proteins that are actually the house with the lights on and the lights off, and what we're trying to do with our targeted therapy is turn the lights off, so it doesn't necessarily get at the blueprint. We want to see if the lights are on or off, and that's where the proteins come in, and it's a really hard thing to study, and that's why I've spent so many years here trying to figure this one out. We want to see if the lights are on or off. And the problem is, you need a big biopsy to measure protein in the tumor. And that's why I've spent so many years here trying to figure this out. And so, serial biopsies, if you wanted to look at one week to see what we're doing at the molecular level in your tumor cells, you'd have to get another surgery to get a big biopsy, and that doesn't make any sense. We're not going to put you through that, so it's just been a big black box where you've simply not been able to look. You'd have to get another surgery to get a big biopsy. And the solution may be that we can get away with little tiny biopsies, or maybe you can get away with cells from your blood if we use super sensitive nanotechnologies to analyze tiny numbers of cells. So I'm going to tell you about one specific nanotechnology that I helped develop to do this in cells, but also put it in the picture of a bigger thing. So Stanford for the past 15 years has had a center for nanotechnology excellence. It's run by Dr. Sam Gambier, who's the chair of radiology, and these are some of the projects that are ongoing. It's actually unbelievable, if you think about it.   And if you inject just the right cocktail, your tumor can take up these little cocktail things and in the tumor cells assemble into something we can image.  So this is actually something we're working on right now in mice, and it's my job as leader for the clinical translation of the center to start thinking about how is this going to apply to you guys, how can we use this in our patients and link these technologies to our patients in clinical trials. So another project is using nanotechnologies with Dr. Shan Wang and magnets. Magnets are incredibly powerful. We know from MRIs that's all based on magnetic technology.  So Dr. Wang is using magneto nanotechnology to analyze cancer cells and signals in the blood and I'm partnering with him. So some of you that have donated blood to my tumor biomarker study, we're using magneto nanotechnologies to fish cells out of your blood. Hopefully they're your cancer cells and study how they're changing early after your treatment. We're using magneto nanotechnology to fish cells out of your blood. Project three, Dr. Gambier is running it himself. He's using smart nanoparticles to image tumors using sound waves. And every time I've heard him talk about this, he said, basically you yell at the tumor and with these nanoparticles, they yell back at you. So now you can say, all right, how are you doing today? And it can say, oh, I'm growing, and looking at all the tumor. And with these nanoparticles, they yell back at you. This is kinda amazing that it's coming. So now you can say, all right, how are you doing today? And it can say, oh, yeah, I'm growing, I'm growing, so hot, hey, this is kinda amazing. But I'm thinking really hard with the teams one and three to figure out when and how we can bring this PC, guys, to figure out when and how we can bring this PC. So one specific nanotechnology that I helped develop is something that's now called the peggy sue instrument, and I didn't make the instrument, but I figured out how to use it. So one specific nanotechnology to think about, I'll tell this thing. now called the Peggy Sano technology is because we make measurements in tiny, tiny capillary tubes. And we can run 96 tubes at the same time, it's automated so the robots do it so it takes out all human error because a lot of steps we can introduce error ourselves. And we get a result in four hours. And what do we do with this?  So can we use nanotechnology to measure proteins in tiny numbers of kidney cancer cells? Yes. To determine protein signatures of kidney cancer, probably many of you have participated with me and John Leppert's study, where we're collecting and profiling tumor tissue at the time of surgery from nephrectomy, as well as at the time that our patients are getting radiology guided biopsy. And so far we've had more than 200 participants, so thank you all for being a part of this. And the things that we're looking at are one, the DNA genomic mutations, but also I'm really passionate about trying to figure out if the lights are on, what proteins are actually out of activated in your tumor, and then once we start a treatment, how they're changing over time. So are we really hitting the targets that we think we're hitting or not? And so far, we've been able to sample tumors directly in the tumor, as well as adjacent non-tumor tissue, and see that the nanotechnologies give really high definition of proteins and patterns that are different in the tumor versus your own normal. And see that the nanotechnologies give really high definition of proteins and patterns. So I've talked about trying to analyze the biologic response. And Peggy Sue, this is a nanoproteomics, is one approach to measure and predict response in real time. Wouldn't it be wonderful if we could then either get a sample before you start treatment either by a radiology biopsy or ideally by blood, and that's the direction we're heading. And then a week later, get another sample and be able, at the protein level, to see if we turn the lights off or not. And then a week later, get another sample. So I think there's a question earlier about how do we get drug companies interested in this, because the standard is to get a drug approved right now, we're still using the size measurements. And that's important. That is our gold standard. So we'll never get away from that, but we're trying to think out of the box and figure out what other things can we add to that to make our targets more clear to us. And so ideally we can use nanotechnologies to help define protein signatures that predict therapeutic response and tell you if you're actually responding in use nanotechnology to help define protein signatures. So we can envision that maybe we can do this with an invinably invasive way. We use the nanomino assay, the Peggy Sue, to profile changes in cellular pathways in small numbers of tumor cells, either by a fine needle aspirate, the IR, the radiology procedure, or from blood, that occur after administering a therapy. And it is hard to get drug companies to do this, because, one, it's a lot of money to do these kinds of studies. And so one approach we've had is we apply for grants to do this, so we partner for a clinical trial, we get the study drug, and then we build a whole thing of biomarkers around it, and we have managed to get a grant from the Stanford Cancer Institute and also grants from NIH to fund the things that drug companies don't. And that way we have a really great partnership to try and figure this out. Because we can figure out which patients early in drug development, which patients really do benefit, we can see if it's the one patient out of 20, that's a drug that would traditionally fail if we couldn't pick out which one it was going to be. But with the right biomarkers in the early development process, if we can find that one patient, that's a drug that might get approved if we know that 90% of those patients respond. So everybody's hunting for these biomarkers, and this is one of our efforts to do that. So if you've been approached in my clinic or in Sandy's clinic to participate in our biomarkers, and this is one of our efforts to do that, so if you've been approached in my clinic or in Sandy's clinic to participate in our biomarkers, and for this, we have enrolled over 100 patients so far. So again, thank you for participating in that. That just entails two extra tubes of blood at routine visits. So I'm going to give you one example of how we're doing this in a clinical trial setting. We want to obtain direct tumor measurements when we're testing a new drug, not just the approval of how we're doing this in a clinical trial setting, but also earlier in the process. And as I said, to develop biomarkers to determine response earlier than eight to 12 weeks, we want to accelerate the development of new drugs and select early which patients are likely to benefit, and help personalize the therapy for patients with advanced disease, so not only predicting based on before you start, but early on, figuring out if you're actually responding at a molecular level. And this is really important. In a lot of drug development or clinical trials, if it doesn't shrink the tumors and patients don't live longer, we never know why the drugs fail. We literally have to go back to the drawing board and take just the next best candidate and put it through the pipeline again. Well, if we can figure out at the molecular level, you know what, the drug didn't actually get to the cells, that helps us, that we know to modify the drug so it can get in there. So this is a really important piece that's been missing, but we're really hopeful that we can start answering these questions to really make the whole process much more efficient. So this is a really important piece that's been missing, but we're really hopeful that we can start to analyze changes in tumor cells for a specific drug, CB839. This is a brand new first in man drug, which is a glutamate inhibitor. Glutamate is like glucose. It's an alternate energy source for tumor cells, and we know that kidney cancer is one of the tumors that tends to rely on glutamate, almost as much, if not more, than glucose. So we at Stanford have a Phase 1-2 study that's testing this brand new drug, CB839, a glutamate inhibitor, for its ability to, one, be tolerated, and two, testing if it can control tumors. And wouldn't it be great if we can actually measure the protein that CB839 is supposed to be inhibiting? We want to measure the protein that's producing these energy molecules and see if that's changing over time. And then measure if the energy molecules themselves, the glutamate, are actually decreasing over time. So patients that are eligible for the clinical trial are almost any RCC patient who's switching treatment. It's not a first-line study, so you have to have one thing first, but if you're considering treatment, Sandy and I are always trying to figure out, okay, what this study makes sense for you. This is run by Dr. Telly at Stanford, and I'm kind of running the RCC on with the study here. And the study coordinator, actually, oh, this should be updated, this is Karen Lau. And this is run by Dr. Telly at Stanford, and I'm kind of running the RCC. And what we built into this is not only the blood test that I told you about using the nanotechnology that I'm working on, but also we built in a novel imaging modality to image that pathway of interest, and this is F-18, F-S-P-G, which F-S-P-G is a glutamate probe interest. And let me show you on the next page what that is. Interestingly, so it makes sense. I told you that a regular PET scan is actually imaging glucose. Well, for this clinical trial, we're trying to change glutamate levels, so it doesn't make sense to use a standard PET scan. So we're using the F-S-P-G glutamate radioactive tracer. But that's a very specific thing, and only a handful of patients across the country are going to get this glutamate inhibitor. Could this particular imaging glutamate radioactive tracer have implications? Well, this is getting back to the whole immunotherapy that we were talking about last hour. Is there a way we can better image response to nevolumab, the PD1 inhibitor? Well, you know what? Glutamate is also a molecule that's used in activated T cells. So when your immune cell is really revved up and it's doing stuff, they might glow with this tracer. So what we're doing is we're offering F-S-P-G imaging to patients that are about to start nevolumab here for kidney cancer, or this is also nevolumab is also approved in kidney, in long cancer melanoma. So those patients are also eligible for this kind of imaging. And this kind of gets that we're going towards molecules. It doesn't necessarily matter what kind of tumor you have. But if you're getting a therapy that's tidying something specific, we want to try and make it more cost-disciplinary.  So I think many of you in the audience have talked to them as well. And again, this is just the glucose image of a glucose scan. But what we hope to see is the hot spots, actually, if nevolumab, we want to see more hot spots. We want it to get more red, showing that there's immune activation. But what we hope to see is hot spots, actually, if nevolumab, we want to see more hot spots. So to summarize, what I've talked about, we can now use new technologies to measure molecular changes in tumors over time. Almost everything I talked about is still in the research stages. So we can't use any of these studies yet to make a clinical decision. Almost everything I talked about is still in the research stages. So we're going to switch. But that's what's coming. This is the very first step. So I talked about profusion CT scan to measure tumor profusion. So we're going to switch. The RGD2 blood vessel probe and the F-S-P-G immune glutamate probe and how we're making nano measurements in blood. And they're not mutually exclusive. You can participate in several of these at once. I gave you an example, how we're incorporating these technologies into clinical trials, including the CB839 study. And you can envision the studies that Samit and Sandy are coming up with with immune combination therapies have this sort of approach to be really helpful. And we aim to develop bioparkers to help personalize treatment. Immune combination therapies have this sort of approach. I will close and just acknowledge so many people that make this research possible, including our study coordinators, Tommy is here in the back. And he's probably talking about drawing teams of blood. You are Asia main, Jared, Denise, as well as our whole clinical team. I don't know if you've noticed, but we have a lot of nurse coordinators sitting in the back who are really dedicated to making sure each of us can get you the care that you need. And you can get all the things we've done. So thank you to everybody, especially to making sure each of us can get you the care that you need. And you can get all the things that you need. Thank you, Alice. Any questions for Dr. Finn? With the glutamate inhibitor, can you use those in conjecture with other drugs? Are they being used with nevolumab and with? That's a perfect question. Yes, I didn't go into it. But they were first studying it as a single agent. And there was some activity, but now we're pairing it. So the specific flavors that we have going, we're pairing it with the mTOR ebrilymus and RCC. And there's a new amendment to now start pairing it with the angiogenesis inhibitors as well. So yes, in fact, they might be most effective in combination. And it is still phase 1, 2. It's phase 1, 2. It's very early. Have you seen any positive results yet? It's been presented at ASCO this year that we do see in kidney cancer and breast cancer some efficacy. So it's promising. And this may be a whole new thing. There's a lot of excitement about immunotherapy. But we're always thinking about what the next pathway is going to be to target. And metabolic pathway is a big one that's coming. I think this is not the subject of your, but you just kind of addressed this. I wanted to ask, I think I read somewhere that cancer cells have a less efficient way of using sugar. Is that something that you're, is that what you're talking about metabolically? Like try to stop glycolysis or some other kind of? Exactly. So cancer cells are incredibly smart and resourceful. One, they have very high energy needs. So just the usual ways of getting a breaking down sugar or making sugar for energy are not necessarily enough. Some patients who have cancers actually have mutations in the sugar Krebs cycle pathway that makes them especially dependent on alternate energy pathways. So studying this balance of energy that's used by tumor cells is definitely a hot area of research right now. And being able to target those is something that we're also actively pursuing. So did that answer your question though? No? Yeah? OK. OK. Any other questions? So you mentioned three different areas of nanotechnology treatments. Now if someone's a relatively new patient and doesn't know much about getting on clinical trials, how does one keep track of what may be taking applicants for trials and deciding if a certain technology might be appropriate for you? That's a fantastic question. Yeah. So for RCC, me and Sandy actually are all over everything that we can offer to you. And in fact, my patients are kind of tired of hearing me talk about it in clinic sometimes. So for kidney cancer, it helps to have somebody that's got a foot in the lab as well as connections to the nanotechnology world. For clinical trials in general, including some of these diagnostic and imaging studies, we do have the Cancer Center website is actually pretty good at Stanford. And all of them are also listed on clinicaltrials.gov. So what I always encourage my friends and patients to do is if there's something that looks interesting to you, bring it to me. And I can help you figure it out if it does make sense for you, whether it's worth traveling to Florida to try this new nanotechnology or therapy even or not. The ones close to the home, we definitely are always thinking about each of you. So it's incredible. We never want to stop till we really continue to find new drugs, new ways to detect this disease, and new ways to treat this disease. So I think Alice is a great example of how that pursuit continues. So thank you so much. Alice.


So my beautiful people, I am back with yet another out and ring ruin farm. Today I bring you another location, another spot within the Mogwin Dynasty area down here within the Silver River area. People call these all kinds of different names but you guys know where I'm talking about. Whiteface Vary questline eventually gets you here but yes, you know where we're at. You know where we're at, the legendary farming spot. Right is another spot here guys, you can throw yourself off the map, swing away and earn runes without fighting anyone. Today we're getting through it all. How's it going guys? My name is dpj and if you enjoyed the video and if you like what you want to see more, be sure to subscribe. Okay, so I've covered two spots here, Pulse Patch, but it was their first spot and I do want to say credit to my pal, Gibroni on my discord who actually showed me the location of this one. Okay so, the original spot, the first spot, the palace approach, alleged road. This spot requires you to jump up there. This isn't a new spot by the way, I'll just demonstrate to you guys the first spot. So this is the first spot, come up here, jump across there and now guys you have to like basically jump this way and then that way like that. This is the, I'd say the first spot, the original spot but hey, the new spot I'm going to show you today is much, much quicker, much less scaling, way easy to get up. I mean, I made that look easy, but hey, it definitely ain't that easy. The other spot guys is back down here and this is the second spot uploaded. This spot is a little more difficult to get down, but once you get it down, it's also easy. I'll quickly show you this and just run down here and pull out my horse. Hey, black grace point by the way is the dynasty mausoleum entrance. So yeah, from here, just pull out your horse and run towards that pillow right there.  Just keep running, keep running. When you get to these rocks guys here, on your left, you have to scale up there. This one can be a little bit tricky, I probably won't make this look any easier. If I say this one, I actually struggle with myself, so jump up here.  And my controller just died. Would you believe it? My controller just died. I would have 100% made it up there guys, and my controller didn't die. Let's try that again. So I just want to jump up there like that, up there like, oh failed. See this one is way more difficult.  Let me get up there first. I want to get up there. I want to showcase it.  But hey, the new spot we shall showcase to you guys today is even easier than that. You want to go back to that dynasty, mausoleum entrance. I want you to go back in here guys, I'll show you exactly where you've got to go. Again, this is way, way easier, there's less jumping involved, there's literally two or three jumps. That's it, there's no, I mean it's harder to fail than it is to actually do. Now I'm my luck now guys, I'll probably fail it. So from here guys, you want to take this route around, around the back here, and you'll see these routes here guys.   Right around here would be completely fine, just jump off here, double jump by the way guys and just swing that weapon, remember you always must double jump, if you don't double jump, you can't swing the weapon, and the reason we're swinging the weapon is because it cancels out the death animation, and what we're doing guys here is we're falling so far down, it's de-spawning the floor that the enemies are on above, and I do believe they're falling through their death, and you're getting those ruins for them. Yes guys, it really is as simple as this, this is by far the easiest method in doing this exploit in any ruins in regards to throwing yourself off the map, this is by far the easiest one found right now, but yeah, let me just, when we get my ruins I'll just run back to that spot, and I'll show you quickly again how you do this just to make sure you're double-certain on how this is done, I apologise if you can hear me spamming my bumper as well, my light attack, that's what you gotta do guys, that's what you gotta do, if you stop doing this now we'll die, yep tried and tested, tried and tested, I think we fought for about, probably about a minute or bit, I actually timed this the other day, there you go right there guys, there you go right there, ruins have been obtained, now you probably can get a few more ticks if you keep falling, but you can try that for yourselves guys, I'm just gonna quickly go back, I don't want the video going on all night, so you guys from here, run round your steps, you can actually jump down there if you want to save yourself a few seconds and put a steal and run round from there, my haste up to you, so come this way guys, pull out your horse, pull out your mount, your steed, your torment, come round here, come as far to the left as you can without falling off, so you don't have to go on your right there, then just jump up on here guys remember, right up there like that, and then guys just run, so I hugged the wall on your right as you jump to the left just like so, and there you go, from here guys just go left, well not there but I guess that works, that's the way you want to go, so yes and then once you're up here guys again remember, come across a little further, don't jump off straight away, sometimes you would die weirdly, don't matter if you swing, come around up here just like so and then throw yourself off anywhere around here guys, and you should be good and there we have it people, guys if you enjoyed the video leaving a like really helps out if you like what you see and want to see more out on Ring, be sure to subscribe and hopefully my better YouTube for people, I will see you on that next one