Well, hello, everyone. Good afternoon, good evening, or good morning, depending on where you're joining us from today. Welcome to Engineering for Change, or E4T for Short. Today, we're pleased to bring you the final installment of our 2017 webinar series on the topic of solutions to reverse global warming. My name is Yana Aranda, and I am the president at Engineering for Change. The webinar you're participating in today is sponsored by the Autodesk Foundation and will be archived on our webinars page and on our YouTube channel. Additionally, those who registered will receive a notification of the recording when it's available. E4C members will also receive invitations to our upcoming webinars, which will be on our webinars page if you haven't registered as a member. 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If you're listening to the audio broadcast and you encounter any trouble, try hitting Stop and then Start. You may also want to try opening up WebEx in a different browser. E4C webinars qualify engineers for one professional development hour. To request your PDH, please follow the instructions on the top of the E4C professional development page after the presentation. The link is available on this slide. A special note about today's webinar, we may push a little bit past the hour in case we have too many questions, but we'll try to keep it to time, as promised. All right, and with this, I'd like to take a moment to introduce our moderator for the webinar, Joe Speicher, the Executive Director of the Autodesk Foundation. Prior to joining Autodesk, Joe was on the founding team of Living Goods, where he spent six years leading operations for the Global Health Organization. He began his career in the banking and finance sector, working with Deutsche Bank and Cambridge Associates. He then spent three years in the Peace Corps in the Philippines and has worked as a consultant for the Economist Intelligence Unit, the World Bank, and Google.org. He earned a master's degree from Columbia University and a bachelor's degree from Washington and the University. We're so thrilled to have Joe join us, and I'm going to hand it over to Joe to share some insights on how the Autodesk Foundation is working to fight climate change and to introduce our speaker. Welcome, Joe. Thanks, Iana, and good morning, everybody. Thank you for the opportunity. I'll keep my remarks brief, but because I'm very excited to hear from Chad and drawdown, but for those of you who don't know Autodesk, we are a software company for people who make things. So I'm sure that with this group, most folks are familiar with some of our engineering tools. We primarily serve the architecture, engineering, and construction market, as well as the design and manufacturing market. And we offer some products in civil infrastructure and media and entertainment. I represent the Autodesk Foundation, and our mandate is to provide support to design and engineering solutions that solve societal challenges. And that manifests in two ways. One is looking at how can we use design and engineering tools to solve for climate change? And the other is looking at workforce transition to prepare for the AI and automation enabled future. So essentially we do two things. Both on the design and engineering side, we provide not only financial grants, but also software and support to organizations that are using these tools to provide impact. And we also provide software and support to commercial or for-profit organizations that are using design and engineering tools to deliver societal impact. You can learn more about that at Autodesk.org, as well as Autodesk's sustainability. Here's just a brief representation of our portfolio of organizations that we support. It spans the gamut. We focus globally. So about 70% of our portfolio is international. We also focus broadly on the markets where Autodesk the company works. So in architecture, engineering, construction, as well as design and manufacturing. I will lastly say that we are a proud and excited partner of Drawdown. Linnell Cameron, the VP of sustainability here at Autodesk was a reviewer of some of the materials for Project Drawdown. And we use the book here around our offense as a reference and are talking about incorporating some of the methodologies that Project Drawdown has pioneered in looking at impact. So without further ado, I'd like to introduce Chad. Hello, thank you. This is Chad. Thank you, Joe, for that introduction. Yeah, well, it was a great pleasure to be here today. And thank you, Joe, for that introduction to Autodesk and making you the honor for allowing us the opportunity to be here today. We're a wonderful organization and we're really excited to be able to present Project Drawdown to you all. I'm just going to start to share my screen now. Thank you for the starting point. I'd like to introduce you all to what Drawdown actually You saw that point in time when the concentration of greenhouse gases in the Earth's atmosphere begins to decline on a year-to-year basis. It's that point when we take out more than we put in. And the proposition here is rather simple. If we can reduce concentrations of greenhouse gas in the atmosphere, we can affect global cooling, essentially reversing anthropogenic global warming. Restoring the natural carbon cycle and essentially creating a regenerative economy society in the process. But why is this important? This graph depicts the concentrations of CO2 in the atmosphere over the past 400,000 years. Now, part of the CO2 represents just a unit of measurement of carbon dioxide. Now, I think there's a lot of variation across a hundreds of thousands of year timescale. But the point here is for the past 400,000 years, for most of human history, we have never lived under an atmosphere of more than 300 parts per unit. And that's what we do in the 1930s. When we broke free thresholds, and now we see this steep rise to current level. Most recently this year, that's about 409 parts per million of carbon dioxide in the atmosphere. And that's just accounting for carbon dioxide. If we include other carbon dioxide like nothing, fluorinated gases, and nitrous oxide, and convert them to CO2 equivalent, we actually are at a level about 490 parts per million in the atmosphere. And we can actually take this graph, this 400,000 year graph, and extend it backwards. Send it backwards for another 400,000 years and for the past 800,000 years, we still have not breached that threshold of 300 parts per million.  Now over the past decades, I think this course has been focused on stable life of certain parts per million, a particular matter, or a degree war maintained acceptable. Now we've heard about limiting parts per million to 450 parts per million, 350 parts per million. We've heard about two degrees warming Celsius, 1.5 degrees warming Celsius. These are targets that has dominated the, just as a quick point, it's getting some comments that people can't hear. Yes, okay, good, it is audible. Yeah, I think it's just occasional for a few folks. For those of you who didn't, who are having trouble, even though this might not be helpful, please hit stop and then start or try opening up WebEx in a new browser. Thank you so much, Chad, please go on. Sorry, I belt that. So with these targets that have dominated a discourse of around climate change and global warming are based on a premise of an existential threat to humanity by 2100. Now, humanity though, has not really evolved to understand long-term existential threats, right? So built on these targets, we have to achieve a two-degree warming, a 1.5-degree warming, or else that's the premise around these targets, or else by 2100, we can have social, economic, and ecological collapse. But if we're a species that can't really think in terms of those long-term existential threats, it's very hard for us. We could hardly take full planning three to five years in advance. And with technology today, we have a hard enough time thinking about six months into the future. So these targets, in addition to the existential threat, the long-term thing that we're hard to grasp, the targets have a large degree of uncertainty built around them. Now, there's a tremendous amount of good science built around the modern that goes into these estimates of to achieve two-degree warming and 1.5-degree warming. The IPCC, the Intergovernmental Panel on Climate Change, has done a fantastic job, one of the greatest scientific endeavors in human history. But built into this assessment is a large range of uncertainty built around these estimations. And it's because these are complex models and they allow us to estimate potential impacts, but you're only starting to really know of its models as they're going to be wrong. You know, the prior challenge here is that when we start to model the interaction between temperature rise and concentration, there is a lot of variability there, a lot of complexity. And we map that to climate modeling. There's a lot of complexity and variability there. And then in turn, we kind of, we've mapped these onto social, economic and ecological models and needless to say, these themselves are complex variable systems. What we can say was confidence, however, that four-degrees warming is better than six. Two-degrees is better than four. And 1.5 is, frankly, better than two-degrees, right? That's what we know as confidence built around these. But are these goals, are these targets that are built around existential threat that we can't understand, that are built around uncertainty, are these kind of goals that we need to set for humanity in order to envision the future that we want? Now, we think at Project Drawdown that we need to set a different kind of goal, a goal that can systematically reverse global warming caused by anthropogenic emissions. And along the way, we are on 1.5-degree trajectories, but we don't say stop there. We don't say stabilize that point. We say, let's go beyond. Let's go beyond that to restore the natural carbon cycle. And this we find to be engaging and empowering people from all levels of agency because the people we're asking to make the changes we need are homeowners, building owners, their businesses, investors, policymakers. They are inherently a group of risk averse short-term thinking and we're asking them to think long-term about existential threats at a high degree of uncertainty. But we change that discourse. We can change the goal, name the goal that we want, name the vision of the future that we actually want and get us there. Is it aspirational? Is it optimistic? Yes, but that's exactly what we need to mobilize the broader segment of society in order to make the changes that we need. And why is this really important? Because, well, how do we get the news about global warming and climate change today? We are increasingly inundated with news of doom and gloom. We have headlines that are terrifying and images that are horrific. Now, this is a Photoshop image. Do not worry, this is a picture of London. It is not flooding right now. This is Photoshop. It is crafted, it's a crafted image in order to incite fear and disillusionment. And we look at this and what is human nature is to be distracted, to run away from the fear, from the disillusionment. We run away, we get easily distracted and so presents the next to it is clickbait. Who wouldn't want to know how a wife used a frog ornament to murder her husband? It's easily able to be redirected and shift our attention to something different. The apocalypse is upon us now. A biblical proportion. Now, this is really important because this is actually derived from a very good paper in the New York Times, a very good article. But again, it's taking really good content, rebranding it, reframing it, creating a stark terrifying image and think there's nothing you can do about it. It is a threat, an existential threat of biblical proportion. So you might as well order takeaway from Grubhub and order some discounted wine. Now, adding together this fear, this empowerment and confusion over the target and the goal that is perpetuated by the cleric climate discourse just results in apathy and indifference to the status quo. A characterization that has been part of the increasingly growing in all of our perception of what we can actually do to make a difference and indifference in apathy. Now, as we know from social science, from history, from political science, fear has been an organizing principle behind oppression. But optimism and opportunity is a guiding light to making change. And that is what Project Drawdown was founded for. It was founded to counter this prevailing incident and reframe the conversation from confusion over targets that are threatening and changing the nature of the presentation of the message from fear and apathy to one of opportunity, understanding and optimism. We feel if global warming has happened to us, we become victims. There's nothing we can do about it. However, if global warming is happening for us, it's an opportunity to make change. This can be a turning point for humanity. And we need to make this shift, we need to make it now. There's an urgency, but we have the tools to do so. So it's not just positive thinking messaging. It is also about providing the understanding around solutions, technologies and practices that can actually achieve this result. And so Project Drawdown is not only a communications organization to put out this message, to create this counter sentiment to fear and apathy, but it is also a living research program that rests on the foundation of data-driven, credible information around solutions to reverse global warming. And it is a coalition of researchers. It is a collaborative effort. We believe that the age of the hero is over. And the only way we can make the change we need around the world today for an issue as pervasive, the challenge that exists with all other challenges, global warming, we need a full collaborative effort to do so. And so we've assembled a global coalition of researchers, policymakers, business leaders, implementers who are researching, assembling, modeling and amplifying the best available information on solutions to global warming. And over the past three years, we've enlisted over 65 researchers from around the world. This is just a smattering of them, all right? There's many more. And we see this group of fellows, research fellows, as a next generation of climate leaders. Nearly 50% have PhDs and all have one or more advanced degree. They come from backgrounds in science and business, architecture, policy analysis, forestry, engineering, agriculture, international development, law. These are not just a group of data scientists, modelers, and climate wonks. So we do love data and we love modeling, all of us. But we really wanted to bring a collection of perspectives, a diversity of experience, diversity of knowledge that can make us a truly collaborative research model, bringing in all of those different perspectives to bear on this question of how to reverse global warming. We've also brought on a coalition of over 130 advisors. And these are counting every week, we bring on a new thought leader, philanthropist, investor, business leader, scientist, policy maker. This is, again, just a small group of the 130 that we've brought together. Now, these advisors actively engage to provide expert review of our research and communication tools, and they lend their voices as speakers and ambassadors of drawdown. Former governor, Martin O'Malley, just taught a class at the University of Maryland where he spoke and had the entire module on drawdown. It is going out to the world through this amazing collection of researchers and advisors. Together, this co-living, collaborative research and communication efforts comprises over 200 individuals. But what are we all doing, precisely? Well, project drawdown set out an ambitious task of determining whether drawdown is not only possible, but financially feasible. Now, there are many global systems models that evaluate possible mitigation pathways. We've mentioned a few from the IPCC, for example, from the International Energy Agency, they're doing this really great work, but it's got a very bottom-up solutions-oriented approach. And few are still had a comprehensive approach that included land use solutions, arguably the only way we know was confidence to sequester carbon from the atmosphere. Now, to achieve our aim that would be meaningful to many levels of agency, we realized we needed to build our own systems model, or I should say system models. And over the past three years, our research fellows have been working to collect and analyze thousands of data points, developing over 80 solution-specific models and accompanying technical reports. And this material represents tens of thousands of person-dollars and is built on the core premise of collecting and assembling the best available information from peer-reviewed and reliable sources out there. Now, since this is a, I assume that you are an engineering crowd, you might also be fans of models and methodologies, so I'm going to go through briefly over some of the approach, sort of open up the hood of the car to take a sneak peek at what the engine looks like. And we're not going to go into the mechanics of it, but just to get a broad view of what we're doing to come up with the results for our study here. And so what we have to do is develop three core model structures. There are essentially three ways, I should say, three mechanisms through which we can affect to reduce emissions and reduce concentrations of greenhouse gas in the atmosphere. The first mechanism is through replacing existing fossil fuel-based energy generation with clean renewable sources, and the enabling technology to allow that to reach, to allow that to reach up to full potential. And the second mechanism is to reduce consumption through technological efficiencies and behavior change. And the third is to bio-sequester carbon through plants, biomass, and soils, through a process we all know called photosynthesis. So we have to build these three model structures to accommodate these different kinds of mechanisms through which this can occur. The first model we built was a reduction replacement solutions model. Now this focuses on the energy and energy efficiency solutions. Here we created a model that evaluates a total addressable global market for functional demand. So what this is essentially doing is looking at, for example, the market for terawatt hours of electricity generation, the electricity generation market. And within that market, we compare a solution, for example, geothermal energy, which competes with an existing fossil fuel-based energy generation, such as natural gas fires, or plant, coal, oil. And similarly, when we think about the total addressable market for material-based energy, we think about how recycling competes with landfilling within that market of functional demand. The second model that we've had to build was a land-use solutions model. Now this is because the allocation of the world's land types functions in a very different way than markets do. And so we created a model based on abracological zones and thermal moisture regimes that create constraints and boundaries around different biophysical conditions that are suitable for different practices. And we can again, there are as well clear solutions to a existing high emitting practice. And the third core model that we have to build is a food system model. Now this is integrated supply-side solutions, demand-side, integrated supply and demand-side solutions that create a country-scale consumption pattern. And so this is a model in which we have valued over 450,000 data points from country-specific patterns around different commodities and connect this to a supply-side yield model that allows us to evaluate what are the needs for demand in the future in terms of food consumption. And throughout this entire, each one of these core models compares a high-growth scenario with a solution compared to a relatively low reference adoption. We use sources throughout, a variety of sources to create a metanail that's around each input and each adoption trajectory that we take. Sources that include the IEA, International Energy Agency, the Intergovernmental Panel on Climate Change, United States Energy Agency, the US EPA, ICCT, et cetera, the World Bank. peer-reviews, reliable sources come in and we create boundaries using statistical evaluation so that all of our inputs, all of our inputs and adoption cases are bounded by existing sources. And so we have, by and large, a conservative approach to all of our modeling. And as I said earlier, each solution is compared to a conventionally, a conventionally high-emitting option. Again, this is something like recycling compared to land billing, geothermal compared to fossil fuel-based energy generation. And these adoption projections are used to estimate both the emissions and the financial impacts, which are the core results that we present. We evaluate each of these adoption cases, assuming a relatively vigorous adoption process so they're bounded by what is realistic possible. We evaluate, we create three different scenarios, a plausible scenario, a drawdown and an optimum. The plausible scenario is vigorous but reasonably adopted over time. It is our most conservative. It is what is presented on our, most of our work. And we wanted to err on the side of conservatives. We wanted them to say, this is the at least case, at least what we can do. The drawdown scenario actually is optimized to achieve drawdown by 2050. And again, drawdown is at point where we systematically reverse such that we can actually reduce concentrations of greenhouse gases on a new year-to-year basis. And the optimum scenario, what we call as our fairy-tale case, this is where we replace all existing conventional, high-emitting technologies with solutions, with technologies and practices that can reverse global warming in the long run. And we have to integrate these solutions to a system because what we're dealing with is not just isolated solutions working separately, but all these solutions fit within both bounded systems, for example, based on the markets of electricity generation or based on certain land types. But they're also within a system of systems because they intersect together, right? When we think about energy, when we think about land use, when we think about transportation, we think about materials, all of these are actually, many of these are intersecting with each other, so it's a system of systems, right? And so we have to integrate these to ensure we avoid double counting, accounts for system dynamics, interaction effects, and really be cognizant of that market alignment and allocation. And I'm quickly going to go through some of the dynamics that we've used just to give you a sense of how these different solutions are intersecting and what we see here is our transportation schematic here and we see, you know, there's principally freight and intercity trips, commuting trips, urban trips, and there are so many intersecting points that we have to account for, map out those interactions to ensure that we are appropriately on the system. Here's our schematic for buildings, again, it's the input into building energy use, the different type of systems in a building and then again, how these impact other systems. Here is our energy system, and again, what we're seeing here is the interaction between different land types, the types of solutions that are appropriate to those land types and how they intersect with other systems like materials and waste aversion, renewable energy infrastructure, and of course, there's other things that they're connecting to as well in terms of transportation, et cetera. So we have to think about these different ways in which all of these systems are sitting here, our waste model schematic, and again, this is a good one because as we can see, we see, you know, food product and how it is affected by diet and food waste in the space of bioplastics, we're going to fractionate the different types of municipal solid waste into organics, plastics, and other types of waste, and then those and how it becomes a feedstock into other solutions that then in turn become feedstocks into solutions down the chain. So we don't want to show this to you, it's not that you get too deeply involved in it, but just to show, there's a lot that went into this assessment. We have to think about global systems and how all of these different products can work together and map out and ensure that our numbers are as conservative as we can to create that at least case. And all of this material is fed into the results. So this is a methodology that we use to value over well over 100 solutions. And again, what do these solutions do? They replace the energy infrastructure, reduce consumption or bioplastics carbon from the atmosphere. And we look at the over 130 different solutions and we had a certain set of criteria that we had to use to whittle them down. We had to understand these are existing solutions. We wanted to ensure and to show what the world is doing today, what is available today, and how these solutions are currently scaling because all of the existing solutions that we present are economically viable. There's a business case to be had. And we had to consider whether or not the negative externalities outweigh the positives. And if the negative externalities did, we couldn't include that into our assessment. I can put it into my lips. And of course, the core principle, is there enough data to be able to model these technologies at global scale? Now, as I said, we had values over 130 solutions and we brought it down to 80 of the most substantive solutions that fit this criteria. And we also presented some coming attractions. These are solutions or technology practices that are not currently viable, that are not necessarily currently scaling. Or they're so simply not enough data in order to incorporate them into our existing solution approach. So we profile these as coming attractions, things that we hope down the line in five years and 10 years, maybe some cases even further down the line, will have a significant impact on a part of that system of solutions working towards reversing of the warming. And so what we've come up with through this read is 100 solutions to reverse global warming by 2050. This is just a kind of a poster version of this, of our plausible scenario. And all of this research, that kind of a methodology section, happy to dive into more details to those who are interested. But all of this research, all collaborative work from 200 research fellows and advisors, et cetera, all are presented in our recent book, Drawdown, the most comprehensive plan ever to reverse global warming. Now it's a rather cheeky title, but we thought about it long and hard, and realized that it adds comprehensible plan out there to reverse global warming, it just isn't one. And so we felt quite comfortable to put it out there. But this, as you can see, is a New York Times bestseller. It's a week of being released in April of this year. It reached that list. And it's about the October of this year was back on that list at number seven. Now, this isn't to pat ourselves on the back here. This is a collaborative effort. But the reason, I think it's so successful, the way it presents our communications and the research organization, it's a tactical manual. It is not a, you know, it is not that important how the staff moves with every technology. There are stories around these different technologies and practices. Here is just as good, here's one of the solutions rooftop solar. And what this, the way this reads, it's like a kind of book that you could take to the park on a Sunday afternoon and have a good day. It's a kind of book that you could read before bed and not have a nightmare. And how many books about climate change and global warming can you say that about? Not many, not many. And I think that's really why this has been so successful is that it presents solutions in a very accessible way. But it's backed by that rigorous research and methodology that we just quickly went over. And as you can see in the right top right corner, the rankings and results by 2050, those are the sort of the synthesis of all that modeling that we've done. And while the model has actually produced many more results that are useful for different audiences, we felt we wanted to really summarize results in the few of the key results in this particular publication. Now I'm gonna go through a couple of the solutions. Now, this is wind turbine offshore, it's ranked number 22 on our list. As you can see, how do we do our rankings? It's based on the total reduced CO2 equivalent. So again, we evaluate methane, fluorinated gases, nitrous oxide, as well as carbon. And we convert it into a CO2 equivalent in order to add them together and present these results in this way. And so we rank them based on total impact in terms of reduced CO2 or sequestered carbon, the oxide. We also look at the net first cost and the net operational savings. Now again, all of this is in comparison, as I said earlier, to that reference case, a high adoption versus a reference case. So we're always comparing two scenarios here. And this is the net difference. When we think about the net first cost of $542 billion, what we're really saying is that this is the additional cost compared for offshore wind turbines compared to what we would otherwise have to be paying for the equivalent amount of electricity capacity of fossil fuel-based energy generation. And the same with the net operational savings. $763 billion over a 30-year time frame from 2020 to 2050 is the additional savings we would accrue from adopting wind turbines, offshore wind turbines. As you can see here, the mass speaks for itself. It is over a 30-year time frame and this is of course discounted. We have a net benefit, it's a net savings over time over a fossil fuel generation. Now the other point I wanna raise here is that this image is not photoshopped. We do not craft or create images in order to evoke emotions. We use real imagery, real photographs. And it is true, we do want to present these technologies and solutions in a different way because we typically see them in a very standard presentation. For example, rooftop solar. When we think about rooftop solar, the first thing that often comes to mind is an urban environment, perhaps a warehouse with rooftop solar panels on the top. Here is a woman in a household who lives on a straw island in Lake Titicaca who are getting their first rooftop solar panel. Now it's important for us to think of these solutions in a very different way. And also to get out of this notion that all of these technologies and practices are suitable for urbanized developed countries. When we think about rooftop solar, we have to also think about all these technologies and practices are also applicable in low income, developing countries, in rural settings. Many of them are very applicable to these different environments. And so we have to think outside of the standard model of solutions for urban environments and think about how they apply to other environments. And this is also a great example of why these solutions are being adopted in the first place. Many times, this has nothing to do with global warming. This has to do with energy, resiliency, abundance, energy. A energy that can fight the household in safely. Prior to installing the rooftop solar panel, this was in kerosene for all the energy they're cooking in for their lighting. Now the solar panel, I'm a straw island of Lake Titicaca. Now the solar panel not only provides them with abundant clean energy, but it also provides them safety for their household. So there are many reasons why we should be adopting these solutions and global warming is often a second or third order benefit. Now we also have to think outside of this generation. When we typically think about climate change and mitigation, when we think about, we think coal, we think oil, we think natural gas. We have to step out of that and start thinking beyond electricity generation and transportation as a sector that accounts for nearly 14% of global missions. It is a sector that has the potential to be really shift. Because these are where everyone has individual choice to make. It's about how we all get around mobility choices, walking, biking, mass transit, using electric bikes, using bikes, conventional bikes, and the choices we make in driving, whether it's a hybrid or an electric vehicle. We can make these choices, every consumer can make the choice in our day to day lives. And it's not only choice that we can make as individuals, but it's also choices that it's cross agency. So this is also about municipalities that can plan more walkable neighborhoods, like infrastructure, as well as commuters opting to share rides or bikes to work. So this is incredibly important to think beyond just electricity generation. And technology itself can enable new ways of doing business, like as what we're doing right now, telepresence, logging in to a platform that allows us to communicate with long distances instead of flying all over the world for business meetings or conferences, we can use internet-based communications to work together without ever leaving our office and home. And this is what telepresence essentially is doing. It's looking at the difference between the technology, the technology for communicating using the internet compared to business air travel. And I think that only if you're talking about airplanes, but it also creates $1.3 trillion is essentially tickets on this place. And compared to technology to allow us to make this happen. So for example, this is a staff member from Pricewater House Coopers in Toronto and a team member in Prague. And a lot of this technology allows for the experience of conducting business in very, very familiar ways. This device can move around the office, can shift and sit down at the business tables and can actually experience as if the person was there at the table, simulating that experience. And these technologies are advancing, becoming more efficient, more user-friendly. You know, in 10 to 20 years, we can imagine telepresence providing with the experience unlike anything was experienced and all the while reducing emissions. And of course, not only from planes crisscrossing the world, but we can even imagine a future where commuters traveling to and from the office is greatly reduced and we have a fully immersed, interactive business experience using something like telepresence. And I really do think a lot of these technologies are advancing and becoming more efficient over time. And while we don't model that technological efficiency because we're only modeling what exists today, we can anticipate in the future that these technologies in practice would have 10 to half even greater impact. Now, other solutions, we also have to think just beyond electricity, generation materials, buildings, which is sort of the paradigm that we are all familiar with. But we have to think beyond this to how we produce our food and how we use our land resources. Agriculture, forestry and land use contribute 24% of global emissions. And so it's a significant source of emissions. And this is from a number of processes here. We see coastal wetlands and what we, when we think of coastal wetlands and we think of peatlands and we think of forests, what these are, are carbons and sinks. That's being able to put a sense of this, a plan since the extra carbons from the atmosphere and biomass and soils, soil organic matter. And this essentially creates a sink, a safe heart to work carbon in the ecosystems. And every time these ecosystems are degraded through deforestation, conversion to different other land uses, we essentially release over time those greenhouse gases of that carbon that is stored in the soil of the biomass. And so these ecosystems can become net emitters of greenhouse gases over time. So if we can protect our coastal wetlands, not only are we having many benefits in terms of livelihoods and flood protection and so on, but many additional benefits to protecting coastal wetlands besides the intrinsic value. We also are securing and safeguarding that carbon sink. And you can see here the 53.34 gigatonnes of CO2 protected. So not only are we reducing the emission of 3. 73.2 gigatonnes over time through degradation, we safeguard we protect 53 gigatonnes. And if we think about forest protection, we can again avoid 6.2 gigatonnes of emissions through degradation, but at that, by protecting our world forest, we can actually safeguard, secure, prevent for perpetuity the release of over 896 CO2 equivalent. Now of course, what is actually stored as carbon, not carbon dioxide, but again, we convert this carbon dioxide equivalent to see its impact on the overall atmospheric concentrations. I'm gonna have to think about how we use our degraded land. So in tropical forest, our number five solution. What is tropical forest? This is about restoration of degraded land. It's about taking currently degraded lands that are suitable for natural regrowth, protecting them and allowing them to regrow naturally. And in tropical thermal moisture regimes, we see sequestration rates. What's the sequestration rate? If the annual rate at which a certain hectare of land can absorb carbon and biomass and soil, and in tropical forest has one of the highest sequestration rates, which results in over time over the 30-year period, 61 gigatonnes of reduced CO2. That's all sequestration. That's all bringing down, drying down carbon from the atmosphere. We have to think about how we produce our food. We generate an agriculture. Now, the way we have done, the way we're doing business now focuses on annual cropping, killage, synthetic fertilizers, and over production of our resources, of natural resources. And what that ends up doing is degrading the land over time. We have, where cropland becomes a net emitter, but that's not the way we have to do things. We don't have to continue to use more and more synthetic fertilizers to produce the same amount of yield year after year, which is actually declining over time. We can restore that land using regenerative agricultural practices, things like no tillage or reduced tillage, cover cropping, crop rotation. The use of compost or manure instead of synthetic and fertilizers, green manure and organic practices. A combination of these different types of agricultural practices can restore carbon to the soils and produce healthy, productive soils, improve water retention, increase yield. Yields are actually higher than regenerative agricultural crop farms. And about regenerative agricultural practices, and many of the solutions that are on this list, particularly when it pertain to agriculture, is this is actually the traditional method that we have been using for generations. Indigenous peoples are still using this, small whole farming around the world are still using regenerative practices and they're being displaced by modern agricultural practices that are in over time net emitters and greenhouse gases. So many of these practices are returning to ways of doing business that we know work that provides productive, just healthy, increased yield in soils at the same time as sequestering carbon. Let's think about the way we produce livestock. Livestock cover down 3.3 million acres or 25% of the world's land area. It's one of humanity's largest land uses. And modern grazing practices become a net emitter to grade grasslands to pleat soil organic carbon to produce meat and dairy products for a burdening consumer demand. And it's only growing, particularly as low income countries increase their economic development growth and oftentimes it's accompanied by increased meat consumption. So we're actually the world today. We consume more of a plant rich diet than a high meat intake but this is gonna change over time. So we have to think about how we are managing our livestock. And we do have methods, managed grazing which includes controlled intensity and timing of grazing, enclosures of grasslands to encourage resting and other different types of plant and adaptive grazing can in effect create a net turn grasslands from a net emitter to a net sequesterer by shifting to more productive methods of managing livestock. And this can offset most if not all of the netting produced by livestock. And a good point here to note is that when we look at the results here 16.34 gigatons have produced due to Cleveland from managed grazing much of what most of which is from sequestration. This is a very conservative number. We evaluated over 48 peer reviewed data points on different sequestrations potential from around the world. And through our meta-analysis approach we chose an average value. That's what we've done for almost all of the inputs that went into this. We collected as much data as possible we did a statistical evaluation. We chose an average. We didn't want to choose the high or a low to be an advocate of one approach for another. We chose an average. We feel that's the most conservative approach to take. So in theory, this potentially could be much more significant and certain types of land. You can have highest three tons of carbon sequester per hectare. That's that sequestration rate. It could be very, very high. But we intentionally choose a smaller value. Now, produce food waste. Approximately a third of all food produced in the world is not eaten. It is wasted and food emits approximately 8 cents of world screen health. Now if we were to add it all up together and compare it to different countries probably the third largest emitter behind the United States and China just produced food waste. It's astounding. Now, when we think about it if we produce our food waste by 50%, just produce food waste by 50% across the board. It's our number three solution. 70 gigatons of reduced CO2. Now, we have to think about where we can make those gains along with supply chain because waste it occurs and offers it in different places in different regions. When we think about low-income countries, food tends to spoil big production or distribution during the early in the supply chain. This is due to infrastructure and storage challenges to technology problems that we can fix. A food is not wasted by consumers in low-income countries. 3% is wasted. 3% is wasted at the point of consumption. In the developed world, it's the opposite. Almost 20 to 30% of food is wasted at the point of retailing consumers and restaurants. And most of that ends up in a landfill where it decomposes and emits methane. This is a consumer choice problem, not a technology issue. And so addressing this solution means approaching different strategies depending on where we are in the world and where we are along the supply chain and can have significant impact. And this is where everyone can have an impact of individual choices to make. Our number four solution, the plant-rich diet. So it's on how we deal with the food we purchase, how we manage the wastage or what we avoid and so on wasting, it's about what we choose to consume. A plant-rich diet, it's not about being vegetarian or vegan, but about eating a healthy diet. It's in terms of how much we consume overall and particularly how much meat is consumed. And so this also has different dynamics depending on if you're a low-income or high-income country. Low-income countries have a tendency to be on average, per capita consumption, lower than what's considered to be a healthy diet of around 2,200 to 2,000 eggs. You consume more than that. And low-income countries consume less meat. High-income's more meat. But these are naturally changed over time. So when we model out plant-rich diet, we have to have all these considerations in mind. We balance it out so that a plant-rich diet means higher increase daily consumption in low-income countries, lower consumption in high-income countries to balance out of a healthy diet and less meat overall. And if we do this, we can reduce over 66 gigatons of CO2, that is coming from two sources. Both the reduced food waste and the plant-rich diet. It's coming from avoided agricultural production, right? So it's avoiding the production that we would have to do otherwise in order to produce all this extra food that was over-consuming and all that extra meat that we're consuming, as well as all that extra food we're wasting. And so it's about avoiding that production. And it's about avoiding deforestation, avoiding the production on land that we would have to extend out in order to feed the global population now and the population that continues to grow over time. Because the reality is, if we are using a regenerative agricultural system, of giving many different practices, if we are adopting a plant-rich diet and reducing our food waste, we are producing enough food today to feed our entire global population now and into 2050 as a population grows. Educating girls. Number six solution on our list. Around the world, nearly 62 million girls are denied the right to attend school. Many of those girls will get married young, have several children and struggle their whole lives to provide for them. But we see through studies at girls who will provide with equal access and quality education as voice, equal access about universal education, about gender parity. And we study show that girls who have that from 12 to 13 years of schooling have dramatically different life outcomes. They providing equitable resources to girls through education results and delayed onset of marriage, smaller family size, economic growth, a different way of life trajectory. Powering girls to stay in school ultimately increases the uptake of family planning. So that is the mechanism through which family size can be reduced. And how we actually achieve reductions in emissions is by a smaller population size through family planning. And girls education increases the uptake of family planning. If we consider the future population trajectory, the UN medium population estimates 9.7 billion people by 2050. The high population is about 10.6 billion. That's a difference of 1.1 billion people on this planet. And, sorry, that's 10.7 billion in the high scenario and 9.6 billion in the medium scenario. That's a difference of 1.1 billion people on this planet. And most of that impact comes from family planning by increasing the uptake of family planning, increasing the right for men and women to make the choices of when, how, and if they have children by empowering them through gender, parody, through choices, through access to health resources, reproductive health, education, et cetera. And doing so reduces all of that demand for energy, for transportation, for materials, for food, all of the markets and land use, all of the things that we consume will be reduced. And that reduction is roughly 120 gigatons of CO2 equivalent. And we cut that right down the middle between family planning and girls education because there's no good way to really understand the differences between providing equitable, fair, and universal education for all people and family planning choices. Here is our top 20 solutions. Number one was rather a surprise. It's refrigerant management. It's not a very exciting solution necessarily, but actually we're quite excited about it. The reason it is so high is because with our refrigerants today we use hydrofluorocarbons, which are thousands of times more potent than greenhouse gases. And when we dispose of our refrigerators, our air conditioning units, et cetera, to typically get lanthold and leak over time, causing a significant amount of global warming potential. So that's thousands more potent than carbon dioxide. And so if we can, in fact, destroy those refrigerants through appropriate end of life processes, which we have a technology to do, we can prevent over 89 gigatons of CO2 from entering the atmosphere, or CO2 equivalent from entering the atmosphere. And this is conservative. If we include a phase out of hydrofluorocarbons as agreed to through the Cagaldi agreement, these additions can increase from 160 to, some people estimate over 200 gigatons of CO2 equivalent can be avoided through management of end of life with the resistance of refrigerant banks and for phasing out hydrofluorocarbons. So that's our number one solution. Here I think there is anything of electricity that's most important to set a solution that's not that big of a reality is is that there are only five of the electricity solutions are in that top 20. In fact, the majority of those are in top 50 are food. Each of the top 20 most impactful solutions to achieve reduction in concentrations of emissions, concentrations of emissions are related to our choices and how food is produced, how we consume it, and how we waste it and what we try to avoid. So these are actions we can all take and what we choose to purchase and how we choose to consume. I think we also have profiled 20 times in its practice. Again, the technologies that are up and coming, that are things that are in the pipeline, things that within five, 10, 30 years we've been saying hydrofluorone fusion for the past 30 years, it might take a couple of years, but once they get there, it's tremendously impactful, building with wood, high-probe boots, artificial leaves, marine primers, except here with the 20 profile. Some of the extremely exciting from livestock feed is the agonist, the form of the cut emissions, nothing production in livestock by up to 90% to be transformative, right? But what's really important to remember is these come attractions are part of assistance of the existing solution. It brought up possible by 2050 with the existing solutions we have. The answer is yes, it is possible. Droughton can be achieved by the participation of all of these solutions at global scale. There are no solutions or a set of solutions that will get us there. The top solutions take us far along that pathway, but there's no such thing as a small solution. All eight must be vigorously and ambitiously adopted to achieve drawdowns. And when contractions come online, we'll fit into this system and further increase the potential to achieve drawdowns sooner, faster that address the urgency that we need. But many of the solutions are being adopted and they missed earlier. Has nothing to do with global warming. They are technology-impressed. We would want whether or not for the one with this problem. For most, the benefits of reducing concentrations are second, third, fourth benefit. When you think about renewable energy generation, it's about abundant natural energy resilience. Reduced food waste, plant-rich diets about healthy global population with all people pride in their food and sustenance. Family planning, educating girls about human rights and gender equality. It's about economic growth and the freedom to make choices. Global warming impacts are far down that chain. Regenerative agriculture, agroforestry, manna grazing. They restore soil health and productivity to improve the urban sciences, the world's drug of biomes. But if you look at the type of biodiversity and state safeguarding the planet, theory of health, can't look at all species. This is the same calculus of the intrinsic, sorry, this is, they also are carbon things and a sequester of tremendous amounts of carbon. So these are solutions that we would want, whether or not, and they're being adopted anyway. They're scaling and we need to aggressively, ambitiously, optimistically accelerate that adoption and shift our way of doing business, shift our way from exploitation and extraction to regeneration. And these solutions allow us to go there. Allow us, there are a past place to not only restore the natural carbon cycle and reverse global warming, to create regenerative economy and regenerative society as a side benefit. So that is product drawdown. Those are some of our results, our rankings, what we're at the date. I'm gonna take a break here. I know I have a little bit of a time, but I'm happy to take some questions and comments now, as well as offline. Thank you so much. Thank you so very much, Chad. This has been tremendously informative and I think we'll all forgive you for getting a bit over time because there are so much rich information that you have shared. I'm personally very excited to see that the ECRC webinars are aligned with one of your solutions, the telepresence idea and that we have this global convening that we have today with the opportunity to meet with a lot of people around the world without having to travel to those locations. So with that, I'm going to open up the floor, the virtual floor to some Q&A and I'm gonna kick off with a few things that have already come in in the chat. There's actually a healthy chat going on already. So we have here one of our attendees has noted that she's teaching a class in the spring of 2018 at MIT called D-Lab, Water, Climate Change and Health. And her co-instructors are ecologists and MD and she's a water engineer, Yay Engineering. They are using Drawdown as one of the required texts for the class and she's actually curious to see if there are other universities that are currently using Drawdown as a text for the class. I don't know if this is something that you know, Chad, there's already some chatter about this in our chat space here but perhaps you might have some examples of other universities. Well, yeah, I mean, there are quite a few classes that are using Drawdown as a text and it's not only in a higher education but also second in various school education as well. Drawdown, in fact, we just got a news this week that Drawdown is being taught in a number of middle schools and junior high schools across the US which we're quite excited about. So I think that's probably the instructors and educators as well as second in various school education as well. It's really kind of interesting text for that. But there are plenty of examples and in interest of time, what I would say is please reach out to me, I'd be happy to connect you with folks. I'm also, in addition to the head of research, I also work as a VP of partnerships. So I am, I were building a coalition of partners and individuals built around the collective impact model. And one of those things that are kind of important is that higher education is built up and share resources to deliver by presentation instructions that I get to around Drawdown that is currently being developed by different higher education companies. We're gonna be building a network, a sharing network to promote co-creation mutual support and sharing learning from the many people who are teaching Drawdown. So happy to connect people to that. And I suggest you reach out. Fantastic. It's exciting to see that there is that longer term vision of how to bring this to the classroom. And we certainly encourage all of you to continue to share your examples and there's some chats going on already around that. So on a practical note, if you can give us a quick, really rapid refresher from the slide, the differentiator between net first cost and net operational savings really quickly. So net first cost refers to the cost to implement a technology or practice at scale. So it's the cost for the implementation and the difference here, it's a marginal first cost. So it's always gonna be the difference between what we would be having to build in the reference case, in a conservative reference case compared to the adoption of the solution in the high adoption case of the solution. In the plausible scenario, for example. So when we think about this, this is the additional cost that we would incur anyway. So if we were purchasing a fossil, like we were going to install a 10 megawatt coal fire plant, we could do that in the business as usual case or the reference case, or we can build a equivalent 10 megawatt solar farm. And so what's the difference between the costs there? So the first cost, the net first cost is the additional and in some cases it's actually less than, especially cheaper, in the case of solar and wind, it's increasingly becoming cheaper than coal. So we're seeing that to be the first cost. Operational savings is again that difference between say the operation over the life over a year of a coal fire plant compared to the operational cost of that solar PV equivalent. And so it's the difference on an annual basis that is cumulative over the 30 year period of study. So in some cases, again, do you have any operational savings? It's basically cheaper to operating a coal or natural gas plant over time. So you get an operational savings. In other cases, it's true that there's sometimes, and for example, waves and tidal tends to be more expensive operationally than the coal fire plant. So we have operational, a negative net operational savings in that case. But again, it's always in comparison to a conventional technology in the reference case compared to the solution in the adoption scenarios that we present off the case. Right, and I imagine that entire equation is well laid out in the book. So I encourage folks to take a look at the book to get the exact data. And consider you have engineers on the line here. It's not surprising that they would want to know the nitty gritty of that equation. So I think we're gonna take only a couple more questions just because we are approaching time and I appreciate everybody for staying a little bit longer. One question came in from Arjen's regarding the interrelationship between solutions. As you noted right at the beginning, implementation of one solution will impact the effectiveness of other solutions. How do you take into account the interaction between solutions in your numbers? Yeah, so that's a good point. And so what we're, well, that's a good question. I mean, how do we deal with the effectiveness of a given solution? I'd love to give a more particular example for this. But what we do look at is how, within certain markets, different technologies are competing so that we're constrained. We create boundaries around markets through which different technologies are intersecting. We, to whatever extent is possible, we try to be mapping out how the feedstock of one solution can, sorry, the output of one solution can feedstocks into another and so forth. Now there are certain interactions that we can't effectively model at global scale due to variability and so on, between different localities. But it's important that we try to integrate the system as best we can, given the constraints of a global system. Our next phase of research, now I should say our phase one is the current work that we've produced is considered to be phase one of the research. It is the question of what if we were to achieve a specific global scale by 2050, what could the results be? Our next phase of research is looking at how to, where we are creating a contextually specific model that allows for the application of different data at different scales, whether it's municipality or locality, a biophysical region, a state, country, et cetera. And that, when we get into that local dynamics, we're gonna be much better able to map out those interactions between the, certain effectiveness of technologies when being implemented concurrently in parallel. But as a global systems model, we had limited capacity to map out every interaction at that scale, focus principally on again, the system dynamics between stock and flow and ensuring our markets and land allocations are bounded and that solutions that do intersect are not double counting. And a good example for this is, if we're talking about land use solutions, you could, for example, have multiple practices regenerative agriculture and tree intercropping, for example, on the same hectare of land. We intentionally avoided that. So every hectare of land for tree intercropping is isolated to tree intercropping and as a regenerative agriculture, they do not blend though they could. And so we avoid trying to get into the business of the interaction effects of those two solutions on the same implementation and on the same hectare of land, which can be quite challenging. And we just simply don't have enough data to understand what the potential is of the practices are concurrently. So we avoid that by being very discreet about where the implementation occurs. That sounds quite reasonable. So this is gonna be the last question, even though we have such a fantastic chat going on. I apologize if we can't get to all your questions, but what's ended on a kind of a practical note is an aspiration note. This listener notes that he is part, or he or she, Jack, yes. He's a part of a group of students at Penn State University searching for ventures to pursue in the Kasumu Lake Victoria region of Kenya. Do you have any insight as to which of these solutions could be implementable in a two to five year time period? Which of the 80 solutions can be implementable in a two to five year time period? I'm specifically looking toward, yeah. That's a good sound question to ask. Certainly towards Kenya. So, you know, a lot of the agricultural practices can be adopted relatively quickly. Many actually have very low initial capital cost, particularly compared to savings over time. And there's about a three to five year period of transition where the full benefit of shifting to, say, regenerative agricultural practice will be realized, but you will continue to produce yield during that time. So, there are a lot of agricultural conversions to regenerative practices can be three to five years in return, of course, things like how we deal with waste and materials, our food systems. These are choices we can actually make immediately. They're not something that requires a two to five year time period. It's about how we choose to manage our waste and reduce our waste and our consumption patterns. Many of these solutions in terms of efficiency, technological efficiencies and the buildings and so forth, these can be also within two to five years. I mean, in many cases it's about installing LED light bulbs. So, it's about creating a marketplace for them to distribute LED light bulbs and then sort of adopting them immediately. So, there's a lot of solutions that can be done in a very short timeframe. When we think about tropical forest restoration, for example, that actually assumes that we are, on day one, we're protecting this land and then leaving it alone to regenerate over time through naturally growth. So, again, a lot of these decisions can be done relatively, made relatively quickly. Some of the large utility scale technologies, however, they does require infrastructure to be built. It requires time and so forth before the real life. So, there is potentially a delay there that can be had. And particularly if we're at a place like Kenya, where there are other issues to consider that I am personally not fully aware of, I'm sure there's need for growth and for government regulation to help you see there as well as consumer choices and business choices. Absolutely, it's very much an ecosystem and certainly we encourage those listeners who are seeking out solutions to implement to consider the insights that Chad has shared, especially as you look at some of the solutions that we present on E4C through our Solutions Library and through our news and through other webinars. We recently had a really great webinar in microgrids. So, do you leverage this newfound knowledge and really rigorous research that has been done by Project Drawdown in informing your decisions around what solutions would be worthwhile to pursue in order to affect climate change reversal? So, with that, we have gone quite a bit over time, but I cannot imagine time better spent than we have today. And I'd like to thank everyone for attending. We will have the recording of this webinar available soon. Those of you who registered will receive a notification regarding when that recording is available. Otherwise, just check back on our site. For those of you seeking PDHs, the code is available on the current slide for you to redeem for that PDH. If we didn't tackle your question or you have other insights you're seeking, please feel free to email us the address listed on the slide. And with that, I would like to thank Chad. I would like to thank Joe and the Autodesk Foundation team for supporting us in bringing you today's webinar. And I'd like to wish you all seasons greetings, good afternoon, evening or morning, depending where you're joining us from, and invite you all to become E4C members to get information on our upcoming webinars and more information. Thank you, everyone. Goodbye.


It's 9 AM. Good morning everybody. Thank you all for coming and spending a day with us today. We want this day to be productive and hopeful and helpful to all of you. We have a day lined up with a lot of speakers. Most of them are my colleagues here at Stanford. By the way, my name is Sandy Srinivas. I'm a GU medical oncologist. I've been here at Stanford for about 22 years now and I specialize in urology oncology. We see patients with kidney bladder and prostate cancer. I'm going to have my colleagues here at Stanford talk about various aspects of providing care for patients with kidney cancer. We've been doing this meeting now for almost 12 years and it's all done through the kidney cancer association. So we happen to just partner with them to be able to do this for patients in the Bay Area. It used to be up at San Francisco in Japantown and I think in the last three years we decided that Stanford might be an easier place for people to come to than drive to the city. So we host this every year and really the goal of this is to provide education, show you where we are with this disease and what's new and what's upcoming. But I think really the purpose is also for you to feel comfortable.  This is a day just for you to get your thoughts and your questions answered and really to share your stories with amongst yourself with us and it's really that's what this day is for. In the past people have felt a lot of comfort just coming into this meeting learning about what is available and what's new and upcoming in kidney cancer. So that's what we are going to do. I'm going to start off by just doing a little bit by way of introduction but that's just the beginning and we'll talk a lot more about each aspects of kidney cancer, the surgical aspects, the medical aspects and I'm going to talk a lot about genomics and personalized medicine. So I would just encourage each of you don't hold back, you know really this is about how we can help clarify questions, concerns, anxiety, fears. There's really nothing that's off the table for today. So let me start by just giving you a very brief introduction. So I'll first start off with a picture of the kidney. So people think that every tumor that arises in the kidney is kidney cancer but I'll just show you that when we talk about kidney cancer it's really those that arise in the cortex. So the outer circle is what kidney cancer really is and within kidney cancer there are various subtypes and we'll talk about that as well but there are a lot of other cancers that can happen like for instance in the center that's where urine is made and the type of cancer that you can get from that is called ureothelial cancer. So anything that starts in the center of the kidney that's where urin is made goes through the urinary tubes called the ureter and then into the bladder. So we see ureothelial cancers or bladder type of cancers happen in the center of the kidney. Then there are other cancers like lymphoma. So Schanford is a very big institution that's world renowned for lymphoma which can really happen in lymph nodes but because we are a referral center we see a lot of patients who have tumor in their kidney that ends up being a lymphoma. So the point of this slide is really to tell you that not all tumors that start in the kidney are necessarily kidney cancer so especially for people coming from the outside it's really important we look at the location of where the tumor started to give us some ideas to whether it's really a tumor that originated from the cortex or the outer lining of the kidney is what kidney cancer is and that's what we are going to be talking about the whole day today. Stop me at any time okay really I think that's the best way we are going to get comfortable going through these slides. So how big a problem is this? So kidney cancer is not a common cancer but common enough to make it to the top 10 cancers in both men and women. You can see compared to common cancers like prostate cancer and breast cancer which affects close to 250,000 people a year kidney cancer accounts for about 5% of the cancers in men and about 3% in women so it's around 27 to about 48,000 per year and certainly unfortunately there are patients who it still accounts for the top 10 death that can happen from this disease so clearly we have a lot of work cut out for us in terms of what we want to accomplish with this disease. For the most for the majority of patients kidney cancer is still diagnosed at an early stage so this slide shows you that 45% of patients were diagnosed are diagnosed with localized disease meaning that their cancer is contained in the kidney and will undergo a surgical removal. Another 25% we call as locally advanced I'll show you the staging of kidney cancer in a minute but that just means that the tumor has gone from the kidney and is invading either the blood vessels the kidney the renal vein or the inferior vena cava surrounding the kidney and that's about 25% of patients again for these two groups surgery is the first treatment that you would do and is still associated with a good cure rate 30% of patients at diagnosis unfortunately have disease that may have left the kidney and it really comes down to the anatomic location of where the kidney is so it's located in a place where if you don't have blood in your urine this is a disease that you're not going to pick up very frequently so if you have blood that's certainly something that you're not going to ignore so people seek medical attention but most of the time it's like a pregnant uterus you can have you can have a be pregnant and that not be shown for up to six months in people so kidney is located in a location in our body that really doesn't show for a long period of time so these 30% of patients where their first diagnosis is usually by either a spot in their lung they go to the emergency room for something totally different and they find a large mass in the kidney so a third of patients even today present with metastatic disease we can talk a little bit about screening that's being done in other cancers and why screening is really not offered in kidney cancer because it's not a you know you have to have from a from a health perspective from a health care for economic perspective it's not a large enough percent for us to use like mammography for breast cancer so there's really not a great tool that you have for screening and CT scans are associated with a certain level of radiation so there's a lot of concern about just offering screening for every patient which is a shame because clearly cancers that are detected early can be cured but I think we have to get to a point where there is a better tool to screen for kidney cancer so screening is really not standard today for for every patient to just look to see if we can pick up these tumors early in fact I don't know if Dr Chung will talk about it but there are a large number of patients who whose cancers are found incidentally so they come for abdominal pain maybe for a gallstone and as they get a CT scan in the emergency room a small tumor is detected in the kidney for those patients we actually just watch some of them because those tumors are very very slow growing and it takes many years before these tumors can really be detected I think we are going to talk a little bit about the genomics so there is an hereditary condition called VHL so if for patients who are diagnosed with kidney cancer less than age 40 so that's not a normal age for kidney cancer the average age is in the 60s so if you have if you're diagnosed at age 40 there is something that's predisposed to you to develop this cancer so the National Cancer Institute now recommends that patients who are diagnosed less than age 40 have a genetic test to see if there's something that's predisposing you to develop this so if that's the case then perhaps your children or the kids would have to be screened at an earlier age so there is the syndrome called one Hippolynda of syndrome where it's not just kidney cancer but there are other cancers that people are vulnerable to such as brain tumors so as we have a genetics clinic up here that we send patients to and they do a screening and they also come up with a recommendation about what would be good for us to screen for you know are you at risk for getting colon tumors other tumors but I think that's where we are headed in terms of as we acquire more knowledge yeah slides the presentation well you know this is this is being recorded so it will be in the kidney cancer association website I'll ask them if they will have a copy of our presentation available to all of you who are here today yes yeah people have we haven't gotten that far but we know a little bit about the growth pattern so people know how long it takes for the kidney tumor to grow each year and it's relatively slow growing but unfortunately you know as you learn today kidney cancer is so heterogeneous meaning that there are so many different patterns that what we think I mean and we are unable to lump them all together in one bucket so there are patients where the tumor growth is extremely slow and on the other hand there are some very rapidly growing tumors and they are all not the same so we are lumping them all today as kidney cancer but I think as our knowledge increases we are going to be putting them into different pies that we'll probably learn a little bit different so to you to answer your question I think we know a little bit about the growth pattern and that's why patients tumors which are extremely small are actually just watched because we know that tumors that are less than three centimeters their risk of leaving the kidney and causing metastasis is very low so it's not uncommon today that if you were to have multiple medical problems and you have a small tumor that's detected we would just watch you with a scan every six months because we know that the growth pattern is really slow growing that it's very safe for us to watch you and that tumor is may not cause a problem in your lifetime if you have other medical problems that are more pressing okay so here is the staging guidelines you know so all patients need to know this when you have a diagnosis of kidney or any cancer the first thing we do is what's the extent of the cancer so the American Cancer Society there is a big staging system called AJCC this is a common language that all cancer doctors across the country and across the world speak the same language so that we know what the staging system is and that's what we do for kidney cancer so it's stage one is if it's confined to the kidney and it takes into account something called TNM and what it really stands for is the T stands for the tumor and that's really what's what's the size within the kidney and then the N stands for lymph nodes so nodal metastasis is what N stands for and M is for metastasis so you'll always have to know what is the TNM stage and then after you get that they sort of lump you into stage one two three and four so stage one are small tumors that are less than seven centimeters and in fact today we break it down even more into T1A and T1B where tumors that are less than four centimeters are considered T1A and four to seven would be T1B. T2 tumors or stage two is when you have a tumor that's between seven and 10 centimeters is T2A and T2B is those that are greater than 10 centimeters but you still have no evidence of spread to the vena cava or to the lymph nodes or there's no widespread meds and those are considered stage two. Stage three you're now beginning to see involvement of the blood vessel so if there is in you see the tumor that's big and it's gone into the renal vein or into the vena cava which is a big blood vessel channel that brings blood from the lower part of your body to your heart that would be considered stage three and stage four is if there is any spread to lymph nodes outside the kidney area if they're spread to lung, liver, bone and brain are all lumped as stage four disease. So knowing where you are in this is extremely important and I would certainly urge you to check for your individual one so once we have kidney cancer we want to then know what is the histologic subtype so as we are beginning to understand I would say even in 2017 I think we are pretty crude about our knowledge and what we know compared to cancers like lung cancer where they know they can separate a patient with lung cancer into so many different molecular subtypes I think in kidney cancer we are still working our way towards figuring that out but right now it's somewhat classified based on what the pathologist looks under the microscope so the most common cell type is the first one which is called clear cell kidney cancer that's what happens in almost 75 percent of patients have this subtype called clear cell kidney cancer the other cell type is called papillary so there's papillary type one and there's papillary type two and then there are less common subtypes like chromophobe and oncocytoma so it's helpful to know this because A you know the outcomes are very different today our treatments we treat them all the same especially with medical therapy we treat them the same today but I think that's changing probably in the next three years there'll be different treatments that we would do for papillary type one versus papillary type two versus clear cell and then the surgical treatment is also a little bit different where there would be more inclined perhaps to watch an oncocytoma compared to a surgical removal I would still say there's a lot of work left in figuring out exactly these subtypes but I think this is the beginning so just very briefly on background because I know you're going we are going to spend a whole talk dedicated to treatments medical treatment surgical treatment I'm just going to give you a little bit of background so that you know what to look for for the rest of the day so again majority our clear cell 75% our clear cell kidney cancer in the past you know maybe in the 10 years prior to today we had very little that we could offer patients with kidney cancer and there used to be a drug called interferon which we don't even use today that's what we had for patients with kidney cancer and I think the last 10 years there's been a remarkable improvement with almost 10 to 11 drugs that we have today that we can treat patients with kidney cancer and each of these have been associated with longevity but I think the search continues because till we really end up curing kidney cancer I think we can stop but there's definitely been a lot of improvement and we are grateful both as providers and for our patients for the ability that we have to cause prolongation of life today I think you know we use these targeted drugs but clearly the next step in the advancement in this field has really been the emergence of immunotherapy you're going to hear a lot about that today and it's really what these drugs help allow your own body to fight the cancer there's been great progress made in diseases like leukemias where they are able to take your immune cells out of your body completely re-engineer it and send it back into your body to fight these cancer cells and leukemias which were completely fatal even up to two years ago now the cure rate is close to 80%. So I think it's remarkable and I think that's where the hope is that there will be similar things because all of us have an immune system there's really no reason why that immune system can be put to work for each of us so really the hope rests on immunotherapy while we are very grateful for the drugs that we have today which have resulted in prolongation of life I think the hope is to have something that will allow for a cure and I think immunotherapy holds a lot of promise and we learn from other hematologic cancers are much less complex compared to solid tumors because there it's really one abnormality that they have here we need to get down to the understanding of the disease where it's not just one pathway there are so many things that result in causing the cancer so really re-engineering that is somewhat of a challenge but the good news is that there's work being done so here is the progress that's been made in RCC so starting in 1992 was when we had a first drug called intraleukin 2 or I listed there as high dose IL2 it's really an immunotherapy it's a drug that's challenging to give patients end up being in the intensive care unit they are really sick and we have a 5% chance of a cure when we give this drug and it's really a drug that's not applicable to a lot of people because as I said in the beginning this is a disease that happened in the 60s and 70s and giving patients these sort of drugs you need normal kidney function you need normal heart function you need normal liver function all of your systems have to be pristine for us to be able to give you this drug so it's really not applicable to a lot of patients and then starting 2005 the understanding of the biology of kidney cancer has just led to a whole host of new drugs that you can see starting in 2005 we had Surafnib 2006 a drug called Sunitnib got approved 2007 we had a new class of drugs called mTOR inhibitors Temserolimus is an intravenous um mTOR inhibitor in 2008 we had a drug called Bevacissimab which was approved 2009 there was another oral mTOR inhibitor called Everolimus 2010 we had a drug called Pozopinib that was approved 2012 Axitinib which is another oral tyrosine kinase inhibitor and in 2015 we had the first immunotherapy drug called Nivolumab approved 2016 was another year where we had two additional drugs one called Cabozantinib and another drug called Lenvatinib so this is amazing progress to have in 10 years really to have 10 different drugs and I think this list will continue you know the next wave of trials is really looking at combination of drugs and you're going to hear more about those as the day goes by so this is how kidney cancer looks like in 2017 the drug therapy we have immunotherapy with intraleukin-2 interferon and old drug which we don't use anymore and Nivolumab is our choice for immunotherapy that we have today there are these whole class of VEGF inhibitors Sunitnib, Sauraphinib, Pozopinib, Axitinib, Bevacissimab, Cabozantinib and Lenvatinib plus Everolimus and then this class of drugs called mTOR inhibitors so it's really this is a complex slide we will probably go into a little bit more detail in one of our talks but you can see that this is how kidney cancer understanding the biology of kidney cancer has just led to this explosion of many drugs and we hope that list continues so we have a lot of things that we want to know but our goal for you today is to share some of these questions so what's the appropriate surgical management is there a role of kidney removal in patients whose disease had spread elsewhere and we're going to have Dr. Chung talk to you today about that what happens everybody is curious you know we have two kidneys but everybody most people are going to have that kidney removed what happens to kidney function after you lose one kidney and how important is that going to be Dr. Leppert is one of our urologic surgeons he's going to talk a little bit about that one of my junior colleagues up here Dr. Sumit Shah he's going to talk a little bit about immunotherapy and what that promise holds and what is what are we doing at Stanford that you may have access to and then I have one of my star fellows Brian Dietrich he's going to talk about how do we pick between these 10 drugs what is appropriate for us to give you for first line what do we do when one treatment fails how do we pick the next line of therapy and then Alice Phan who many of you may know is a colleague of mine in medical oncology her lab and her research is going to be how can we tell when these drugs are working she's going to share some of her work and help us understand those questions a lot of it is about genomics you know it's all the new era is about personalized medicine so to help us understand this language Alex Elysian who's one of our senior fellows he's going to talk a little bit about genomics and how that pertains to kidney cancer I'll come back and briefly talk about patients who have their kidney removed is there any role of preventive therapy so we do this in breast cancer we do this in colon cancer what's new in kidney cancer how can we not even deal with this disease and is there any role of giving treatment in a preventive fashion and finally I have our social worker Jordan talk to us a little bit for a patient forum this is your day today so we want you to be engaged and Jordan is going to help us have a conversation with all of us so I think I'll stop there there'll be a lot of room for questions during the day but I just wanted to give you a flavor of what's coming so if you're good I think I spent 30 minutes so I'm going to have Dr Chung so Ben Chung is a urologic surgeon so he's one of our surgeons he's the director of the laparoscopic kidney program here at Stanford the robotic program Dr Chung is an associate professor of urology he's been here at Stanford been for 10 years 11 and counting so it's our pleasure to have Dr Chung here today we thank him for spending his morning with us on a Saturday and I would urge all of you to ask any question of surgical that you have feel free again you know don't hesitate the day would be a success if each of you are engaged and have questions that you can have clarified