0:00:01.207,0:00:03.901
What's the worst that can happen?

0:00:04.293,0:00:06.786
Almost exactly 10 years ago,

0:00:06.786,0:00:10.505
I was sitting in an exam room[br]that was way too cold

0:00:10.505,0:00:12.841
waiting to meet my new oncologist.

0:00:13.058,0:00:14.443
I was terrified.

0:00:14.443,0:00:17.002
Even though my partner at the time

0:00:17.002,0:00:19.121
was sitting right by my side,

0:00:19.121,0:00:21.672
I felt completely alone.

0:00:21.672,0:00:24.491
I had just been diagnosed[br]with breast cancer,

0:00:24.491,0:00:26.535
and it seemed at the time

0:00:26.535,0:00:29.804
that a single bright spot[br]on a scan of my right lung

0:00:30.155,0:00:33.540
meant that the cancer had already spread.

0:00:33.941,0:00:36.533
I had metastatic breast cancer.

0:00:36.916,0:00:39.404
I had no medical training at this point,

0:00:39.404,0:00:42.339
but I knew what it meant if it were true:

0:00:42.339,0:00:44.923
incurable breast cancer.

0:00:45.849,0:00:48.367
Terminal breast cancer.

0:00:49.218,0:00:51.704
I was 27 years old,

0:00:51.704,0:00:54.288
had just been accepted to medical school,

0:00:54.288,0:00:58.653
and I wondered if I was already[br]at the end of my life.

0:00:58.653,0:01:03.221
My new oncologist was not a warm person.

0:01:03.872,0:01:06.998
She dealt in simple facts,

0:01:06.998,0:01:09.834
as many brilliant physicians do.

0:01:10.018,0:01:13.187
"Our body is made up[br]of cells," she started.

0:01:13.187,0:01:15.996
I stopped her.

0:01:15.996,0:01:18.598
"I'm starting medical school soon.

0:01:18.598,0:01:20.467
I know."

0:01:20.467,0:01:25.021
Instead of taking this as a signal[br]to go backward, to start again,

0:01:25.021,0:01:27.463
she went forward.

0:01:27.463,0:01:30.081
She said that I would need[br]to start on chemotherapy

0:01:30.081,0:01:31.373
to control the cancer.

0:01:31.373,0:01:34.992
She launched into the details[br]of the drug and the side effects

0:01:34.992,0:01:36.444
and the schedule.

0:01:36.444,0:01:40.797
I reminded her that we hadn't even yet[br]biopsied the bright spot on my lung,

0:01:40.797,0:01:44.474
and I asked if she was sure[br]that it was cancer.

0:01:45.425,0:01:50.914
I remember viscerally how she seemed[br]almost frustrated with my question.

0:01:50.914,0:01:54.490
Perhaps she thought I wasn't[br]following along with her explanations,

0:01:54.490,0:01:56.826
or, worse still, I was in denial.

0:01:58.166,0:02:01.587
I simply wanted her to understand[br]that, as her patient,

0:02:01.587,0:02:06.897
the biopsy was not just a mere formality[br]to prove an already foregone conclusion.

0:02:06.897,0:02:11.168
It was a steel needle[br]through skin, muscle and bone

0:02:11.168,0:02:15.646
that would deliver a deep piece of me[br]to the surface and answer a question

0:02:15.646,0:02:18.365
I wish didn't have to be asked.

0:02:18.649,0:02:22.668
Before the biopsy, I could be[br]a 27-year old woman

0:02:22.668,0:02:25.813
who might have metastatic breast cancer,

0:02:25.813,0:02:29.198
who probably had metastatic breast cancer.

0:02:29.198,0:02:31.767
This is a critical distinction,

0:02:31.767,0:02:35.894
but it's not one that's emphasized[br]in the most elite oncology training.

0:02:36.248,0:02:41.103
Instead, I was dismissed[br]with an appointment to start treatment

0:02:41.103,0:02:42.821
in just a few weeks.

0:02:43.571,0:02:47.333
So much has happened[br]since that first visit.

0:02:47.333,0:02:50.786
Ironically, the biopsy was not[br]just a mere formality.

0:02:50.786,0:02:53.571
My former oncologist was right.

0:02:53.571,0:02:56.297
It did show cancer,

0:02:56.297,0:03:00.301
but it was a totally separate lung cancer,

0:03:00.301,0:03:02.502
and as crazy as it sounds,

0:03:02.502,0:03:04.778
this was great news.

0:03:04.994,0:03:08.181
I did not have metastatic breast cancer,

0:03:08.181,0:03:10.033
I had two different cancers,

0:03:10.033,0:03:12.134
but both of them were localized,

0:03:12.134,0:03:15.378
and so the lung cancer[br]was localized enough

0:03:15.378,0:03:16.930
that it could be removed.

0:03:16.930,0:03:20.584
And so the onslaught of treatments began[br]with a lung surgery,

0:03:20.584,0:03:23.068
continued with chemotherapy,

0:03:23.068,0:03:27.814
and ended with a breast surgery[br]just after my 28th birthday.

0:03:27.814,0:03:29.815
And then two weeks later,

0:03:29.815,0:03:32.867
I started medical school.

0:03:32.867,0:03:35.978
My new oncologist,

0:03:35.978,0:03:40.064
who deals much more fluidly[br]both with facts and their implications,

0:03:40.530,0:03:42.583
very reasonably suggested

0:03:42.583,0:03:45.876
that I should defer my acceptance[br]to medical school for a year,

0:03:45.876,0:03:49.011
take some time to rest, to recover,

0:03:49.011,0:03:52.748
and I trusted her advice.

0:03:52.748,0:03:56.743
I felt terrible during the intensive[br]chemotherapy sessions.

0:03:56.743,0:03:58.461
And so I wrote to the Dean.

0:03:58.461,0:04:00.346
I explained my circumstances,

0:04:00.346,0:04:02.648
and a deferral was speedily granted.

0:04:03.683,0:04:06.191
But as the chemo fog lifted,

0:04:06.191,0:04:09.478
I wondered what I was going[br]to do with a year.

0:04:09.478,0:04:12.847
Should I go to the beach?

0:04:13.282,0:04:15.998
I wasn't really a beach person.

0:04:15.998,0:04:17.099
(Laughter)

0:04:17.099,0:04:20.402
And how many years did I have left anyway?

0:04:21.153,0:04:23.512
I really wanted to go to medical school.

0:04:23.512,0:04:26.648
It seemed like a missing[br]piece of my puzzle.

0:04:26.848,0:04:30.703
So instead of going around[br]and around with indecision,

0:04:30.703,0:04:33.611
I asked myself, what's the worst[br]that could happen?

0:04:33.611,0:04:37.065
Well, I could be too weak[br]or too sick to do the work.

0:04:37.065,0:04:39.467
It could be too hard for me emotionally.

0:04:39.467,0:04:42.443
I could fail out of medical school.

0:04:42.443,0:04:46.346
But then I remembered, that wouldn't be[br]the worst thing that happened to me

0:04:46.346,0:04:47.481
even that year.

0:04:47.481,0:04:51.217
So why not get started?

0:04:51.217,0:04:53.125
Why not continue living[br]the way that I wanted to live?

0:04:53.125,0:04:56.563
So I did.

0:04:56.563,0:04:58.580
Bald and rail thin,

0:04:58.580,0:05:02.201
I put on my best earrings[br]and my favorite dress,

0:05:02.201,0:05:04.843
and I started.

0:05:04.843,0:05:06.094
I pretended to belong,

0:05:06.094,0:05:08.212
and I began to.

0:05:08.212,0:05:12.016
There is no way to describe[br]how hard it was.

0:05:12.016,0:05:13.875
Some days it felt impossible.

0:05:13.875,0:05:18.440
It felt as I was doing things[br]that would never matter in the future.

0:05:18.440,0:05:21.982
But every day, I asked myself,[br]are you still enjoying this?

0:05:21.982,0:05:24.825
Is this still what you want to be doing?

0:05:24.825,0:05:26.977
And every day, the answer was yes,

0:05:26.977,0:05:29.847
sometimes a very qualified yes,

0:05:29.847,0:05:31.564
but a yes.

0:05:31.564,0:05:33.839
And then, just as I[br]was getting comfortable

0:05:33.839,0:05:37.360
and feeling like I might not necessarily[br]fail out of medical school,

0:05:37.360,0:05:40.562
I received even more devastating news.

0:05:40.562,0:05:47.159
I learned that I had a mutation[br]in a gene called TP53, or p53 for short.

0:05:47.159,0:05:50.446
Known as the guardian of the genome,

0:05:50.446,0:05:56.492
a mutation, p53 is responsible[br]for supervising the repair of our DNA.

0:05:56.492,0:05:59.645
A mutation in this gene[br]means errors go uncorrected.

0:05:59.645,0:06:03.621
It means that normal cells[br]become cancerous at a much higher rate.

0:06:04.739,0:06:07.241
All of a sudden, with this knowledge,

0:06:07.241,0:06:10.187
my medical history[br]made a terrible kind of sense.

0:06:10.187,0:06:13.787
I had had a childhood cancer --[br]rhabdomyosarcoma -- at age seven.

0:06:13.787,0:06:16.756
It recurred when I was a teenager.

0:06:16.756,0:06:20.626
And this was all before p53[br]had been discovered in the lab.

0:06:20.626,0:06:24.636
Then I'd had young adult[br]breast and lung cancers.

0:06:24.636,0:06:26.989
With the knowledge of this mutation,

0:06:26.989,0:06:30.491
it seemed that there was likely[br]no end to the number of cancers

0:06:30.491,0:06:32.733
that I could expect in my future.

0:06:32.950,0:06:35.353
And yet,

0:06:35.353,0:06:39.274
I decided to become[br]a radiation oncologist.

0:06:39.274,0:06:40.308
(Laughter)

0:06:40.308,0:06:44.186
I hoped to graduate from residency[br]in just a few months,

0:06:44.186,0:06:46.622
move to a new city,

0:06:46.622,0:06:48.240
and start my first real job

0:06:48.240,0:06:51.883
as a doctor and researcher,

0:06:51.883,0:06:54.218
because of grit,

0:06:54.218,0:06:55.704
because of privilege,

0:06:55.704,0:06:57.572
because of therapy,

0:06:57.572,0:07:01.729
because of my medical teams[br]and my family and my teachers,

0:07:02.675,0:07:08.688
because genetic diagnoses

0:07:08.688,0:07:09.477
should give us the knowledge[br]to move forward.

0:07:09.477,0:07:12.408
And even in the year 2020,

0:07:12.408,0:07:15.567
that generally doesn't mean[br]miracle cures or medical breakthroughs.

0:07:15.567,0:07:20.067
Having a devastating genetic diagnosis

0:07:20.067,0:07:23.961
means learning to live with uncertainty.

0:07:23.961,0:07:27.938
It means learning that you,[br]and your diagnosis,

0:07:27.938,0:07:30.775
are not the worst thing that could happen.

0:07:30.775,0:07:32.982
Learning to live with uncertainty

0:07:32.982,0:07:35.603
means walking forward into a life

0:07:35.603,0:07:39.773
that is as full of beauty[br]as it is of challenges.

0:07:40.173,0:07:45.204
It means learning for yourself[br]that cancer is just part of your story.

0:07:45.204,0:07:47.739
It may not be the worst thing[br]that happens to you,

0:07:47.739,0:07:49.593
and if it is, that's OK.

0:07:49.593,0:07:52.134
You can claim that, and you can own that,

0:07:52.134,0:07:55.008
but let that be a narrative[br]that you author and you authorize,

0:07:55.008,0:07:59.112
not one that's prescribed to you[br]by someone else.

0:07:59.112,0:08:01.281
Have your deferral letter in hand,[br]but use it on your terms.

0:08:01.281,0:08:04.267
As I come to the end[br]of my oncology training,

0:08:04.267,0:08:07.893
I have deja vu again and again[br]with the following scenario.

0:08:07.893,0:08:12.199
A patient has cancer.

0:08:12.199,0:08:14.160
There are several options,

0:08:14.160,0:08:20.533
all of which offer a different balance[br]between cure and quality of life,

0:08:20.533,0:08:24.427
between the possibility[br]of alleviating suffering

0:08:24.427,0:08:29.515
and the possibility of causing suffering.

0:08:29.515,0:08:31.073
An oncologist lays out the options,

0:08:31.073,0:08:33.057
but, somewhere in the discussion,[br]things get skewed.

0:08:33.057,0:08:35.327
The choice becomes something more like,

0:08:35.327,0:08:38.312
well, you could choose to do something

0:08:38.312,0:08:41.522
or you could choose to do nothing.

0:08:41.522,0:08:43.958
We could be aggressive

0:08:43.958,0:08:45.993
and treat your cancer,

0:08:45.993,0:08:48.028
or we could watch it,

0:08:48.028,0:08:51.705
and 9.9 times out of 10, the patient says,

0:08:51.705,0:08:54.724
"I want to do everything I can do."

0:08:54.941,0:08:56.659
Of course.

0:08:56.659,0:08:59.930
Who wouldn't want everything?

0:09:00.280,0:09:02.925
But what is everything?

0:09:02.925,0:09:08.729
Is everything the ability to sit[br]in your own home in front of your window

0:09:08.729,0:09:11.823
bathed in sunshine[br]and surrounded by family?

0:09:12.041,0:09:16.811
Is everything still being able[br]to feel your fingers and your toes

0:09:16.811,0:09:20.021
because they haven't gone numb[br]from chemotherapy.

0:09:20.021,0:09:22.390
As oncologists, our everything[br]is cancer treatment.

0:09:22.390,0:09:30.038
It's radiation and surgery[br]and chemotherapy and novel treatments.

0:09:30.038,0:09:33.323
And for us, the worst thing[br]that could happen,

0:09:33.323,0:09:35.826
and I have heard more than one[br]oncologist say this,

0:09:35.826,0:09:38.244
the worst thing that could happen[br]is that the patient will develop

0:09:38.244,0:09:39.903
metastatic disease.

0:09:39.903,0:09:43.723
Or, the worst thing that could happen[br]is that five years from now,

0:09:43.723,0:09:47.293
the cancer will grow and I'll[br]have to give more radiation.

0:09:47.293,0:09:49.936
As a patient and as an oncologist,

0:09:49.936,0:09:54.072
I would never argue that these[br]are not devastating outcomes.

0:09:54.072,0:09:56.124
But are they the worst?

0:09:56.124,0:09:58.493
Should cancer control,

0:09:58.493,0:10:03.774
be at the center, of our thinking always?

0:10:03.774,0:10:11.036
Many unspeakably, unfathomably painful[br]and brutal things have happened to me

0:10:11.036,0:10:15.005
because of my cancers[br]and my genetic mutation.

0:10:15.005,0:10:19.332
And yet, I consider myself[br]very lucky indeed,

0:10:19.332,0:10:23.236
because the worst thing[br]that could happen never came to pass,

0:10:23.236,0:10:28.474
because I have let devastation[br]and uncertainty sit at the table,

0:10:28.474,0:10:30.899
but somewhere off to the side.

0:10:30.899,0:10:33.618
When I was diagnosed[br]with metastatic breast cancer,

0:10:33.618,0:10:37.722
I went to Boston for a second opinion,[br]because what could I lose?

0:10:37.722,0:10:40.715
When my oncologist gave me[br]very good and very safe

0:10:40.715,0:10:42.501
and very standard advice,

0:10:42.501,0:10:44.402
I started medical school anyway,

0:10:44.402,0:10:48.072
even though I was undergoing[br]active cancer treatment.

0:10:48.323,0:10:51.933
Instead of shying away[br]from patients with cancer,

0:10:51.933,0:10:54.067
I became a radiation oncologist,

0:10:54.067,0:10:57.304
and I work with patients[br]who are very much like me

0:10:57.304,0:10:58.556
every single day.

0:10:58.556,0:11:03.733
Instead of imagining the suffering[br]that I might cause to a future partner

0:11:03.733,0:11:05.818
when I died of cancer,

0:11:05.818,0:11:09.245
I married my wonderful husband.

0:11:09.446,0:11:13.449
Because, the worst thing that can happen

0:11:13.449,0:11:15.023
is always a series of negatives.

0:11:15.023,0:11:17.469
It's blank spaces

0:11:17.469,0:11:19.878
that should be filled with life.

0:11:20.613,0:11:27.336
So what is the most that I have leaned in[br]to this kind of radical uncertainty?

0:11:27.918,0:11:31.062
Well, this is William.

0:11:32.263,0:11:37.618
He is the most joyful person[br]that I have ever met,

0:11:38.802,0:11:44.464
and in just over a year, he has already[br]made the world a better place.

0:11:45.448,0:11:50.521
As oncologists, we talk to our patients

0:11:50.521,0:11:52.428
as if the worst thing that could happen

0:11:52.428,0:11:54.680
is that their cancer could come back,

0:11:54.680,0:11:57.867
or that it could spread,[br]or that they could die from it.

0:11:58.301,0:12:01.860
As a patient, I know[br]that these are paramount,

0:12:01.860,0:12:04.247
but I want to change the way[br]that we think about this,

0:12:04.247,0:12:08.382
and I want to change the way[br]that we talk about this with our patients.

0:12:08.549,0:12:09.924
As a patient,

0:12:09.924,0:12:14.679
the worst thing that can happen[br]is that cancer robs you of opportunity,

0:12:14.679,0:12:17.232
of the ability to be and to do

0:12:17.232,0:12:19.350
and to love.

0:12:20.291,0:12:21.725
And it will.

0:12:21.725,0:12:25.112
At least, temporarily, it will.

0:12:25.112,0:12:28.365
But to minimize this loss[br]of life in the living,

0:12:28.365,0:12:31.507
that is the harder

0:12:31.507,0:12:34.710
and I would say truer job[br]of the oncologist:

0:12:34.710,0:12:39.097
to take all the tools that we have[br]and situate them in the context

0:12:39.097,0:12:41.775
of a patient's whole entire life;

0:12:41.775,0:12:45.877
to be guides for how[br]to sit with suffering,

0:12:45.877,0:12:47.996
acknowledge it deeply,

0:12:47.996,0:12:54.275
but to not let fear of future suffering[br]be the narrative for the journey forward.

0:12:54.275,0:12:56.413
One of my mentors always says,

0:12:56.413,0:13:00.016
the medicine part is easy,

0:13:00.016,0:13:03.270
and it never feels that way[br]to a junior doctor,

0:13:03.270,0:13:06.862
but it's contours are finite.

0:13:06.862,0:13:13.735
We have big studies to guide us,[br]and it's what we learn to do in residency.

0:13:13.735,0:13:21.032
Much harder is learning how to help[br]each patient navigate the multitudes

0:13:21.032,0:13:24.185
contained in their illness.

0:13:24.786,0:13:28.696
So I find it really funny

0:13:28.696,0:13:33.033
that, in retrospect, my life[br]looks like a neat package.

0:13:33.033,0:13:37.427
It looks as if I planned[br]each successive step,

0:13:37.427,0:13:42.166
and that perhaps cancer[br]has led to the good things in my life.

0:13:42.465,0:13:45.910
Step one: apply to medical school.

0:13:45.910,0:13:49.496
Step two: get diagnosed with[br]and treated for cancer.

0:13:49.496,0:13:52.122
And step three: have it all,

0:13:52.122,0:13:56.584
a career and a family.

0:13:56.584,0:13:58.394
But I will tell you

0:13:58.394,0:14:02.888
that each phase was a leap of faith

0:14:02.888,0:14:08.476
despite an almost paralyzing uncertainty.

0:14:08.476,0:14:10.061
And so it's that courage

0:14:10.061,0:14:13.438
that I try to give to each of my patients.

0:14:13.621,0:14:17.858
I try to do this regardless[br]of the technical medical details

0:14:17.858,0:14:21.028
of cancers and treatment decisions

0:14:21.028,0:14:22.069
and mutations,

0:14:22.069,0:14:25.555
regardless of the slippery fiction

0:14:25.555,0:14:26.756
of prognosis.

0:14:26.756,0:14:29.659
I try to learn what they want

0:14:29.659,0:14:31.619
and what they need,

0:14:31.619,0:14:35.037
what they wish and what they worry,

0:14:36.438,0:14:39.859
what they dream about,

0:14:39.859,0:14:42.735
what animated them before

0:14:43.489,0:14:49.761
and what will sustain them during[br]the beastly process of cancer treatment.

0:14:51.329,0:14:54.571
It doesn't actually take that much time.

0:14:55.540,0:15:00.677
It does take a few focused, quiet moments

0:15:00.677,0:15:03.803
that require intentional cultivation.

0:15:04.956,0:15:08.408
But this is partnership,

0:15:08.408,0:15:10.911
and it matters,

0:15:11.745,0:15:14.538
because the worst thing that can happen

0:15:14.538,0:15:19.359
is to have an oncologist[br]who does everything,

0:15:19.359,0:15:24.103
everything to help cure your cancer

0:15:24.103,0:15:29.024
and who does nothing[br]to help you live your life.

0:15:29.675,0:15:31.927
Thank you.

0:15:31.927,0:15:35.937
(Applause)