1
00:00:01,207 --> 00:00:03,901
What's the worst that can happen?

2
00:00:04,293 --> 00:00:06,786
Almost exactly 10 years ago,

3
00:00:06,786 --> 00:00:10,505
I was sitting in an exam room
that was way too cold

4
00:00:10,505 --> 00:00:12,841
waiting to meet my new oncologist.

5
00:00:13,058 --> 00:00:14,443
I was terrified.

6
00:00:14,443 --> 00:00:17,002
Even though my partner at the time

7
00:00:17,002 --> 00:00:19,121
was sitting right by my side,

8
00:00:19,121 --> 00:00:21,672
I felt completely alone.

9
00:00:21,672 --> 00:00:24,491
I had just been diagnosed
with breast cancer,

10
00:00:24,491 --> 00:00:26,535
and it seemed at the time

11
00:00:26,535 --> 00:00:29,804
that a single bright spot
on a scan of my right lung

12
00:00:30,155 --> 00:00:33,540
meant that the cancer had already spread.

13
00:00:33,941 --> 00:00:36,533
I had metastatic breast cancer.

14
00:00:36,916 --> 00:00:39,404
I had no medical training at this point,

15
00:00:39,404 --> 00:00:42,339
but I knew what it meant if it were true:

16
00:00:42,339 --> 00:00:44,923
incurable breast cancer.

17
00:00:45,849 --> 00:00:48,367
Terminal breast cancer.

18
00:00:49,218 --> 00:00:51,704
I was 27 years old,

19
00:00:51,704 --> 00:00:54,288
had just been accepted to medical school,

20
00:00:54,288 --> 00:00:58,653
and I wondered if I was already
at the end of my life.

21
00:00:58,653 --> 00:01:03,221
My new oncologist was not a warm person.

22
00:01:03,872 --> 00:01:06,998
She dealt in simple facts,

23
00:01:06,998 --> 00:01:09,834
as many brilliant physicians do.

24
00:01:10,018 --> 00:01:13,187
"Our body is made up
of cells," she started.

25
00:01:13,187 --> 00:01:15,996
I stopped her.

26
00:01:15,996 --> 00:01:18,598
"I'm starting medical school soon.

27
00:01:18,598 --> 00:01:20,467
I know."

28
00:01:20,467 --> 00:01:25,021
Instead of taking this as a signal
to go backward, to start again,

29
00:01:25,021 --> 00:01:27,463
she went forward.

30
00:01:27,463 --> 00:01:30,081
She said that I would need
to start on chemotherapy

31
00:01:30,081 --> 00:01:31,373
to control the cancer.

32
00:01:31,373 --> 00:01:34,992
She launched into the details
of the drug and the side effects

33
00:01:34,992 --> 00:01:36,444
and the schedule.

34
00:01:36,444 --> 00:01:40,797
I reminded her that we hadn't even yet
biopsied the bright spot on my lung,

35
00:01:40,797 --> 00:01:44,474
and I asked if she was sure
that it was cancer.

36
00:01:45,425 --> 00:01:50,914
I remember viscerally how she seemed
almost frustrated with my question.

37
00:01:50,914 --> 00:01:54,490
Perhaps she thought I wasn't
following along with her explanations,

38
00:01:54,490 --> 00:01:56,826
or, worse still, I was in denial.

39
00:01:58,166 --> 00:02:01,587
I simply wanted her to understand
that, as her patient,

40
00:02:01,587 --> 00:02:06,897
the biopsy was not just a mere formality
to prove an already foregone conclusion.

41
00:02:06,897 --> 00:02:11,168
It was a steel needle
through skin, muscle and bone

42
00:02:11,168 --> 00:02:15,646
that would deliver a deep piece of me
to the surface and answer a question

43
00:02:15,646 --> 00:02:18,365
I wish didn't have to be asked.

44
00:02:18,649 --> 00:02:22,668
Before the biopsy, I could be
a 27-year old woman

45
00:02:22,668 --> 00:02:25,813
who might have metastatic breast cancer,

46
00:02:25,813 --> 00:02:29,198
who probably had metastatic breast cancer.

47
00:02:29,198 --> 00:02:31,767
This is a critical distinction,

48
00:02:31,767 --> 00:02:35,894
but it's not one that's emphasized
in the most elite oncology training.

49
00:02:36,248 --> 00:02:41,103
Instead, I was dismissed
with an appointment to start treatment

50
00:02:41,103 --> 00:02:42,821
in just a few weeks.

51
00:02:43,571 --> 00:02:47,333
So much has happened
since that first visit.

52
00:02:47,333 --> 00:02:50,786
Ironically, the biopsy was not
just a mere formality.

53
00:02:50,786 --> 00:02:53,571
My former oncologist was right.

54
00:02:53,571 --> 00:02:56,297
It did show cancer,

55
00:02:56,297 --> 00:03:00,301
but it was a totally separate lung cancer,

56
00:03:00,301 --> 00:03:02,502
and as crazy as it sounds,

57
00:03:02,502 --> 00:03:04,778
this was great news.

58
00:03:04,994 --> 00:03:08,181
I did not have metastatic breast cancer,

59
00:03:08,181 --> 00:03:10,033
I had two different cancers,

60
00:03:10,033 --> 00:03:12,134
but both of them were localized,

61
00:03:12,134 --> 00:03:15,378
and so the lung cancer
was localized enough

62
00:03:15,378 --> 00:03:16,930
that it could be removed.

63
00:03:16,930 --> 00:03:20,584
And so the onslaught of treatments began
with a lung surgery,

64
00:03:20,584 --> 00:03:23,068
continued with chemotherapy,

65
00:03:23,068 --> 00:03:27,814
and ended with a breast surgery
just after my 28th birthday.

66
00:03:27,814 --> 00:03:29,815
And then two weeks later,

67
00:03:29,815 --> 00:03:32,867
I started medical school.

68
00:03:32,867 --> 00:03:35,978
My new oncologist,

69
00:03:35,978 --> 00:03:40,064
who deals much more fluidly
both with facts and their implications,

70
00:03:40,530 --> 00:03:42,583
very reasonably suggested

71
00:03:42,583 --> 00:03:45,876
that I should defer my acceptance
to medical school for a year,

72
00:03:45,876 --> 00:03:49,011
take some time to rest, to recover,

73
00:03:49,011 --> 00:03:52,748
and I trusted her advice.

74
00:03:52,748 --> 00:03:56,743
I felt terrible during the intensive
chemotherapy sessions.

75
00:03:56,743 --> 00:03:58,461
And so I wrote to the Dean.

76
00:03:58,461 --> 00:04:00,346
I explained my circumstances,

77
00:04:00,346 --> 00:04:02,648
and a deferral was speedily granted.

78
00:04:03,683 --> 00:04:06,191
But as the chemo fog lifted,

79
00:04:06,191 --> 00:04:09,478
I wondered what I was going
to do with a year.

80
00:04:09,478 --> 00:04:12,847
Should I go to the beach?

81
00:04:13,282 --> 00:04:15,998
I wasn't really a beach person.

82
00:04:15,998 --> 00:04:17,099
(Laughter)

83
00:04:17,099 --> 00:04:20,402
And how many years did I have left anyway?

84
00:04:21,153 --> 00:04:23,512
I really wanted to go to medical school.

85
00:04:23,512 --> 00:04:26,648
It seemed like a missing
piece of my puzzle.

86
00:04:26,848 --> 00:04:30,703
So instead of going around
and around with indecision,

87
00:04:30,703 --> 00:04:33,611
I asked myself, what's the worst
that could happen?

88
00:04:33,611 --> 00:04:37,065
Well, I could be too weak
or too sick to do the work.

89
00:04:37,065 --> 00:04:39,467
It could be too hard for me emotionally.

90
00:04:39,467 --> 00:04:42,443
I could fail out of medical school.

91
00:04:42,443 --> 00:04:46,346
But then I remembered, that wouldn't be
the worst thing that happened to me

92
00:04:46,346 --> 00:04:47,481
even that year.

93
00:04:47,481 --> 00:04:51,217
So why not get started?

94
00:04:51,217 --> 00:04:53,125
Why not continue living
the way that I wanted to live?

95
00:04:53,125 --> 00:04:56,563
So I did.

96
00:04:56,563 --> 00:04:58,580
Bald and rail thin,

97
00:04:58,580 --> 00:05:02,201
I put on my best earrings
and my favorite dress,

98
00:05:02,201 --> 00:05:04,843
and I started.

99
00:05:04,843 --> 00:05:06,094
I pretended to belong,

100
00:05:06,094 --> 00:05:08,212
and I began to.

101
00:05:08,212 --> 00:05:12,016
There is no way to describe
how hard it was.

102
00:05:12,016 --> 00:05:13,875
Some days it felt impossible.

103
00:05:13,875 --> 00:05:18,440
It felt as I was doing things
that would never matter in the future.

104
00:05:18,440 --> 00:05:21,982
But every day, I asked myself,
are you still enjoying this?

105
00:05:21,982 --> 00:05:24,825
Is this still what you want to be doing?

106
00:05:24,825 --> 00:05:26,977
And every day, the answer was yes,

107
00:05:26,977 --> 00:05:29,847
sometimes a very qualified yes,

108
00:05:29,847 --> 00:05:31,564
but a yes.

109
00:05:31,564 --> 00:05:33,839
And then, just as I
was getting comfortable

110
00:05:33,839 --> 00:05:37,360
and feeling like I might not necessarily
fail out of medical school,

111
00:05:37,360 --> 00:05:40,562
I received even more devastating news.

112
00:05:40,562 --> 00:05:47,159
I learned that I had a mutation
in a gene called TP53, or p53 for short.

113
00:05:47,159 --> 00:05:50,446
Known as the guardian of the genome,

114
00:05:50,446 --> 00:05:56,492
a mutation, p53 is responsible
for supervising the repair of our DNA.

115
00:05:56,492 --> 00:05:59,645
A mutation in this gene
means errors go uncorrected.

116
00:05:59,645 --> 00:06:03,621
It means that normal cells
become cancerous at a much higher rate.

117
00:06:04,739 --> 00:06:07,241
All of a sudden, with this knowledge,

118
00:06:07,241 --> 00:06:10,187
my medical history
made a terrible kind of sense.

119
00:06:10,187 --> 00:06:13,787
I had had a childhood cancer --
rhabdomyosarcoma -- at age seven.

120
00:06:13,787 --> 00:06:16,756
It recurred when I was a teenager.

121
00:06:16,756 --> 00:06:20,626
And this was all before p53
had been discovered in the lab.

122
00:06:20,626 --> 00:06:24,636
Then I'd had young adult
breast and lung cancers.

123
00:06:24,636 --> 00:06:26,989
With the knowledge of this mutation,

124
00:06:26,989 --> 00:06:30,491
it seemed that there was likely
no end to the number of cancers

125
00:06:30,491 --> 00:06:32,733
that I could expect in my future.

126
00:06:32,950 --> 00:06:35,353
And yet,

127
00:06:35,353 --> 00:06:39,274
I decided to become
a radiation oncologist.

128
00:06:39,274 --> 00:06:40,308
(Laughter)

129
00:06:40,308 --> 00:06:44,186
I hoped to graduate from residency
in just a few months,

130
00:06:44,186 --> 00:06:46,622
move to a new city,

131
00:06:46,622 --> 00:06:48,240
and start my first real job

132
00:06:48,240 --> 00:06:51,883
as a doctor and researcher,

133
00:06:51,883 --> 00:06:54,218
because of grit,

134
00:06:54,218 --> 00:06:55,704
because of privilege,

135
00:06:55,704 --> 00:06:57,572
because of therapy,

136
00:06:57,572 --> 00:07:01,729
because of my medical teams
and my family and my teachers,

137
00:07:02,675 --> 00:07:08,688
because genetic diagnoses

138
00:07:08,688 --> 00:07:09,477
should give us the knowledge
to move forward.

139
00:07:09,477 --> 00:07:12,408
And even in the year 2020,

140
00:07:12,408 --> 00:07:15,567
that generally doesn't mean
miracle cures or medical breakthroughs.

141
00:07:15,567 --> 00:07:20,067
Having a devastating genetic diagnosis

142
00:07:20,067 --> 00:07:23,961
means learning to live with uncertainty.

143
00:07:23,961 --> 00:07:27,938
It means learning that you,
and your diagnosis,

144
00:07:27,938 --> 00:07:30,775
are not the worst thing that could happen.

145
00:07:30,775 --> 00:07:32,982
Learning to live with uncertainty

146
00:07:32,982 --> 00:07:35,603
means walking forward into a life

147
00:07:35,603 --> 00:07:39,773
that is as full of beauty
as it is of challenges.

148
00:07:40,173 --> 00:07:45,204
It means learning for yourself
that cancer is just part of your story.

149
00:07:45,204 --> 00:07:47,739
It may not be the worst thing
that happens to you,

150
00:07:47,739 --> 00:07:49,593
and if it is, that's OK.

151
00:07:49,593 --> 00:07:52,134
You can claim that, and you can own that,

152
00:07:52,134 --> 00:07:55,008
but let that be a narrative
that you author and you authorize,

153
00:07:55,008 --> 00:07:59,112
not one that's prescribed to you
by someone else.

154
00:07:59,112 --> 00:08:01,281
Have your deferral letter in hand,
but use it on your terms.

155
00:08:01,281 --> 00:08:04,267
As I come to the end
of my oncology training,

156
00:08:04,267 --> 00:08:07,893
I have deja vu again and again
with the following scenario.

157
00:08:07,893 --> 00:08:12,199
A patient has cancer.

158
00:08:12,199 --> 00:08:14,160
There are several options,

159
00:08:14,160 --> 00:08:20,533
all of which offer a different balance
between cure and quality of life,

160
00:08:20,533 --> 00:08:24,427
between the possibility
of alleviating suffering

161
00:08:24,427 --> 00:08:29,515
and the possibility of causing suffering.

162
00:08:29,515 --> 00:08:31,073
An oncologist lays out the options,

163
00:08:31,073 --> 00:08:33,057
but, somewhere in the discussion,
things get skewed.

164
00:08:33,057 --> 00:08:35,327
The choice becomes something more like,

165
00:08:35,327 --> 00:08:38,312
well, you could choose to do something

166
00:08:38,312 --> 00:08:41,522
or you could choose to do nothing.

167
00:08:41,522 --> 00:08:43,958
We could be aggressive

168
00:08:43,958 --> 00:08:45,993
and treat your cancer,

169
00:08:45,993 --> 00:08:48,028
or we could watch it,

170
00:08:48,028 --> 00:08:51,705
and 9.9 times out of 10, the patient says,

171
00:08:51,705 --> 00:08:54,724
"I want to do everything I can do."

172
00:08:54,941 --> 00:08:56,659
Of course.

173
00:08:56,659 --> 00:08:59,930
Who wouldn't want everything?

174
00:09:00,280 --> 00:09:02,925
But what is everything?

175
00:09:02,925 --> 00:09:08,729
Is everything the ability to sit
in your own home in front of your window

176
00:09:08,729 --> 00:09:11,823
bathed in sunshine
and surrounded by family?

177
00:09:12,041 --> 00:09:16,811
Is everything still being able
to feel your fingers and your toes

178
00:09:16,811 --> 00:09:20,021
because they haven't gone numb
from chemotherapy.

179
00:09:20,021 --> 00:09:22,390
As oncologists, our everything
is cancer treatment.

180
00:09:22,390 --> 00:09:30,038
It's radiation and surgery
and chemotherapy and novel treatments.

181
00:09:30,038 --> 00:09:33,323
And for us, the worst thing
that could happen,

182
00:09:33,323 --> 00:09:35,826
and I have heard more than one
oncologist say this,

183
00:09:35,826 --> 00:09:38,244
the worst thing that could happen
is that the patient will develop

184
00:09:38,244 --> 00:09:39,903
metastatic disease.

185
00:09:39,903 --> 00:09:43,723
Or, the worst thing that could happen
is that five years from now,

186
00:09:43,723 --> 00:09:47,293
the cancer will grow and I'll
have to give more radiation.

187
00:09:47,293 --> 00:09:49,936
As a patient and as an oncologist,

188
00:09:49,936 --> 00:09:54,072
I would never argue that these
are not devastating outcomes.

189
00:09:54,072 --> 00:09:56,124
But are they the worst?

190
00:09:56,124 --> 00:09:58,493
Should cancer control,

191
00:09:58,493 --> 00:10:03,774
be at the center, of our thinking always?

192
00:10:03,774 --> 00:10:11,036
Many unspeakably, unfathomably painful
and brutal things have happened to me

193
00:10:11,036 --> 00:10:15,005
because of my cancers
and my genetic mutation.

194
00:10:15,005 --> 00:10:19,332
And yet, I consider myself
very lucky indeed,

195
00:10:19,332 --> 00:10:23,236
because the worst thing
that could happen never came to pass,

196
00:10:23,236 --> 00:10:28,474
because I have let devastation
and uncertainty sit at the table,

197
00:10:28,474 --> 00:10:30,899
but somewhere off to the side.

198
00:10:30,899 --> 00:10:33,618
When I was diagnosed
with metastatic breast cancer,

199
00:10:33,618 --> 00:10:37,722
I went to Boston for a second opinion,
because what could I lose?

200
00:10:37,722 --> 00:10:40,715
When my oncologist gave me
very good and very safe

201
00:10:40,715 --> 00:10:42,501
and very standard advice,

202
00:10:42,501 --> 00:10:44,402
I started medical school anyway,

203
00:10:44,402 --> 00:10:48,072
even though I was undergoing
active cancer treatment.

204
00:10:48,323 --> 00:10:51,933
Instead of shying away
from patients with cancer,

205
00:10:51,933 --> 00:10:54,067
I became a radiation oncologist,

206
00:10:54,067 --> 00:10:57,304
and I work with patients
who are very much like me

207
00:10:57,304 --> 00:10:58,556
every single day.

208
00:10:58,556 --> 00:11:03,733
Instead of imagining the suffering
that I might cause to a future partner

209
00:11:03,733 --> 00:11:05,818
when I died of cancer,

210
00:11:05,818 --> 00:11:09,245
I married my wonderful husband.

211
00:11:09,446 --> 00:11:13,449
Because, the worst thing that can happen

212
00:11:13,449 --> 00:11:15,023
is always a series of negatives.

213
00:11:15,023 --> 00:11:17,469
It's blank spaces

214
00:11:17,469 --> 00:11:19,878
that should be filled with life.

215
00:11:20,613 --> 00:11:27,336
So what is the most that I have leaned in
to this kind of radical uncertainty?

216
00:11:27,918 --> 00:11:31,062
Well, this is William.

217
00:11:32,263 --> 00:11:37,618
He is the most joyful person
that I have ever met,

218
00:11:38,802 --> 00:11:44,464
and in just over a year, he has already
made the world a better place.

219
00:11:45,448 --> 00:11:50,521
As oncologists, we talk to our patients

220
00:11:50,521 --> 00:11:52,428
as if the worst thing that could happen

221
00:11:52,428 --> 00:11:54,680
is that their cancer could come back,

222
00:11:54,680 --> 00:11:57,867
or that it could spread,
or that they could die from it.

223
00:11:58,301 --> 00:12:01,860
As a patient, I know
that these are paramount,

224
00:12:01,860 --> 00:12:04,247
but I want to change the way
that we think about this,

225
00:12:04,247 --> 00:12:08,382
and I want to change the way
that we talk about this with our patients.

226
00:12:08,549 --> 00:12:09,924
As a patient,

227
00:12:09,924 --> 00:12:14,679
the worst thing that can happen
is that cancer robs you of opportunity,

228
00:12:14,679 --> 00:12:17,232
of the ability to be and to do

229
00:12:17,232 --> 00:12:19,350
and to love.

230
00:12:20,291 --> 00:12:21,725
And it will.

231
00:12:21,725 --> 00:12:25,112
At least, temporarily, it will.

232
00:12:25,112 --> 00:12:28,365
But to minimize this loss
of life in the living,

233
00:12:28,365 --> 00:12:31,507
that is the harder

234
00:12:31,507 --> 00:12:34,710
and I would say truer job
of the oncologist:

235
00:12:34,710 --> 00:12:39,097
to take all the tools that we have
and situate them in the context

236
00:12:39,097 --> 00:12:41,775
of a patient's whole entire life;

237
00:12:41,775 --> 00:12:45,877
to be guides for how
to sit with suffering,

238
00:12:45,877 --> 00:12:47,996
acknowledge it deeply,

239
00:12:47,996 --> 00:12:54,275
but to not let fear of future suffering
be the narrative for the journey forward.

240
00:12:54,275 --> 00:12:56,413
One of my mentors always says,

241
00:12:56,413 --> 00:13:00,016
the medicine part is easy,

242
00:13:00,016 --> 00:13:03,270
and it never feels that way
to a junior doctor,

243
00:13:03,270 --> 00:13:06,862
but it's contours are finite.

244
00:13:06,862 --> 00:13:13,735
We have big studies to guide us,
and it's what we learn to do in residency.

245
00:13:13,735 --> 00:13:21,032
Much harder is learning how to help
each patient navigate the multitudes

246
00:13:21,032 --> 00:13:24,185
contained in their illness.

247
00:13:24,786 --> 00:13:28,696
So I find it really funny

248
00:13:28,696 --> 00:13:33,033
that, in retrospect, my life
looks like a neat package.

249
00:13:33,033 --> 00:13:37,427
It looks as if I planned
each successive step,

250
00:13:37,427 --> 00:13:42,166
and that perhaps cancer
has led to the good things in my life.

251
00:13:42,465 --> 00:13:45,910
Step one: apply to medical school.

252
00:13:45,910 --> 00:13:49,496
Step two: get diagnosed with
and treated for cancer.

253
00:13:49,496 --> 00:13:52,122
And step three: have it all,

254
00:13:52,122 --> 00:13:56,584
a career and a family.

255
00:13:56,584 --> 00:13:58,394
But I will tell you

256
00:13:58,394 --> 00:14:02,888
that each phase was a leap of faith

257
00:14:02,888 --> 00:14:08,476
despite an almost paralyzing uncertainty.

258
00:14:08,476 --> 00:14:10,061
And so it's that courage

259
00:14:10,061 --> 00:14:13,438
that I try to give to each of my patients.

260
00:14:13,621 --> 00:14:17,858
I try to do this regardless
of the technical medical details

261
00:14:17,858 --> 00:14:21,028
of cancers and treatment decisions

262
00:14:21,028 --> 00:14:22,069
and mutations,

263
00:14:22,069 --> 00:14:25,555
regardless of the slippery fiction

264
00:14:25,555 --> 00:14:26,756
of prognosis.

265
00:14:26,756 --> 00:14:29,659
I try to learn what they want

266
00:14:29,659 --> 00:14:31,619
and what they need,

267
00:14:31,619 --> 00:14:35,037
what they wish and what they worry,

268
00:14:36,438 --> 00:14:39,859
what they dream about,

269
00:14:39,859 --> 00:14:42,735
what animated them before

270
00:14:43,489 --> 00:14:49,761
and what will sustain them during
the beastly process of cancer treatment.

271
00:14:51,329 --> 00:14:54,571
It doesn't actually take that much time.

272
00:14:55,540 --> 00:15:00,677
It does take a few focused, quiet moments

273
00:15:00,677 --> 00:15:03,803
that require intentional cultivation.

274
00:15:04,956 --> 00:15:08,408
But this is partnership,

275
00:15:08,408 --> 00:15:10,911
and it matters,

276
00:15:11,745 --> 00:15:14,538
because the worst thing that can happen

277
00:15:14,538 --> 00:15:19,359
is to have an oncologist
who does everything,

278
00:15:19,359 --> 00:15:24,103
everything to help cure your cancer

279
00:15:24,103 --> 00:15:29,024
and who does nothing
to help you live your life.

280
00:15:29,675 --> 00:15:31,927
Thank you.

281
00:15:31,927 --> 00:15:35,937
(Applause)