WEBVTT

00:00:00.730 --> 00:00:03.424
What's the worst that can happen?

00:00:04.336 --> 00:00:06.558
Almost exactly 10 years ago,

00:00:06.582 --> 00:00:10.307
I was sitting in an exam room
that was way too cold

00:00:10.331 --> 00:00:12.828
waiting to meet my new oncologist.

00:00:12.852 --> 00:00:14.787
I was terrified.

00:00:14.811 --> 00:00:18.788
Even though my partner at the time
was sitting right by my side,

00:00:18.812 --> 00:00:20.787
I felt completely alone.

00:00:21.298 --> 00:00:24.284
I had just been diagnosed
with breast cancer,

00:00:24.308 --> 00:00:25.934
and it seemed at the time

00:00:25.958 --> 00:00:30.131
that a single bright spot
on a scan of my right lung

00:00:30.155 --> 00:00:33.090
meant that the cancer had already spread.

00:00:33.719 --> 00:00:36.123
I had metastatic breast cancer.

00:00:36.701 --> 00:00:39.166
I had no medical training at this point,

00:00:39.190 --> 00:00:41.280
but I knew what it meant if it were true:

00:00:42.076 --> 00:00:44.360
incurable breast cancer.

00:00:45.745 --> 00:00:48.263
Terminal breast cancer.

00:00:48.988 --> 00:00:51.390
I was 27 years old,

00:00:51.414 --> 00:00:54.075
had just been accepted to medical school,

00:00:54.099 --> 00:00:57.357
and I wondered if I was already
at the end of my life.

NOTE Paragraph

00:00:58.438 --> 00:01:03.006
My new oncologist was not a warm person.

00:01:04.117 --> 00:01:06.371
She dealt in simple facts,

00:01:06.395 --> 00:01:08.774
as many brilliant physicians do.

NOTE Paragraph

00:01:09.747 --> 00:01:13.623
"Our body is made up
of cells," she started.

NOTE Paragraph

00:01:14.361 --> 00:01:15.941
I stopped her.

NOTE Paragraph

00:01:16.385 --> 00:01:18.574
"I'm starting medical school soon.

00:01:18.598 --> 00:01:19.828
I know."

NOTE Paragraph

00:01:20.796 --> 00:01:25.493
Instead of taking this as a signal
to go backward, to start again,

00:01:25.517 --> 00:01:27.227
she went forward.

00:01:27.251 --> 00:01:29.704
She said that I would need
to start on chemotherapy

00:01:29.728 --> 00:01:31.188
to control the cancer.

00:01:31.212 --> 00:01:34.744
She launched into the details
of the drug and the side effects

00:01:34.768 --> 00:01:35.963
and the schedule.

00:01:36.542 --> 00:01:40.504
I reminded her that we hadn't even yet
biopsied the bright spot on my lung,

00:01:40.528 --> 00:01:44.474
and I asked if she was sure
that it was cancer.

00:01:45.282 --> 00:01:50.748
I remember viscerally how she seemed
almost frustrated with my question.

00:01:50.772 --> 00:01:54.266
Perhaps she thought I wasn't
following along with her explanations,

00:01:54.290 --> 00:01:56.852
or, worse still, I was in denial.

00:01:57.935 --> 00:02:01.372
I simply wanted her to understand
that, as her patient,

00:02:01.396 --> 00:02:06.730
the biopsy was not just a mere formality
to prove an already foregone conclusion.

00:02:06.754 --> 00:02:11.057
It was a steel needle
through skin, muscle and bone

00:02:11.081 --> 00:02:15.353
that would deliver a deep piece of me
to the surface and answer a question

00:02:15.377 --> 00:02:18.251
I wish didn't have to be asked.

00:02:18.275 --> 00:02:22.540
Before the biopsy, I could be
a 27-year-old woman

00:02:22.564 --> 00:02:25.578
who might have metastatic breast cancer,

00:02:25.602 --> 00:02:29.023
who probably had metastatic breast cancer.

00:02:29.047 --> 00:02:31.427
This is a critical distinction,

00:02:31.451 --> 00:02:35.917
but it's not one that's emphasized
in the most elite oncology training.

00:02:36.774 --> 00:02:40.771
Instead, I was dismissed
with an appointment to start treatment

00:02:40.795 --> 00:02:42.487
in just a few weeks.

NOTE Paragraph

00:02:43.531 --> 00:02:47.185
So much has happened
since that first visit.

00:02:47.209 --> 00:02:50.459
Ironically, the biopsy was not
just a mere formality.

00:02:50.483 --> 00:02:53.514
My former oncologist was right.

00:02:53.538 --> 00:02:54.661
(Laughter)

00:02:54.685 --> 00:02:56.273
It did show cancer,

00:02:56.297 --> 00:03:00.237
but it was a totally separate lung cancer,

00:03:00.261 --> 00:03:02.256
and as crazy as it sounds,

00:03:02.280 --> 00:03:04.996
this was great news.

00:03:05.020 --> 00:03:07.596
I did not have metastatic breast cancer,

00:03:07.620 --> 00:03:09.909
I had two different cancers,

00:03:09.933 --> 00:03:12.377
but both of them were localized,

00:03:12.401 --> 00:03:14.655
and so the lung cancer
was localized enough

00:03:14.679 --> 00:03:16.563
that it could be removed.

00:03:16.587 --> 00:03:20.258
And so the onslaught of treatments began
with a lung surgery,

00:03:20.282 --> 00:03:21.996
continued with chemotherapy

00:03:22.020 --> 00:03:26.228
and ended with a breast surgery
just after my 28th birthday.

00:03:26.925 --> 00:03:28.623
And then two weeks later,

00:03:29.298 --> 00:03:31.355
I started medical school.

00:03:32.360 --> 00:03:34.675
My new oncologist --

00:03:34.699 --> 00:03:35.733
(Laughter)

00:03:35.757 --> 00:03:40.626
who deals much more fluidly
both with facts and their implications,

00:03:40.650 --> 00:03:42.138
very reasonably suggested

00:03:42.162 --> 00:03:46.195
that I should defer my acceptance
to medical school for a year,

00:03:46.219 --> 00:03:49.954
take some time to rest, to recover,

00:03:49.978 --> 00:03:51.793
and I trusted her advice.

00:03:51.817 --> 00:03:56.442
I felt terrible during the intensive
chemotherapy sessions.

00:03:56.466 --> 00:03:58.077
And so I wrote to the dean.

00:03:58.101 --> 00:04:00.125
I explained my circumstances,

00:04:00.149 --> 00:04:02.648
and a deferral was speedily granted.

NOTE Paragraph

00:04:03.460 --> 00:04:05.945
But as the chemo fog lifted,

00:04:05.969 --> 00:04:09.232
I wondered what
I was going to do with a year.

00:04:09.804 --> 00:04:12.201
Should I go to the beach?

00:04:12.225 --> 00:04:13.257
(Laughter)

00:04:13.281 --> 00:04:15.704
I wasn't really a beach person.

00:04:15.728 --> 00:04:16.806
(Laughter)

00:04:16.830 --> 00:04:20.851
And how many years
did I have left, anyway?

00:04:20.875 --> 00:04:23.029
I really wanted to go to medical school.

00:04:23.053 --> 00:04:25.869
It seemed like
a missing piece of my puzzle.

NOTE Paragraph

00:04:26.474 --> 00:04:30.018
So instead of going around
and around with indecision,

00:04:30.042 --> 00:04:33.044
I asked myself: What's the worst
that could happen?

00:04:33.068 --> 00:04:36.882
Well, I could be too weak
or too sick to do the work.

00:04:36.906 --> 00:04:39.328
It could be too hard for me emotionally.

00:04:39.352 --> 00:04:42.279
I could fail out of medical school.

00:04:42.303 --> 00:04:45.901
But then I remembered, that wouldn't be
the worst thing that happened to me

00:04:45.925 --> 00:04:47.341
even that year.

00:04:47.365 --> 00:04:50.142
So why not get started?

00:04:50.166 --> 00:04:54.123
Why not continue living
the way that I wanted to live?

00:04:54.671 --> 00:04:56.218
So I did.

00:04:56.242 --> 00:04:58.221
Bald and rail thin,

00:04:58.245 --> 00:05:01.894
I put on my best earrings
and my favorite dress,

00:05:01.918 --> 00:05:03.624
and I started.

00:05:03.648 --> 00:05:05.807
I pretended to belong,

00:05:05.831 --> 00:05:07.292
and I began to.

00:05:07.918 --> 00:05:11.029
There is no way to describe
how hard it was.

00:05:11.053 --> 00:05:13.509
Some days it felt impossible.

00:05:13.533 --> 00:05:17.787
It felt as I was doing things
that would never matter in the future.

00:05:18.312 --> 00:05:21.780
But every day, I asked myself:
Are you still enjoying this?

00:05:21.804 --> 00:05:23.963
Is this still what you want to be doing?

00:05:24.451 --> 00:05:26.651
And every day, the answer was yes,

00:05:26.675 --> 00:05:29.175
sometimes a very qualified yes,

00:05:29.199 --> 00:05:30.619
but a yes.

00:05:31.079 --> 00:05:33.465
And then, just as I was
getting comfortable

00:05:33.489 --> 00:05:37.208
and feeling like I might not necessarily
fail out of medical school,

00:05:37.232 --> 00:05:40.377
I received even more devastating news.

00:05:40.401 --> 00:05:47.032
I learned that I had a mutation
in a gene called TP53, or p53 for short.

00:05:47.056 --> 00:05:49.618
Known as the guardian of the genome,

00:05:49.642 --> 00:05:50.934
a mutation,

00:05:50.958 --> 00:05:55.782
p53 is responsible for supervising
the repair of our DNA.

00:05:56.166 --> 00:05:59.666
A mutation in this gene
means errors go uncorrected.

00:05:59.690 --> 00:06:03.602
It means that normal cells
become cancerous at a much higher rate.

00:06:04.358 --> 00:06:06.250
All of a sudden, with this knowledge,

00:06:06.274 --> 00:06:09.196
my medical history
made a terrible kind of sense.

00:06:09.544 --> 00:06:14.044
I had had a childhood cancer --
rhabdomyosarcoma -- at age seven.

00:06:14.068 --> 00:06:16.074
It recurred when I was a teenager.

00:06:16.098 --> 00:06:19.709
And this was all before p53
had been discovered in the lab.

00:06:20.221 --> 00:06:23.661
Then I'd had young adult
breast and lung cancers.

NOTE Paragraph

00:06:24.373 --> 00:06:26.502
With the knowledge of this mutation,

00:06:26.526 --> 00:06:29.023
it seemed that there was likely no end

00:06:29.047 --> 00:06:32.164
to the number of cancers
that I could expect in my future.

00:06:33.414 --> 00:06:34.749
And yet,

00:06:34.773 --> 00:06:38.753
I decided to become
a radiation oncologist.

00:06:38.777 --> 00:06:39.841
(Laughter)

00:06:39.865 --> 00:06:43.885
I hoped to graduate from residency
in just a few months,

00:06:43.909 --> 00:06:45.384
move to a new city

00:06:45.408 --> 00:06:49.814
and start my first real job
as a doctor and researcher,

00:06:50.882 --> 00:06:53.265
because of grit,

00:06:53.289 --> 00:06:54.910
because of privilege,

00:06:54.934 --> 00:06:57.317
because of therapy,

00:06:57.341 --> 00:07:01.804
because of my medical teams
and my family and my teachers,

00:07:02.595 --> 00:07:06.704
because genetic diagnoses
should give us the knowledge

00:07:06.728 --> 00:07:08.046
to move forward.

00:07:08.683 --> 00:07:11.701
And even in the year 2020,

00:07:11.725 --> 00:07:16.406
that generally doesn't mean
miracle cures or medical breakthroughs.

00:07:16.993 --> 00:07:20.043
Having a devastating genetic diagnosis

00:07:20.067 --> 00:07:23.314
means learning to live with uncertainty.

00:07:24.028 --> 00:07:27.371
It means learning that you
and your diagnosis

00:07:27.395 --> 00:07:29.625
are not the worst thing that could happen.

00:07:30.481 --> 00:07:32.393
Learning to live with uncertainty

00:07:32.417 --> 00:07:34.791
means walking forward into a life

00:07:34.815 --> 00:07:39.334
that is as full of beauty
as it is of challenges.

00:07:39.911 --> 00:07:44.856
It means learning for yourself
that cancer is just part of your story.

00:07:44.880 --> 00:07:47.392
It may not be the worst thing
that happens to you,

00:07:47.416 --> 00:07:49.323
and if it is, that's OK.

00:07:49.347 --> 00:07:51.816
You can claim that, and you can own that,

00:07:51.840 --> 00:07:55.572
but let that be a narrative
that you author and you authorize,

00:07:55.596 --> 00:07:58.634
not one that's prescribed to you
by someone else.

00:07:58.658 --> 00:08:02.896
Have your deferral letter in hand,
but use it on your terms.

NOTE Paragraph

00:08:04.353 --> 00:08:07.075
As I come to the end
of my oncology training,

00:08:07.099 --> 00:08:10.537
I have déjà vu again and again
with the following scenario:

00:08:10.561 --> 00:08:12.531
A patient has cancer.

00:08:12.555 --> 00:08:14.317
There are several options,

00:08:14.341 --> 00:08:20.286
all of which offer a different balance
between cure and quality of life,

00:08:20.310 --> 00:08:24.166
between the possibility
of alleviating suffering

00:08:24.190 --> 00:08:27.098
and the possibility of causing suffering.

00:08:27.122 --> 00:08:29.202
An oncologist lays out the options,

00:08:29.226 --> 00:08:32.540
but, somewhere in the discussion,
things get skewed.

00:08:32.564 --> 00:08:34.614
The choice becomes something more like,

00:08:34.638 --> 00:08:37.957
"Well, you could choose to do something

00:08:37.981 --> 00:08:40.566
or you could choose to do nothing.

00:08:41.394 --> 00:08:45.735
We could be aggressive,
and treat your cancer,

00:08:45.759 --> 00:08:47.117
or we could watch it."

00:08:47.844 --> 00:08:50.412
And 9.9 times out of 10, the patient says,

00:08:50.436 --> 00:08:54.050
"I want to do everything I can do."

00:08:54.655 --> 00:08:56.350
Of course.

00:08:56.374 --> 00:08:59.741
Who wouldn't want everything?

00:09:00.446 --> 00:09:02.049
But what is everything?

00:09:02.781 --> 00:09:08.424
Is everything the ability to sit
in your own home in front of your window

00:09:08.448 --> 00:09:11.577
bathed in sunshine
and surrounded by family?

00:09:12.041 --> 00:09:16.043
Is everything still being able
to feel your fingers and your toes

00:09:16.067 --> 00:09:18.749
because they haven't gone numb
from chemotherapy?

00:09:19.719 --> 00:09:24.061
As oncologists, our everything
is cancer treatment.

00:09:24.672 --> 00:09:29.962
It's radiation and surgery
and chemotherapy and novel treatments.

00:09:29.986 --> 00:09:32.383
And for us, the worst thing
that could happen --

00:09:32.407 --> 00:09:35.121
and I have heard more than one
oncologist say this --

00:09:35.145 --> 00:09:36.731
the worst thing that could happen

00:09:36.755 --> 00:09:39.715
is that the patient
will develop metastatic disease.

00:09:39.739 --> 00:09:43.306
Or, the worst thing that could happen
is that five years from now,

00:09:43.330 --> 00:09:46.417
the cancer will grow,
and I'll have to give more radiation.

NOTE Paragraph

00:09:47.047 --> 00:09:49.667
As a patient and as an oncologist,

00:09:49.691 --> 00:09:53.843
I would never argue that these
are not devastating outcomes.

00:09:53.867 --> 00:09:55.779
But are they the worst?

00:09:56.192 --> 00:09:58.691
Should cancer control,

00:09:58.715 --> 00:10:01.942
be at the center of our thinking, always?

00:10:03.727 --> 00:10:10.727
Many unspeakably, unfathomably painful
and brutal things have happened to me

00:10:10.751 --> 00:10:14.357
because of my cancers
and my genetic mutation.

00:10:14.845 --> 00:10:19.031
And yet, I consider myself
very lucky indeed,

00:10:19.055 --> 00:10:22.063
because the worst thing
that could happen never came to pass;

00:10:22.902 --> 00:10:28.183
because I have let devastation
and uncertainty sit at the table,

00:10:28.207 --> 00:10:30.712
but somewhere off to the side.

00:10:30.736 --> 00:10:33.348
When I was diagnosed
with metastatic breast cancer,

00:10:33.372 --> 00:10:37.539
I went to Boston for a second opinion,
because what could I lose?

00:10:37.563 --> 00:10:40.533
When my oncologist gave me
very good and very safe

00:10:40.557 --> 00:10:41.935
and very standard advice,

00:10:41.959 --> 00:10:44.171
I started medical school anyway,

00:10:44.195 --> 00:10:47.207
even though I was undergoing
active cancer treatment.

00:10:48.390 --> 00:10:51.402
Instead of shying away
from patients with cancer,

00:10:51.426 --> 00:10:53.768
I became a radiation oncologist,

00:10:53.792 --> 00:10:56.255
and I work with patients
who are very much like me

00:10:56.279 --> 00:10:57.622
every single day.

00:10:58.325 --> 00:11:03.534
Instead of imagining the suffering
that I might cause to a future partner

00:11:03.558 --> 00:11:05.620
when I died of cancer,

00:11:05.644 --> 00:11:08.557
I married my wonderful husband.

00:11:09.398 --> 00:11:11.475
Because the worst thing that can happen

00:11:11.499 --> 00:11:14.728
is always a series of negatives.

00:11:14.752 --> 00:11:16.859
It's blank spaces

00:11:16.883 --> 00:11:18.974
that should be filled with life.

NOTE Paragraph

00:11:20.351 --> 00:11:26.498
So what is the most that I have leaned in
to this kind of radical uncertainty?

00:11:27.656 --> 00:11:30.800
Well, this is William.

00:11:32.064 --> 00:11:37.692
He is the most joyful person
that I have ever met,

00:11:38.691 --> 00:11:43.857
and in just over a year, he has already
made the world a better place.

NOTE Paragraph

00:11:46.341 --> 00:11:50.263
As oncologists, we talk to our patients

00:11:50.287 --> 00:11:52.188
as if the worst thing that could happen

00:11:52.212 --> 00:11:54.490
is that their cancer could come back,

00:11:54.514 --> 00:11:57.598
or that it could spread,
or that they could die from it.

00:11:58.071 --> 00:12:00.888
As a patient, I know
that these are paramount.

00:12:00.912 --> 00:12:03.812
But I want to change the way
that we think about this,

00:12:03.836 --> 00:12:07.600
and I want to change the way
that we talk about this with our patients.

00:12:08.171 --> 00:12:09.702
As a patient,

00:12:09.726 --> 00:12:14.545
the worst thing that can happen
is that cancer robs you of opportunity,

00:12:14.569 --> 00:12:16.564
of the ability to be

00:12:16.588 --> 00:12:17.901
and to do

00:12:17.925 --> 00:12:19.442
and to love.

00:12:20.044 --> 00:12:21.570
And it will.

00:12:21.594 --> 00:12:24.276
At least temporarily it will.

00:12:24.802 --> 00:12:28.032
But to minimize this loss
of life in the living,

00:12:28.056 --> 00:12:34.432
that is the harder, and I would say,
truer job of the oncologist:

00:12:34.456 --> 00:12:38.820
to take all the tools that we have
and situate them in the context

00:12:38.844 --> 00:12:41.461
of a patient's whole entire life;

00:12:41.485 --> 00:12:45.505
to be guides for how
to sit with suffering,

00:12:45.529 --> 00:12:47.713
acknowledge it deeply,

00:12:47.737 --> 00:12:52.820
but to not let fear of future suffering
be the narrative for the journey forward.

NOTE Paragraph

00:12:54.053 --> 00:12:58.525
One of my mentors always says
the medicine part is easy.

00:12:59.571 --> 00:13:03.491
And it never feels that way
to a junior doctor,

00:13:03.515 --> 00:13:06.104
but its contours are finite.

00:13:06.695 --> 00:13:12.680
We have big studies to guide us,
and it's what we learn to do in residency.

00:13:13.695 --> 00:13:20.686
Much harder is learning how to help
each patient navigate the multitudes

00:13:20.710 --> 00:13:22.876
contained in their illness.

NOTE Paragraph

00:13:24.548 --> 00:13:29.618
So I find it really funny
that, in retrospect,

00:13:29.642 --> 00:13:32.380
my life looks like a neat package.

00:13:32.938 --> 00:13:37.134
It looks as if I planned
each successive step,

00:13:37.158 --> 00:13:41.620
and that perhaps cancer
has led to the good things in my life.

00:13:42.465 --> 00:13:45.672
Step one: apply to medical school.

00:13:45.696 --> 00:13:49.107
Step two: get diagnosed with
and treated for cancer.

00:13:49.131 --> 00:13:51.580
And step three: have it all,

00:13:51.604 --> 00:13:54.085
a career and a family.

00:13:55.266 --> 00:13:57.187
But I will tell you

00:13:57.941 --> 00:14:02.586
that each phase was a leap of faith

00:14:02.610 --> 00:14:06.868
despite an almost paralyzing uncertainty.

00:14:08.102 --> 00:14:09.798
And so it's that courage

00:14:09.822 --> 00:14:12.698
that I try to give to each of my patients.

00:14:13.287 --> 00:14:17.501
I try to do this regardless
of the technical medical details

00:14:17.525 --> 00:14:19.651
of cancers and treatment decisions

00:14:19.675 --> 00:14:21.401
and mutations,

00:14:21.425 --> 00:14:24.281
regardless of the slippery fiction

00:14:24.305 --> 00:14:25.833
of prognosis.

00:14:26.637 --> 00:14:29.483
I try to learn what they want

00:14:29.507 --> 00:14:31.444
and what they need,

00:14:31.468 --> 00:14:34.886
what they wish and what they worry,

00:14:36.239 --> 00:14:39.122
what they dream about,

00:14:40.400 --> 00:14:43.258
what animated them before

00:14:43.282 --> 00:14:49.901
and what will sustain them during
the beastly process of cancer treatment.

00:14:51.082 --> 00:14:54.538
It doesn't actually take that much time.

00:14:55.746 --> 00:15:00.342
It does take a few focused, quiet moments

00:15:00.366 --> 00:15:03.803
that require intentional cultivation.

00:15:04.956 --> 00:15:07.430
But this is partnership,

00:15:08.487 --> 00:15:10.482
and it matters,

00:15:11.538 --> 00:15:14.587
because the worst thing that can happen

00:15:14.611 --> 00:15:20.921
is to have an oncologist
who does everything -- everything --

00:15:20.945 --> 00:15:24.079
to help cure your cancer

00:15:24.103 --> 00:15:26.399
and who does nothing

00:15:26.423 --> 00:15:29.024
to help you live your life.

NOTE Paragraph

00:15:30.587 --> 00:15:31.913
Thank you.

NOTE Paragraph

00:15:31.937 --> 00:15:36.460
(Applause)