0:00:00.730,0:00:03.424
What's the worst that can happen?

0:00:04.336,0:00:06.558
Almost exactly 10 years ago,

0:00:06.582,0:00:10.307
I was sitting in an exam room[br]that was way too cold

0:00:10.331,0:00:12.828
waiting to meet my new oncologist.

0:00:12.852,0:00:14.787
I was terrified.

0:00:14.811,0:00:18.788
Even though my partner at the time[br]was sitting right by my side,

0:00:18.812,0:00:20.787
I felt completely alone.

0:00:21.298,0:00:24.284
I had just been diagnosed[br]with breast cancer,

0:00:24.308,0:00:25.934
and it seemed at the time

0:00:25.958,0:00:30.131
that a single bright spot[br]on a scan of my right lung

0:00:30.155,0:00:33.090
meant that the cancer had already spread.

0:00:33.719,0:00:36.123
I had metastatic breast cancer.

0:00:36.701,0:00:39.166
I had no medical training at this point,

0:00:39.190,0:00:41.280
but I knew what it meant if it were true:

0:00:42.076,0:00:44.360
incurable breast cancer.

0:00:45.745,0:00:48.263
Terminal breast cancer.

0:00:48.988,0:00:51.390
I was 27 years old,

0:00:51.414,0:00:54.075
had just been accepted to medical school,

0:00:54.099,0:00:57.357
and I wondered if I was already[br]at the end of my life.

0:00:58.438,0:01:03.006
My new oncologist was not a warm person.

0:01:04.117,0:01:06.371
She dealt in simple facts,

0:01:06.395,0:01:08.774
as many brilliant physicians do.

0:01:09.747,0:01:13.623
"Our body is made up[br]of cells," she started.

0:01:14.361,0:01:15.941
I stopped her.

0:01:16.385,0:01:18.574
"I'm starting medical school soon.

0:01:18.598,0:01:19.828
I know."

0:01:20.796,0:01:25.493
Instead of taking this as a signal[br]to go backward, to start again,

0:01:25.517,0:01:27.227
she went forward.

0:01:27.251,0:01:29.704
She said that I would need[br]to start on chemotherapy

0:01:29.728,0:01:31.188
to control the cancer.

0:01:31.212,0:01:34.744
She launched into the details[br]of the drug and the side effects

0:01:34.768,0:01:35.963
and the schedule.

0:01:36.542,0:01:40.504
I reminded her that we hadn't even yet[br]biopsied the bright spot on my lung,

0:01:40.528,0:01:44.474
and I asked if she was sure[br]that it was cancer.

0:01:45.282,0:01:50.748
I remember viscerally how she seemed[br]almost frustrated with my question.

0:01:50.772,0:01:54.266
Perhaps she thought I wasn't[br]following along with her explanations,

0:01:54.290,0:01:56.852
or, worse still, I was in denial.

0:01:57.935,0:02:01.372
I simply wanted her to understand[br]that, as her patient,

0:02:01.396,0:02:06.730
the biopsy was not just a mere formality[br]to prove an already foregone conclusion.

0:02:06.754,0:02:11.057
It was a steel needle[br]through skin, muscle and bone

0:02:11.081,0:02:15.353
that would deliver a deep piece of me[br]to the surface and answer a question

0:02:15.377,0:02:18.251
I wish didn't have to be asked.

0:02:18.275,0:02:22.540
Before the biopsy, I could be[br]a 27-year-old woman

0:02:22.564,0:02:25.578
who might have metastatic breast cancer,

0:02:25.602,0:02:29.023
who probably had metastatic breast cancer.

0:02:29.047,0:02:31.427
This is a critical distinction,

0:02:31.451,0:02:35.917
but it's not one that's emphasized[br]in the most elite oncology training.

0:02:36.774,0:02:40.771
Instead, I was dismissed[br]with an appointment to start treatment

0:02:40.795,0:02:42.487
in just a few weeks.

0:02:43.531,0:02:47.185
So much has happened[br]since that first visit.

0:02:47.209,0:02:50.459
Ironically, the biopsy was not[br]just a mere formality.

0:02:50.483,0:02:53.514
My former oncologist was right.

0:02:53.538,0:02:54.661
(Laughter)

0:02:54.685,0:02:56.273
It did show cancer,

0:02:56.297,0:03:00.237
but it was a totally separate lung cancer,

0:03:00.261,0:03:02.256
and as crazy as it sounds,

0:03:02.280,0:03:04.996
this was great news.

0:03:05.020,0:03:07.596
I did not have metastatic breast cancer,

0:03:07.620,0:03:09.909
I had two different cancers,

0:03:09.933,0:03:12.377
but both of them were localized,

0:03:12.401,0:03:14.655
and so the lung cancer[br]was localized enough

0:03:14.679,0:03:16.563
that it could be removed.

0:03:16.587,0:03:20.258
And so the onslaught of treatments began[br]with a lung surgery,

0:03:20.282,0:03:21.996
continued with chemotherapy

0:03:22.020,0:03:26.228
and ended with a breast surgery[br]just after my 28th birthday.

0:03:26.925,0:03:28.623
And then two weeks later,

0:03:29.298,0:03:31.355
I started medical school.

0:03:32.360,0:03:34.675
My new oncologist --

0:03:34.699,0:03:35.733
(Laughter)

0:03:35.757,0:03:40.626
who deals much more fluidly[br]both with facts and their implications,

0:03:40.650,0:03:42.138
very reasonably suggested

0:03:42.162,0:03:46.195
that I should defer my acceptance[br]to medical school for a year,

0:03:46.219,0:03:49.954
take some time to rest, to recover,

0:03:49.978,0:03:51.793
and I trusted her advice.

0:03:51.817,0:03:56.442
I felt terrible during the intensive[br]chemotherapy sessions.

0:03:56.466,0:03:58.077
And so I wrote to the dean.

0:03:58.101,0:04:00.125
I explained my circumstances,

0:04:00.149,0:04:02.648
and a deferral was speedily granted.

0:04:03.460,0:04:05.945
But as the chemo fog lifted,

0:04:05.969,0:04:09.232
I wondered what[br]I was going to do with a year.

0:04:09.804,0:04:12.201
Should I go to the beach?

0:04:12.225,0:04:13.257
(Laughter)

0:04:13.281,0:04:15.704
I wasn't really a beach person.

0:04:15.728,0:04:16.806
(Laughter)

0:04:16.830,0:04:20.851
And how many years[br]did I have left, anyway?

0:04:20.875,0:04:23.029
I really wanted to go to medical school.

0:04:23.053,0:04:25.869
It seemed like[br]a missing piece of my puzzle.

0:04:26.474,0:04:30.018
So instead of going around[br]and around with indecision,

0:04:30.042,0:04:33.044
I asked myself: What's the worst[br]that could happen?

0:04:33.068,0:04:36.882
Well, I could be too weak[br]or too sick to do the work.

0:04:36.906,0:04:39.328
It could be too hard for me emotionally.

0:04:39.352,0:04:42.279
I could fail out of medical school.

0:04:42.303,0:04:45.901
But then I remembered, that wouldn't be[br]the worst thing that happened to me

0:04:45.925,0:04:47.341
even that year.

0:04:47.365,0:04:50.142
So why not get started?

0:04:50.166,0:04:54.123
Why not continue living[br]the way that I wanted to live?

0:04:54.671,0:04:56.218
So I did.

0:04:56.242,0:04:58.221
Bald and rail thin,

0:04:58.245,0:05:01.894
I put on my best earrings[br]and my favorite dress,

0:05:01.918,0:05:03.624
and I started.

0:05:03.648,0:05:05.807
I pretended to belong,

0:05:05.831,0:05:07.292
and I began to.

0:05:07.918,0:05:11.029
There is no way to describe[br]how hard it was.

0:05:11.053,0:05:13.509
Some days it felt impossible.

0:05:13.533,0:05:17.787
It felt as I was doing things[br]that would never matter in the future.

0:05:18.312,0:05:21.780
But every day, I asked myself:[br]Are you still enjoying this?

0:05:21.804,0:05:23.963
Is this still what you want to be doing?

0:05:24.451,0:05:26.651
And every day, the answer was yes,

0:05:26.675,0:05:29.175
sometimes a very qualified yes,

0:05:29.199,0:05:30.619
but a yes.

0:05:31.079,0:05:33.465
And then, just as I was[br]getting comfortable

0:05:33.489,0:05:37.208
and feeling like I might not necessarily[br]fail out of medical school,

0:05:37.232,0:05:40.377
I received even more devastating news.

0:05:40.401,0:05:47.032
I learned that I had a mutation[br]in a gene called TP53, or p53 for short.

0:05:47.056,0:05:49.618
Known as the guardian of the genome,

0:05:49.642,0:05:50.934
a mutation,

0:05:50.958,0:05:55.782
p53 is responsible for supervising[br]the repair of our DNA.

0:05:56.166,0:05:59.666
A mutation in this gene[br]means errors go uncorrected.

0:05:59.690,0:06:03.602
It means that normal cells[br]become cancerous at a much higher rate.

0:06:04.358,0:06:06.250
All of a sudden, with this knowledge,

0:06:06.274,0:06:09.196
my medical history[br]made a terrible kind of sense.

0:06:09.544,0:06:14.044
I had had a childhood cancer --[br]rhabdomyosarcoma -- at age seven.

0:06:14.068,0:06:16.074
It recurred when I was a teenager.

0:06:16.098,0:06:19.709
And this was all before p53[br]had been discovered in the lab.

0:06:20.221,0:06:23.661
Then I'd had young adult[br]breast and lung cancers.

0:06:24.373,0:06:26.502
With the knowledge of this mutation,

0:06:26.526,0:06:29.023
it seemed that there was likely no end

0:06:29.047,0:06:32.164
to the number of cancers[br]that I could expect in my future.

0:06:33.414,0:06:34.749
And yet,

0:06:34.773,0:06:38.753
I decided to become[br]a radiation oncologist.

0:06:38.777,0:06:39.841
(Laughter)

0:06:39.865,0:06:43.885
I hoped to graduate from residency[br]in just a few months,

0:06:43.909,0:06:45.384
move to a new city

0:06:45.408,0:06:49.814
and start my first real job[br]as a doctor and researcher,

0:06:50.882,0:06:53.265
because of grit,

0:06:53.289,0:06:54.910
because of privilege,

0:06:54.934,0:06:57.317
because of therapy,

0:06:57.341,0:07:01.804
because of my medical teams[br]and my family and my teachers,

0:07:02.595,0:07:06.704
because genetic diagnoses[br]should give us the knowledge

0:07:06.728,0:07:08.046
to move forward.

0:07:08.683,0:07:11.701
And even in the year 2020,

0:07:11.725,0:07:16.406
that generally doesn't mean[br]miracle cures or medical breakthroughs.

0:07:16.993,0:07:20.043
Having a devastating genetic diagnosis

0:07:20.067,0:07:23.314
means learning to live with uncertainty.

0:07:24.028,0:07:27.371
It means learning that you[br]and your diagnosis

0:07:27.395,0:07:29.625
are not the worst thing that could happen.

0:07:30.481,0:07:32.393
Learning to live with uncertainty

0:07:32.417,0:07:34.791
means walking forward into a life

0:07:34.815,0:07:39.334
that is as full of beauty[br]as it is of challenges.

0:07:39.911,0:07:44.856
It means learning for yourself[br]that cancer is just part of your story.

0:07:44.880,0:07:47.392
It may not be the worst thing[br]that happens to you,

0:07:47.416,0:07:49.323
and if it is, that's OK.

0:07:49.347,0:07:51.816
You can claim that, and you can own that,

0:07:51.840,0:07:55.572
but let that be a narrative[br]that you author and you authorize,

0:07:55.596,0:07:58.634
not one that's prescribed to you[br]by someone else.

0:07:58.658,0:08:02.896
Have your deferral letter in hand,[br]but use it on your terms.

0:08:04.353,0:08:07.075
As I come to the end[br]of my oncology training,

0:08:07.099,0:08:10.537
I have déjà vu again and again[br]with the following scenario:

0:08:10.561,0:08:12.531
A patient has cancer.

0:08:12.555,0:08:14.317
There are several options,

0:08:14.341,0:08:20.286
all of which offer a different balance[br]between cure and quality of life,

0:08:20.310,0:08:24.166
between the possibility[br]of alleviating suffering

0:08:24.190,0:08:27.098
and the possibility of causing suffering.

0:08:27.122,0:08:29.202
An oncologist lays out the options,

0:08:29.226,0:08:32.540
but, somewhere in the discussion,[br]things get skewed.

0:08:32.564,0:08:34.614
The choice becomes something more like,

0:08:34.638,0:08:37.957
"Well, you could choose to do something

0:08:37.981,0:08:40.566
or you could choose to do nothing.

0:08:41.394,0:08:45.735
We could be aggressive,[br]and treat your cancer,

0:08:45.759,0:08:47.117
or we could watch it."

0:08:47.844,0:08:50.412
And 9.9 times out of 10, the patient says,

0:08:50.436,0:08:54.050
"I want to do everything I can do."

0:08:54.655,0:08:56.350
Of course.

0:08:56.374,0:08:59.741
Who wouldn't want everything?

0:09:00.446,0:09:02.049
But what is everything?

0:09:02.781,0:09:08.424
Is everything the ability to sit[br]in your own home in front of your window

0:09:08.448,0:09:11.577
bathed in sunshine[br]and surrounded by family?

0:09:12.041,0:09:16.043
Is everything still being able[br]to feel your fingers and your toes

0:09:16.067,0:09:18.749
because they haven't gone numb[br]from chemotherapy?

0:09:19.719,0:09:24.061
As oncologists, our everything[br]is cancer treatment.

0:09:24.672,0:09:29.962
It's radiation and surgery[br]and chemotherapy and novel treatments.

0:09:29.986,0:09:32.383
And for us, the worst thing[br]that could happen --

0:09:32.407,0:09:35.121
and I have heard more than one[br]oncologist say this --

0:09:35.145,0:09:36.731
the worst thing that could happen

0:09:36.755,0:09:39.715
is that the patient[br]will develop metastatic disease.

0:09:39.739,0:09:43.306
Or, the worst thing that could happen[br]is that five years from now,

0:09:43.330,0:09:46.417
the cancer will grow,[br]and I'll have to give more radiation.

0:09:47.047,0:09:49.667
As a patient and as an oncologist,

0:09:49.691,0:09:53.843
I would never argue that these[br]are not devastating outcomes.

0:09:53.867,0:09:55.779
But are they the worst?

0:09:56.192,0:09:58.691
Should cancer control,

0:09:58.715,0:10:01.942
be at the center of our thinking, always?

0:10:03.727,0:10:10.727
Many unspeakably, unfathomably painful[br]and brutal things have happened to me

0:10:10.751,0:10:14.357
because of my cancers[br]and my genetic mutation.

0:10:14.845,0:10:19.031
And yet, I consider myself[br]very lucky indeed,

0:10:19.055,0:10:22.063
because the worst thing[br]that could happen never came to pass;

0:10:22.902,0:10:28.183
because I have let devastation[br]and uncertainty sit at the table,

0:10:28.207,0:10:30.712
but somewhere off to the side.

0:10:30.736,0:10:33.348
When I was diagnosed[br]with metastatic breast cancer,

0:10:33.372,0:10:37.539
I went to Boston for a second opinion,[br]because what could I lose?

0:10:37.563,0:10:40.533
When my oncologist gave me[br]very good and very safe

0:10:40.557,0:10:41.935
and very standard advice,

0:10:41.959,0:10:44.171
I started medical school anyway,

0:10:44.195,0:10:47.207
even though I was undergoing[br]active cancer treatment.

0:10:48.390,0:10:51.402
Instead of shying away[br]from patients with cancer,

0:10:51.426,0:10:53.768
I became a radiation oncologist,

0:10:53.792,0:10:56.255
and I work with patients[br]who are very much like me

0:10:56.279,0:10:57.622
every single day.

0:10:58.325,0:11:03.534
Instead of imagining the suffering[br]that I might cause to a future partner

0:11:03.558,0:11:05.620
when I died of cancer,

0:11:05.644,0:11:08.557
I married my wonderful husband.

0:11:09.398,0:11:11.475
Because the worst thing that can happen

0:11:11.499,0:11:14.728
is always a series of negatives.

0:11:14.752,0:11:16.859
It's blank spaces

0:11:16.883,0:11:18.974
that should be filled with life.

0:11:20.351,0:11:26.498
So what is the most that I have leaned in[br]to this kind of radical uncertainty?

0:11:27.656,0:11:30.800
Well, this is William.

0:11:32.064,0:11:37.692
He is the most joyful person[br]that I have ever met,

0:11:38.691,0:11:43.857
and in just over a year, he has already[br]made the world a better place.

0:11:46.341,0:11:50.263
As oncologists, we talk to our patients

0:11:50.287,0:11:52.188
as if the worst thing that could happen

0:11:52.212,0:11:54.490
is that their cancer could come back,

0:11:54.514,0:11:57.598
or that it could spread,[br]or that they could die from it.

0:11:58.071,0:12:00.888
As a patient, I know[br]that these are paramount.

0:12:00.912,0:12:03.812
But I want to change the way[br]that we think about this,

0:12:03.836,0:12:07.600
and I want to change the way[br]that we talk about this with our patients.

0:12:08.171,0:12:09.702
As a patient,

0:12:09.726,0:12:14.545
the worst thing that can happen[br]is that cancer robs you of opportunity,

0:12:14.569,0:12:16.564
of the ability to be

0:12:16.588,0:12:17.901
and to do

0:12:17.925,0:12:19.442
and to love.

0:12:20.044,0:12:21.570
And it will.

0:12:21.594,0:12:24.276
At least temporarily it will.

0:12:24.802,0:12:28.032
But to minimize this loss[br]of life in the living,

0:12:28.056,0:12:34.432
that is the harder, and I would say,[br]truer job of the oncologist:

0:12:34.456,0:12:38.820
to take all the tools that we have[br]and situate them in the context

0:12:38.844,0:12:41.461
of a patient's whole entire life;

0:12:41.485,0:12:45.505
to be guides for how[br]to sit with suffering,

0:12:45.529,0:12:47.713
acknowledge it deeply,

0:12:47.737,0:12:52.820
but to not let fear of future suffering[br]be the narrative for the journey forward.

0:12:54.053,0:12:58.525
One of my mentors always says[br]the medicine part is easy.

0:12:59.571,0:13:03.491
And it never feels that way[br]to a junior doctor,

0:13:03.515,0:13:06.104
but its contours are finite.

0:13:06.695,0:13:12.680
We have big studies to guide us,[br]and it's what we learn to do in residency.

0:13:13.695,0:13:20.686
Much harder is learning how to help[br]each patient navigate the multitudes

0:13:20.710,0:13:22.876
contained in their illness.

0:13:24.548,0:13:29.618
So I find it really funny[br]that, in retrospect,

0:13:29.642,0:13:32.380
my life looks like a neat package.

0:13:32.938,0:13:37.134
It looks as if I planned[br]each successive step,

0:13:37.158,0:13:41.620
and that perhaps cancer[br]has led to the good things in my life.

0:13:42.465,0:13:45.672
Step one: apply to medical school.

0:13:45.696,0:13:49.107
Step two: get diagnosed with[br]and treated for cancer.

0:13:49.131,0:13:51.580
And step three: have it all,

0:13:51.604,0:13:54.085
a career and a family.

0:13:55.266,0:13:57.187
But I will tell you

0:13:57.941,0:14:02.586
that each phase was a leap of faith

0:14:02.610,0:14:06.868
despite an almost paralyzing uncertainty.

0:14:08.102,0:14:09.798
And so it's that courage

0:14:09.822,0:14:12.698
that I try to give to each of my patients.

0:14:13.287,0:14:17.501
I try to do this regardless[br]of the technical medical details

0:14:17.525,0:14:19.651
of cancers and treatment decisions

0:14:19.675,0:14:21.401
and mutations,

0:14:21.425,0:14:24.281
regardless of the slippery fiction

0:14:24.305,0:14:25.833
of prognosis.

0:14:26.637,0:14:29.483
I try to learn what they want

0:14:29.507,0:14:31.444
and what they need,

0:14:31.468,0:14:34.886
what they wish and what they worry,

0:14:36.239,0:14:39.122
what they dream about,

0:14:40.400,0:14:43.258
what animated them before

0:14:43.282,0:14:49.901
and what will sustain them during[br]the beastly process of cancer treatment.

0:14:51.082,0:14:54.538
It doesn't actually take that much time.

0:14:55.746,0:15:00.342
It does take a few focused, quiet moments

0:15:00.366,0:15:03.803
that require intentional cultivation.

0:15:04.956,0:15:07.430
But this is partnership,

0:15:08.487,0:15:10.482
and it matters,

0:15:11.538,0:15:14.587
because the worst thing that can happen

0:15:14.611,0:15:20.921
is to have an oncologist[br]who does everything -- everything --

0:15:20.945,0:15:24.079
to help cure your cancer

0:15:24.103,0:15:26.399
and who does nothing

0:15:26.423,0:15:29.024
to help you live your life.

0:15:30.587,0:15:31.913
Thank you.

0:15:31.937,0:15:36.460
(Applause)