0:00:11.880,0:00:13.735
"We're declaring war against cancer,

0:00:13.760,0:00:16.360
and we will win this war by 2015."

0:00:17.440,0:00:21.176
This is what the US Congress[br]and the National Cancer Institute declared

0:00:21.200,0:00:23.760
just a few years ago, in 2003.

0:00:24.560,0:00:27.656
Now, I don't know about you,[br]but I don't buy that.

0:00:27.680,0:00:29.736
I don't think we quite won this war yet,

0:00:29.760,0:00:32.400
and I don't think[br]anyone here will question that.

0:00:32.800,0:00:35.296
Now, I will argue that a primary reason

0:00:35.320,0:00:37.456
why we're not winning[br]this war against cancer

0:00:37.480,0:00:39.776
is because we're fighting blindly.

0:00:39.800,0:00:43.375
I'm going to start by sharing with you[br]a story about a good friend of mine.

0:00:43.400,0:00:44.616
His name is Ehud,

0:00:44.640,0:00:47.776
and a few years ago,[br]Ehud was diagnosed with brain cancer.

0:00:47.800,0:00:49.656
And not just any type of brain cancer:

0:00:49.680,0:00:52.856
he was diagnosed with one[br]of the most deadly forms of brain cancer.

0:00:52.880,0:00:54.096
In fact, it was so deadly

0:00:54.120,0:00:56.776
that the doctors told him[br]that they only have 12 months,

0:00:56.800,0:01:00.216
and during those 12 months,[br]they have to find a treatment.

0:01:00.240,0:01:01.696
They have to find a cure,

0:01:01.720,0:01:03.880
and if they cannot[br]find a cure, he will die.

0:01:04.800,0:01:06.256
Now, the good news, they said,

0:01:06.280,0:01:09.216
is that there are tons[br]of different treatments to choose from,

0:01:09.240,0:01:10.456
but the bad news is

0:01:10.480,0:01:14.016
that in order for them to tell[br]if a treatment is even working or not,

0:01:14.040,0:01:16.536
well, that takes them[br]about three months or so.

0:01:16.560,0:01:18.936
So they cannot try that many things.

0:01:18.960,0:01:22.056
Well, Ehud is now going[br]into his first treatment,

0:01:22.080,0:01:25.336
and during that first treatment,[br]just a few days into that treatment,

0:01:25.360,0:01:28.696
I'm meeting with him, and he tells me,[br]"Adam, I think this is working.

0:01:28.720,0:01:31.536
I think we really lucked out here.[br]Something is happening."

0:01:31.560,0:01:34.016
And I ask him, "Really?[br]How do you know that, Ehud?"

0:01:34.040,0:01:36.256
And he says, "Well,[br]I feel so terrible inside.

0:01:36.280,0:01:38.136
Something's gotta be working up there.

0:01:38.160,0:01:39.376
It just has to."

0:01:39.400,0:01:43.840
Well, unfortunately, three months later,[br]we got the news, it didn't work.

0:01:44.520,0:01:46.576
And so Ehud goes[br]into his second treatment.

0:01:46.600,0:01:47.856
And again, the same story.

0:01:47.880,0:01:50.616
"It feels so bad, something's[br]gotta be working there."

0:01:50.640,0:01:53.576
And then three months later,[br]again we get bad news.

0:01:53.600,0:01:57.536
Ehud is going into his third treatment,[br]and then his fourth treatment.

0:01:57.560,0:02:00.080
And then, as predicted, Ehud dies.

0:02:00.800,0:02:05.376
Now, when someone really close to you[br]is going through such a huge struggle,

0:02:05.400,0:02:07.216
you get really swamped with emotions.

0:02:07.240,0:02:09.336
A lot of things[br]are going through your head.

0:02:09.360,0:02:10.816
For me, it was mostly outrage.

0:02:10.840,0:02:15.536
I was just outraged that, how come[br]this is the best that we can offer?

0:02:15.560,0:02:17.856
And I started looking[br]more and more into this.

0:02:17.880,0:02:21.336
As it turns out, this is not just[br]the best that doctors could offer Ehud.

0:02:21.360,0:02:25.176
It's not just the best doctors could offer[br]patients with brain cancer generally.

0:02:25.200,0:02:28.400
We're actually not doing that well[br]all across the board with cancer.

0:02:29.240,0:02:31.096
I picked up one of those statistics,

0:02:31.120,0:02:33.896
and I'm sure some of you[br]have seen those statistics before.

0:02:33.920,0:02:37.376
This is going to show you here[br]how many patients actually died of cancer,

0:02:37.400,0:02:39.416
in this case females in the United States,

0:02:39.440,0:02:40.736
ever since the 1930s.

0:02:40.760,0:02:43.936
You'll notice that there aren't[br]that many things that have changed.

0:02:43.960,0:02:45.256
It's still a huge issue.

0:02:45.280,0:02:47.016
You'll see a few changes though.

0:02:47.040,0:02:49.576
You'll see lung cancer,[br]for example, on the rise.

0:02:49.600,0:02:50.800
Thank you, cigarettes.

0:02:51.360,0:02:53.856
And you'll also see that,[br]for example, stomach cancer

0:02:53.880,0:02:57.216
once used to be one[br]of the biggest killers of all cancers,

0:02:57.240,0:02:58.680
is essentially eliminated.

0:02:59.480,0:03:01.536
Now, why is that?[br]Anyone knows, by the way?

0:03:01.560,0:03:04.896
Why is it that humanity is no longer[br]struck by stomach cancer?

0:03:04.920,0:03:09.776
What was the huge, huge[br]medical technology breakthrough

0:03:09.800,0:03:13.160
that came to our world[br]that saved humanity from stomach cancer?

0:03:14.240,0:03:18.056
Was it maybe a new drug,[br]or a better diagnostic?

0:03:18.080,0:03:19.376
You guys are right, yeah.

0:03:19.400,0:03:22.016
It's the invention of the refrigerator,

0:03:22.040,0:03:24.656
and the fact that we're[br]no longer eating spoiled meats.

0:03:24.680,0:03:26.976
So the best thing[br]that happened to us so far

0:03:27.000,0:03:28.936
in the medical arena in cancer research

0:03:28.960,0:03:31.151
is the fact that[br]the refrigerator was invented.

0:03:31.175,0:03:32.376
(Laughter)

0:03:32.400,0:03:33.656
And so -- yeah, I know.

0:03:33.680,0:03:35.096
We're not doing so well here.

0:03:35.120,0:03:37.456
I don't want to miniaturize the progress

0:03:37.480,0:03:40.856
and everything that's been done[br]in cancer research.

0:03:40.880,0:03:44.296
Look, there is like 50-plus years[br]of good cancer research

0:03:44.320,0:03:47.736
that discovered major, major things[br]that taught us about cancer.

0:03:47.760,0:03:49.496
But all that said,

0:03:49.520,0:03:52.092
we have a lot of heavy lifting[br]to still do ahead of us.

0:03:53.920,0:03:57.016
Again, I will argue that the primary[br]reason why this is the case,

0:03:57.040,0:03:59.040
why we have not done that remarkably well,

0:03:59.064,0:04:00.896
is really we're fighting blindly here.

0:04:00.920,0:04:03.136
And this is where[br]medical imaging comes in.

0:04:03.160,0:04:04.840
This is where my own work comes in.

0:04:05.400,0:04:08.136
And so to give you a sense[br]of the best medical imaging

0:04:08.160,0:04:10.656
that's offered today[br]to brain cancer patients,

0:04:10.680,0:04:12.856
or actually generally[br]to all cancer patients,

0:04:12.880,0:04:14.816
take a look at this PET scan right here.

0:04:14.840,0:04:16.079
Let's see. There we go.

0:04:16.640,0:04:18.336
So this is a PET/CT scan,

0:04:18.360,0:04:20.815
and what you'll see in this PET/CT scan

0:04:20.839,0:04:24.056
is the CT scan will show you[br]where the bones are,

0:04:24.080,0:04:26.480
and the PET scan will show you[br]where tumors are.

0:04:26.960,0:04:29.176
Now, what you can see here

0:04:29.200,0:04:31.616
is essentially a sugar molecule

0:04:31.640,0:04:33.456
that was added a small little tag

0:04:33.480,0:04:35.576
that is signaling to us[br]outside of the body,

0:04:35.600,0:04:36.896
"Hey, I'm here."

0:04:36.920,0:04:40.736
And those sugar molecules are injected[br]into these patients by the billions,

0:04:40.760,0:04:42.456
and they're going all over the body

0:04:42.480,0:04:44.560
looking for cells[br]that are hungry for sugar.

0:04:45.320,0:04:47.976
You'll see that the heart,[br]for example, lights up there.

0:04:48.000,0:04:50.216
That's because the heart[br]needs a lot of sugar.

0:04:50.240,0:04:52.576
You'll also see that the bladder[br]lights up there.

0:04:52.600,0:04:55.216
That's because the bladder[br]is the thing that's clearing

0:04:55.240,0:04:56.640
the sugar away from our body.

0:04:57.096,0:04:59.096
And then you'll see a few other hot spots,

0:04:59.120,0:05:00.736
and these are in fact the tumors.

0:05:00.760,0:05:02.896
Now, this is a really[br]a wonderful technology.

0:05:02.920,0:05:06.056
For the first time it allowed us[br]to look into someone's body

0:05:06.080,0:05:08.456
without picking up[br]each and every one of the cells

0:05:08.480,0:05:10.336
and putting them under the microscope,

0:05:10.360,0:05:13.376
but in a noninvasive way[br]allowing us to look into someone's body

0:05:13.400,0:05:15.536
and ask, "Hey,[br]has the cancer metastasized?

0:05:15.560,0:05:16.776
Where is it?"

0:05:16.800,0:05:19.296
And the PET scans here[br]are showing you very clearly

0:05:19.320,0:05:21.600
where are these hot spots,[br]where is the tumor.

0:05:22.480,0:05:25.776
So as miraculous as this might seem,

0:05:25.800,0:05:28.680
unfortunately, well, it's not that great.

0:05:29.320,0:05:31.400
You see, those[br]small little hot spots there.

0:05:32.240,0:05:35.760
Can anyone guess how many cancer cells[br]are in any one of these tumors?

0:05:37.600,0:05:39.936
So it's about 100 million cancer cells,

0:05:39.960,0:05:42.656
and let me make sure[br]that this number sunk in.

0:05:42.680,0:05:45.016
In each and every one[br]of these small little blips

0:05:45.040,0:05:46.616
that you're seeing on the image,

0:05:46.640,0:05:50.736
there needs to be[br]at least 100 million cancer cells

0:05:50.760,0:05:52.296
in order for it to be detected.

0:05:52.320,0:05:54.776
Now, if that seemed to you[br]like a very large number,

0:05:54.800,0:05:56.480
it is a very large number.

0:05:57.640,0:05:59.696
This is in fact[br]an incredibly large number,

0:05:59.720,0:06:03.056
because what we really need[br]in order to pick up something early enough

0:06:03.080,0:06:06.016
to do something about it,[br]to do something meaningful about it,

0:06:06.040,0:06:09.176
well, we need to pick up tumors[br]that are a thousand cells in size,

0:06:09.200,0:06:11.336
and ideally just[br]a handful of cells in size.

0:06:11.360,0:06:13.376
So we're clearly[br]pretty far away from this.

0:06:13.400,0:06:15.656
So we're going to play[br]a little experiment here.

0:06:15.680,0:06:18.136
I'm going to ask each of you[br]to now play and imagine

0:06:18.160,0:06:19.520
that you are brain surgeons.

0:06:20.000,0:06:24.016
And you guys are now at an operating room,

0:06:24.040,0:06:26.056
and there's a patient in front of you,

0:06:26.080,0:06:29.800
and your task is to make sure[br]that the tumor is out.

0:06:30.400,0:06:33.776
So you're looking down at the patient,

0:06:33.800,0:06:36.136
the skin and the skull[br]have already been removed,

0:06:36.160,0:06:37.696
so you're looking at the brain.

0:06:37.720,0:06:39.416
And all you know about this patient

0:06:39.440,0:06:42.256
is that there's a tumor[br]about the size of a golf ball or so

0:06:42.280,0:06:44.600
in the right frontal lobe[br]of this person's brain.

0:06:45.080,0:06:46.416
And that's more or less it.

0:06:46.440,0:06:49.656
So you're looking down, and unfortunately[br]everything looks the same,

0:06:49.680,0:06:52.776
because brain cancer tissue[br]and healthy brain tissue

0:06:52.800,0:06:54.376
really just look the same.

0:06:54.400,0:06:56.296
And so you're going in with your thumb,

0:06:56.320,0:06:58.656
and you start to press[br]a little bit on the brain,

0:06:58.680,0:07:01.096
because tumors tend to be[br]a little harder, stiffer,

0:07:01.120,0:07:03.736
and so you go in and go[br]a little bit like this and say,

0:07:03.760,0:07:05.736
"It seems like the tumor is right there."

0:07:05.760,0:07:08.416
Then you take out your knife[br]and start cutting the tumor

0:07:08.440,0:07:09.696
piece by piece by piece,

0:07:09.720,0:07:11.416
and as you're taking the tumor out,

0:07:11.440,0:07:13.656
then you're getting[br]to a stage where you think,

0:07:13.680,0:07:15.816
"All right, I'm done.[br]I took out everything."

0:07:15.840,0:07:17.376
And at this stage, if that's --

0:07:17.400,0:07:20.096
so far everything sounded,[br]like, pretty crazy --

0:07:20.120,0:07:23.816
you're now about to face the most[br]challenging decision of your life here.

0:07:23.840,0:07:25.376
Because now you need to decide,

0:07:25.400,0:07:28.096
should I stop here[br]and let this patient go,

0:07:28.120,0:07:31.056
risking that there might be[br]some leftover cancer cells behind

0:07:31.080,0:07:32.936
that I just couldn't see,

0:07:32.960,0:07:35.616
or should I take away some extra margins,

0:07:35.640,0:07:38.496
typically about an inch or so[br]around the tumor

0:07:38.520,0:07:40.720
just to be sure that I removed everything?

0:07:42.400,0:07:46.240
So this is not a simple decision to make,

0:07:46.840,0:07:48.776
and unfortunately this is the decision

0:07:48.800,0:07:52.136
that brain cancer surgeons[br]have to take every single day

0:07:52.160,0:07:53.760
as they're seeing their patients.

0:07:54.320,0:07:57.256
And so I remember talking[br]to a few friends of mine in the lab,

0:07:57.280,0:07:59.656
and we say, "Boy,[br]there's got to be a better way."

0:07:59.680,0:08:03.096
But not just like you tell a friend[br]that there's got to be a better way.

0:08:03.120,0:08:05.073
There's just got to be a better way here.

0:08:05.097,0:08:06.616
This is just incredible.

0:08:06.640,0:08:08.296
And so we looked back.

0:08:08.320,0:08:11.296
Remember those PET scans I told you about,[br]the sugar and so on.

0:08:11.320,0:08:14.056
We said, hey, how about[br]instead of using sugar molecules,

0:08:14.080,0:08:17.216
let's maybe take tiny, tiny[br]little particles made of gold

0:08:17.240,0:08:20.896
and let's program them with some[br]interesting chemistry around them.

0:08:20.920,0:08:23.336
Let's program them[br]to look for cancer cells.

0:08:23.360,0:08:25.456
And then we will inject[br]these gold particles

0:08:25.480,0:08:27.736
into these patients by the billions again,

0:08:27.760,0:08:29.736
and we'll have them go all over the body,

0:08:29.760,0:08:31.736
and just like secret agents, if you will,

0:08:31.760,0:08:34.576
go and walk by[br]every single cell in our body

0:08:34.600,0:08:36.296
and knock on the door of that cell,

0:08:36.320,0:08:39.056
and ask, "Are you a cancer cell[br]or are you a healthy cell?

0:08:39.080,0:08:41.096
If you're a healthy cell, we're moving on.

0:08:41.120,0:08:43.856
If you're a cancer cell,[br]we're sticking in and shining out

0:08:43.880,0:08:45.976
and telling us,[br]"Hey, look at me, I'm here."

0:08:46.000,0:08:48.376
And they'll do it[br]through some interesting cameras

0:08:48.400,0:08:49.816
that we developed in the lab.

0:08:49.840,0:08:52.775
And once we see that,[br]maybe we can guide brain cancer surgeons

0:08:52.799,0:08:56.200
towards taking only the tumor[br]and leaving the healthy brain alone.

0:08:56.720,0:08:59.776
And so we've tested that,[br]and boy, this works well.

0:08:59.800,0:09:01.776
So I'm going to show you an example now.

0:09:01.800,0:09:03.576
What you're looking at here

0:09:03.600,0:09:07.536
is an image of a mouse's brain,

0:09:07.560,0:09:10.696
and we've implanted[br]into this mouse's brain

0:09:10.720,0:09:11.976
a small little tumor.

0:09:12.000,0:09:14.616
And so this tumor is now[br]growing in this mouse's brain,

0:09:14.640,0:09:17.296
and then we've taken a doctor[br]and just asked this doctor

0:09:17.320,0:09:20.136
to please operate on the mouse[br]as if that was a patient,

0:09:20.160,0:09:22.576
and take out piece by piece[br]out of the tumor,

0:09:22.600,0:09:24.376
and while he's doing that,

0:09:24.400,0:09:27.376
we're going to take images[br]to see where the gold particles are.

0:09:27.400,0:09:29.016
And so we're going to first start

0:09:29.040,0:09:31.456
by injecting these gold particles[br]into this mouse,

0:09:31.480,0:09:34.376
and we're going to see[br]right here at the very left there

0:09:34.400,0:09:35.656
that image at the bottom

0:09:35.680,0:09:38.176
is the image that shows[br]where the gold particles are.

0:09:38.200,0:09:40.256
The nice thing[br]is that these gold particles

0:09:40.280,0:09:42.296
actually made it all the way to the tumor,

0:09:42.320,0:09:45.976
and then they shine out and tell us,[br]"Hey, we're here. Here's the tumor."

0:09:46.000,0:09:47.376
So now we can see the tumor,

0:09:47.400,0:09:49.536
but we're not showing this[br]to the doctor yet.

0:09:49.560,0:09:52.616
We're asking the doctor,[br]now please start cutting away the tumor,

0:09:52.640,0:09:56.056
and you'll see here the doctor[br]just took the first quadrant of the tumor

0:09:56.080,0:09:58.296
and you see that first quadrant[br]is now missing.

0:09:58.320,0:10:00.776
The doctor then took[br]the second quadrant, the third,

0:10:00.800,0:10:02.536
and now it appears to be everything.

0:10:02.560,0:10:05.296
And so at this stage,[br]the doctor came back to us and said,

0:10:05.320,0:10:07.576
"All right, I'm done.[br]What do you want me to do?

0:10:07.600,0:10:09.176
Should I keep things as they are

0:10:09.200,0:10:11.696
or do you want me to take[br]some extra margins around?"

0:10:11.720,0:10:13.376
And then we said, "Well, hang on."

0:10:13.400,0:10:15.816
We told the doctor,[br]"You've missed those two spots,

0:10:15.840,0:10:17.840
so rather than taking huge margins around,

0:10:17.864,0:10:19.696
only take out those tiny little areas.

0:10:19.720,0:10:21.736
Take them out,[br]and then let's take a look."

0:10:21.760,0:10:24.616
And so the doctor took them away,[br]and lo and behold,

0:10:24.640,0:10:26.656
the cancer is now completely gone.

0:10:26.680,0:10:28.056
Now, the important thing

0:10:28.080,0:10:30.700
is that it's not just[br]that the cancer is completely gone

0:10:30.724,0:10:32.056
from this person's brain,

0:10:32.080,0:10:33.400
or from this mouse's brain.

0:10:34.160,0:10:35.416
The most important thing

0:10:35.440,0:10:38.336
is that we did not have to take[br]huge amounts of healthy brain

0:10:38.360,0:10:39.576
in the process.

0:10:39.600,0:10:41.776
And so now we can actually imagine a world

0:10:41.800,0:10:45.696
where doctors and surgeons,[br]as they take away a tumor,

0:10:45.720,0:10:49.160
they actually know what to take out,[br]and they no longer have to guess.

0:10:50.520,0:10:54.456
Now, here's why it's extremely important[br]to take those tiny little leftover tumors.

0:10:54.480,0:10:57.336
Those leftover tumors,[br]even if it's just a handful of cells,

0:10:57.360,0:11:00.416
they will grow to recur the tumor,

0:11:00.440,0:11:02.096
for the tumor to come back.

0:11:02.120,0:11:04.056
In fact, the reason why 80 to 90 percent

0:11:04.080,0:11:06.296
of those brain cancer surgeries[br]ultimately fail

0:11:06.320,0:11:10.096
is because of those small little[br]extra margins that were left positive,

0:11:10.120,0:11:12.800
those small little leftover tumors[br]that were left there.

0:11:14.440,0:11:16.616
So this is clearly very nice,

0:11:16.640,0:11:20.936
but what I really want to share with you[br]is where I think we're heading from here.

0:11:20.960,0:11:22.616
And so in my lab at Stanford,

0:11:22.640,0:11:28.160
my students and I are asking,[br]what should we be working on now?

0:11:28.600,0:11:31.456
And I think where[br]medical imaging is heading to

0:11:31.480,0:11:33.816
is the ability to look into the human body

0:11:33.840,0:11:37.280
and actually see each and every one[br]of these cells separately.

0:11:38.000,0:11:39.736
The ability like this would allow us

0:11:39.760,0:11:42.656
to actually pick up tumors[br]way, way earlier in the process,

0:11:42.680,0:11:46.600
way before it's 100 million cells inside,[br]so we can actually do something about it.

0:11:47.200,0:11:50.616
An ability to see each and every one[br]of the cells might also allow us

0:11:50.640,0:11:52.016
to ask insightful questions.

0:11:52.040,0:11:54.136
So in the lab,[br]we are now getting to a point

0:11:54.160,0:11:57.416
where we can actually start asking[br]these cancer cells real questions,

0:11:57.440,0:12:01.216
like, for example, are you responding[br]to the treatment we are giving you or not?

0:12:01.240,0:12:04.696
So if you're not responding, we'll know[br]to stop the treatment right away,

0:12:04.720,0:12:06.760
days into the treatment, not three months.

0:12:07.480,0:12:09.656
And so also for patients like Ehud

0:12:09.680,0:12:14.096
that are going through these[br]nasty, nasty chemotherapy drugs,

0:12:14.120,0:12:15.376
for them not to suffer

0:12:15.400,0:12:18.296
through those horrendous[br]side effects of the drugs

0:12:18.320,0:12:20.976
when the drugs are[br]in fact not even helping them.

0:12:21.000,0:12:23.936
So to be frank here,

0:12:23.960,0:12:27.416
we're pretty far away[br]from winning the war against cancer,

0:12:27.440,0:12:28.696
just to be realistic.

0:12:28.720,0:12:30.616
But at least I am hopeful

0:12:30.640,0:12:34.776
that we should be able to fight this war[br]with better medical imaging techniques

0:12:34.800,0:12:36.656
in the way that is not blind.

0:12:36.680,0:12:37.896
Thank you.

0:12:37.920,0:12:40.160
(Applause)