some radical terrorist activity happening around the world. and so that's what drives me to do what i do. >> and quickly, can you tell me what your next project is? >> my -- i'm working on another book, and it's going to be discussing the grassroots movements around the world, not only in the united states, but how -- [inaudible] rides up and mobilize and get up and get involved in their own government. we are witnessing a revolution, and can the internet is empowering that. i can tell you my organization started out of my bedroom on the internet, we were nothing but a web site. today we are the largest national security grassroots movement in the united states. 160,000 members, 510 chapters nationwide with a full-time lobbyist on capitol hill. it all started from a web site from the internet. so my next book is going to be about power to the people. ..

>> this is about an hour and a half. >> i have a very personal relationship to this bookstore. i was a student very close by here, an undergraduate from a foreign country. when i could get my spirits up, i would like to this bookstore and spend time here. there's something wonderful about things coming back. so thank you very much for

having me here. and thank you for those really wonderful words of praise. i must say though, my favorite praise that it received for the book came this morning when i was reading through my e-mails. someone sent me a note from some blogger who says arthur cliff notes for the "the emperor of all maladies"? [laughter] it's been my lifelong ambition to have a book to which there are cliffsnotes. [laughter] so if anyone is inspired to write cliffsnotes, please let you know. i would be delighted. i thought i would begin today rather than talking about the content of the book, i thought i would begin about talking about process because that's more interesting. that's something you don't get just from reading the book itself. sort of a behind the scenes look of what motivated some parts of the book and how they got written. first i have to write -- a note

of apology. when his book was widely handed in was three times its length. by necessity, a vast amount of the commission had to be cut. there is a fundamental, you know, my editors at 500 pages is the final limit. no more. we ended up with about 600 that was a bargain. but nontheless, so i have to start with a note of apology saying that not every story could make it into the book. so i would welcome other attempts to write for the histories of the disease that will continue to be part of our lives in the future. that said, i wanted to talk a little bit about the process of writing the book. in the first moment, one of the most pivotal moments in the writing of the book happened sometime early on when i was confronting the vastness of the

challenge. the fastest of the challenge is, here you have a history that spans about 4000 odd years. about 100 odd characters that move in and out of the book. there are scientific terms. there's sometimes political terms. there's politics, science. and, of course, in the middle of all this is this kind of world of stories. i was having a conversation with my very excellent editor, nan graham, and she said something to be very pivotal. she said, we're talking about something different and she said if one forgets the book publishing industries, if one forgets for a second the vast paraphernalia that allows the book to come into play, the bookstore, the actual product, the printer, the business of book making, marketing, et cetera, she said in the end of book is an amazing instrument by which one author sitting alone in the room can talk to one reader sitting alone in a room.

and that comment resonated with me very deeply because i thought to myself, well, if you forget for a second that passed their finale of medicine, the cat scans, mris, the billion dollar devices, the national cancer institute, the wonderful crown jewels of medicine that exist in this country and others, in the end the act of medicine is a mechanism by which one person sitting alone in a room can talk to another person sitting alone in a row. one doctor can talk to one patient. that analogy was very deep for me because it reminded me about what was it essential and was not essential. and the essential piece of it was that much like a book, medicine is about storytelling. medicine begins with the most shamanic act. if you take away all its paraphernalia, medicine begins with someone saying tell me her story, what happened. that is the first thing that happens when you meet the

doctor, is that you begin to unpack a story. and as i make a claim in the book, doctors then tell a story back to you. and it's this interchange, ancient, one of the most ancient interchanges we have as human beings. and that itself, that process in itself begins the unpacking or unburdening of an illness. long before you receive your first dose of whatever medicine you will or will not have received, it is the unburdening of a story that is the first shamanic act of medicine. and if we forget that comment seems to me that something very important will start happening in medicine. once i come to that realization again inspired by this comment, it became very clear to me how one could write this book. again, remember that there was a vastness of history here. but it could be written through

the eyes of patients. it to be written by telling stories. and if i could tell stories that begin whatever point of time, 4000 years ago, if i could fill, flush out the source, then what seems like an insurmountable problem which is how does one tell this history, we become actually solvable, which is tell the history by moving from story to story to story, typically focusing on those who were right there, those who have experienced it most drug. and that is patients. now, again, that was the solution in principle of the problem. but then that raises a second question which is how does one find these missing stories. how does one cover the story of a woman who expect breast cancer in 1950s. remember, i recount a moment in time in 1950, in fact, when a woman, calls of the new times and she says i'd like to place

an advertisement for survivors of breast cancer. and in your times, the society attributes on the phone and says, we can't print the words breast and cancer in in your times. what if we said this was a survivors group of women of disease of the chest wall. i said make sure you print it because it's a reminder for us, all of us including us, doctors, we need to be humble about what can and can't be cheated. so this was the background again, these missing stories, a word that can't be uttered, a word that is whispered about. the big c. and again, the question was what were the stories. and one thread became very early on is that any that somewhere in this story would have to be the story of one of the most remarkable women in recent intellectual history, and that

is mary lasker. mary lasker who, among many other things, directed her philanthropic energies. she was a very unusual woman for her times, and out of a number, -- and entrepreneur, a one who directed an enormous amount of energy to solving, as she put it, transforming the geography of american health, the landscape of american health. and if there was one sort of central characters think to the story it would be mary lasker. and for mary lasker then, it very quickly, i found sidney farber who begins the book. said the farmer was mary lasker's friend. scientific collaborator, and is mary lasker a political litmus he to the war on cancer, sidney farber provide kind of a scientific legitimacy for the war on cancer. so the book begins with sidney farber. sidney farber was a pathologist.

we begin in the 1940s. he was a so-called doctor of the dead because primarily pathologist in the 1950s would perform autopsies. he was a pathologist who specialize in children pathology. and typically bodies of children who died in the hospital would be wheeled out into space and laboratory. the laboratory was no bigger than about 12 feet by about 12 feet, kind of a frozen cube at the bottom of one of the buildings. so that's where we are in 1948. and then barber became interested in trying to find a mechanism or an understanding of the disease which was extremely lethal form of cancer. and that was childhood acute bikini and that's where our story begins. it is a disease that typically, although not always, affects

children. and usually in the 1950s it was almost uniformly, 100% mortality. often kids would die, to be diagnosed within and they would die within a span of a week or two weeks, sometimes they would live longer and dyson farber. farber began particularly interest in the. and one of the reasons of this, leukemia could be counted. at a talk about in this book, size begins with measurement. whenever you can measure something you can begin to form a scientific activity on. this was a time before cat scans and mris, is very hard to count the size of it internal tumor because it was inside. leukemia because it's a tumor of the blood could be counted because you could draw a drop of blood or perform a born merrill biopsy. you could see the death or the life of the team excels. and thereby you could say this therapy worked or didn't work. it was an objective mechanism by which one could have a conversation about the increase or decrease of leukemic cells.

and farber became interested in the. now, are% figure that one of the things that would be very interesting was to find the chemical that would thereby kill these leukemic cells and launch and, therefore, he launched chemotherapy. he fantasize about such a chemical. it turns out there was an indian chemist, a chemist was born in india, and he had come to boston to harvard to study at the school of tropical health. now, what he didn't know, as we all know, there's nothing tropical about boston. [laughter] >> so he was stuck in the middle of arriving in what appeared to stuck in the middle of winter. and she couldn't find a job. and he found a job in fact cleaning your nose. that was the best job that he could get. but then somehow to a series of exchanges he eventually found a job in the department of chemistry and he made several

discoveries. he discovered, as some of you might know, a very important molecule. face several discoveries. but because he was indian, he was denied tenure. and he was sent off from harvard. he sent himself off to a pharmaceutical company in new york, it was a subbranch of the american side endemic company. and then yella took up a problem which was a very insurance of a. and that is that he began to synthesize, synthetic versions of vitamins. one vitamin villages particularly then was called folic acid. and in the past, an english physician, a young woman had figured out that full of acid was responsible for the growth of normal blood cells.

so in other words, often in women, particularly in pregnant women, deficiency can if you'd have enough for what acid your blood would not grow number. so farber begin to put all these things together piece by piece. he started wondering, what a second, if folic acid is required to make normal blood grow, then could be that if you block the folic acid you could block the growth of malignant blood which is leukemia. so in other words, he said to himself, if folic acid is a factor, key factor for the growth of normal blood cells, then could one take an anti-folic and thereby block the growth of leukemic cells. and so he began to fantasize about an anti-folic. and this was the drug that yella had discovered during the process of finding fully, yella had found its opposite, and anti-fully. so farber wrote to yella in new york. yella sent him an anti-folic, and he began to inject, farber

begin to inject children with these anti-volokhs and demonstrated one of the first times in history a remission in childhood leukemia. and thereby invented chemotherapy. that is farber's moment in which he comes out of his basement. and, in fact, the idea of using an anti-metabolite, anti-folic is central to even the way we perform every today's for many types of cancer. so that's a back story. but the front story was, if that's the case, if it's a case that this is story about full of, who was the patient was the first person to receive folic acid. again i want to tell this from the eyes of the child receiving chemotherapy. not the eye such as the scientist administering chemotherapy, because it seems to me again that we violate the fundamental principles of the book. this was about page 60 in the book, i said wait a second, i have no idea who this child is. i'm on page 60 and i can't find the first patients or first series of patients of leukemia.

the only thing i knew about this child was that he was three years old and that he lived in boston, and his initials were are as big that was all that was in sidney farber's paper. so i begin, i was in boston and but began to send out the e-mails which would say, if you happen to know a child called r.s. with leukemia in the 1940s, please call me. please write to me, and center at such a. months passed by and was actually nothing, no response whatsoever. and i kept saying to myself, i'm a page 60, this book is never going to get written. and then i got dejected and i went on vacation. to my parents house in india. someone said to me, yella the chemist has only one biographer action, a single bug was written only by rookie of yella i know. and yella biography is about 85

years old but he lives three blocks with my parents house in india. [laughter] so someone to go and talk to yella biography and i said fine of ago. psycho to talk to yell as a biographer and were having a conversation. we talk to and our about his chemistry et cetera, et cetera, et cetera about leone is what a second. before you go i don't know if you're interested but i was in boston in 1950 visiting sidney farber's clinic, and i have a roster of all his patients with leukemia. and this was, it was a stunning moment for me. out of his files came a series of patients names, and a series of pictures. and that's how i found this child, this missing child, r.s. was robert sandler, a three-year old child. and affect the boston sunday herald had printed a picture of him in 1948 when he just begun

to respond to chemotherapy because again, this was a historic moment for medicine. but, of course, none of this is searchable. this is not indexed so i would have never, ever discovered him. so in a sense this became a metaphor for writing this book. which is that you might look for something and yet in reality you might find it 6000 miles away. and the second metaphor was that things always come around. there's a circularity to this process, a circular to history. and so i came back to boston. now armed with the name of this child. and then using the medical records and choosing the boston directories address book, i could find his parents name. and then using the record, the death records of boston, the certificate of death which is publicly accessible, i could find exact time that he died, where he died, where he had been

buried, where he had lived, et cetera, et cetera. all of a sudden the story that had vanished came alive for me. and that's how, again, that's how this book got written. so the first passage i'm going to read to you is now going to be what i call, now that i've given you the behind the scenes look is the front of the scenes look, about what happens once you have done all of this legwork, as it were, and found this child, how then you can construct a story. because again piece by piece, for me it all started coming together here is a section in which i now reconstruct the story of this child having visited his house. seven miles south of the longwood hospital in boston, the town of dorchester, which is where robert sandler lived, is a typical story new england suburb, waged between the industrial settlement to the west and the great green days to these. in the late 1940s

shipbuilders, iron, religious, fishermen and factory workers said and dorchester occupied rows of houses that snake up the avenue. again, part of writing of the sentence was now i could go back into history of dorchester and read about the history and reconstruct. and it turns out that robert sanders father was a shipbuilder. again, he was no link into the larger history of the town of dorchester. dorchester reinvented itself as the quintessential family down with parks and rivers, a gulf shores, a church and a synagogue. on sunday afternoons families converged at franklin park to walk our partners are to watch animals at the zoo. again is the kind of snow -- small note to come when i was writing all this, i kept thinking, i went to robert sanders house and i looked out what might have been his window. i don't know exactly where he lived in terms of what floor. but looking at it looked into

fica bark which was at that point in time, part of it was the zoo. i kept thinking to myself if i was a three-year old child, what would a member most about the zoo. i had a three-year old daughter that i kept thinking what would it be. and i thought to myself it would have to be the animals. so it took only a couple agrees to figure out that there were ostriches. they had come nearly to the dorchester park zoo. was a nice is again, history is so circular. someone came to be, i was doing with these readings in seattle, and someone said how do you know there were ostriches in the zoo? and it was so nice as a writer, filed away somewhere in the back of my cabinet was a little article about the fact that the hostages at dorchester park zoo. it was very nice. a strange, odd things that give you pleasure as a writer. in the house across from this is a child of a ship worker in the boston yards for a mr. siegel with a low-grade fever that waxed and waned over two weeks without having filed by increasing power.

robert sanger was two years old. his twin, it, it turns i had it to end, he was in perfect health. truth being stranger than fiction, we talk a lot in this book about how genes are activated or inactivate to cause cancer. if you want to find a mechanism to describe this comment to describe the role of carcinogens and entered a genetic after mounties and the idea that there's, they can some kind a family history, you would probably choose to identical twins and one of them would develop cancer and other would not develop cancer. that would allow you to begin to enter the biology of what makes one twin had cancer. and yet i didn't ask for this, and yet of course there is a twin. robert sandler has a twin and, therefore, sets up the capacity for this discussion to happen down the road about the idea of what does a twin mean, what is he claiming in genetic terms. i will come to that. we enter farber's paper, again.

and there's reminder how incredible medical writing can be because in a very cold clinical paper there's the story of human beings being killed. whenever doctors exchange medical papers, but they are really exchanging again i think our stories. stories dressed up in tactical language but exchanging so this will return to farber's paper and i'm literally restating what's in the paper. 10 days after his first fever, robert's condition worsens but his temperature climbs higher. his complexion turned from rosie to a milky white. he was brought to the children's hospital in boston. his splint, -- is explain was visibly large but a drop of blood under the micro-scrub identified the illness.

santa arrived at the childers hospital a few weeks after farber had received his first package from yella. on september 61947 he began to inject sandler with paa, the first of yella and i pulled. consent to run a java drug even a toxic drug was not typically required. parents were occasionally informed about a child, but you'll almost never informed or consulted. the norberg code for extreme edition quite explicit consent from patients was drafted in august 9, 1947. that is loaded one month before this drug, less than a month from the p.a. trucker it is in doubt that farber in boston had heard of such a good. the drunken little effect over the next monthsandler turned lethargic. he developed a limp, the result of the kenya president on his spinal court. leukemia burst causing a

fracture and unleashing a blindingly intense indescribable pain. by december the case seemed hopeless. the tip of this dropped onto his poster he was pale. on september 28, however, we know that from sydney's papers, farber received a new version of anti-volokh from yella. this one was called, nocturne. a chemical with a small change the structure of paa. farber began to inject the boy with it. hoping it best for a minor reprieve in his cancer. but the response was market. nearly 70,000 in december, suddenly stopped rising and covered at a plateau. then even more remarkably the town started to drop the leukemic thickening out in the blood and all but dissipated by new year's eve, the count had dropped in at 16 of peak value. bottoming out at nearly a normal

level. the cancer that we hadn't vanished under the microscope there was still malignant white cells, but it temporally updated, frozen into a stalemate in the first boston winter. on january 13, 1948, sandler returned to the clinic walking on his own for the first time in two months. his spleen and liver had shrunk so dramatically that his clothes had become loose around the obtaining. again, just the observations and farber writing. and he said, he says r.s. close became loose around the abdomen. what an amazingly deadly description but if you want to describe the remission of a child with leukemia, what an amazing choice of simple words that would tell you that this child had become so swollen, that his mother had to make new clothes. and now this child, his clothes had become loose and. again come you don't require very much to go to a medical

paper to reconstruct a story that is so vivid. is bleeding had stopped at his appetite had returned ravenous as if he had tried to pick up on his bill. for brief month or so robert sandler and elliot sander seemed identical again. now, like all stories this and also had an apple appear in the epilogue is more amazing that even the story itself. about 10 days after the book was published i got a phone call from my editor, and she said, you need to sit down because this is a very important phone call. i was writing a grant on my computer and i sat down, and it was elliot sander on the phone. and he had walked a bookstore never having known about this book remembered the story of his twin who died at three years old. and people who had the copy of the book know that the book

opens with robert sanders in 1945-1948, and those who came before and after him. and he opened the book. he lives in me. i would have never found him. he lives in me. he opened the book and he saw his brother's name. the brother that had vanished from his life at three years old. he was moved to tears than. and he moved back and he told me this amazing story, which was his mother, helen, whose pictures in the book because i found her picture from the saturday morning post, "saturday evening post." helen, helen and robert and elliot and the whole family was jewish. and this was a time when, this was, i mean, still remains she was a deep believer, and as many of you might know, opening a body, performing in a topsy after death is considered a violation of sanctity. and helen didn't want her child

to be autopsied, but farber was a pathologist and the only way he knew he could learn from this first remission was to perform an autopsy. and so farber had begged helen sandler to let helen to let her open roberts body and perform a normal autopsy. and she had refused, and then finally he had really begged her and said for the sake of medical history, for medical science that he opened his body up. and she had said fine, do it. and she said to l.a., she told me that this decision had haunted her for decades. for decades you think to herself it was the wrong decision. and so i think the finest raise i got from helen santos said in drug to me that the brooke brought her story to a close. she said that now that robert sandler has found a place, a rightful place in medical history. it was as if her decade-long haunted memory had come to an end. and i think that's in some ways, you know, a finer praise and

many that i have personally received and it's the most moving thing that happened to me around the book. i think i have time for one more passage that i'm going to read, and this is from the end of the book. which takes a very different kind of a challenge. the first kind of challenge that i described to you is the challenge of storing making, which is how do you pocket a book. it's a challenge that appeared in the content. a book like this also raises every different kind of challenge, and that's the challenge of summary making, which is at the end of the book how to summarize 4000 years of history, how does one prepare to give them how does one kind of all of this? the quick answer is that there is no simple solution, that's something you learn in the book. one of the challenges of this book is there is no pat answer that i didn't want to answer above, this is how you kill cancer. this is i eat broccoli, some nonsense like that.

so here i take up the challenge by actually performing a thought experiment. and i recount the story early in the book i recount the story of a persian queen who is described in no less than about four lines in herodotus. and becomes one of the earliest descriptions of what might have been breast cancer. we don't have word for cancer in his time. arises sort of inviting history which is a description of the early history of the west that were focusing on greece, since a little bit of the message, about two or three lines. what he described as i did that the queen of persia developed a malignancy, a swelling in her breast. , a a mass in a press to some people have translated. and her response intensely

contemporary prose, her response response, she was so ashamed of it that she hid herself in her shame. again, remember 1950, rosenthal coming of the new concert she hid herself in her shame and she would anyone examine her breast. until a greek slave intervenes and promises to cure her. and he does care. and if so, he probably does so by performing one of the first recorded mastectomies, or cobectomy's breast cancer. she is very grateful and as a return favor, she turns tells that she tells the king of persia who is invading the eastern border of persia, she will persuade him to invade the western border of persia in towards greece so that he can return back to his native greece. and in doing so, this launches the persian war. so here is this woman, and act

according to the recording from history to this is the moment in the history when the face of persia as it were turned towards eastern face to the western face because of this, because of his illness that she had. derided as dedicate four or five lines but, of course, this launches the early history of the west. the turning of the face of persia away from its eastern border towards its western border, launches as we very well know now, the famous persian wars. so we now, 500 pages later, return back, recalled the persian queen who likely had breast cancer 500 b.c. to imagine her trying to time appearing and reappearing in my doctrine after the next as she moves through the art of history, her tumor frozen ends the age remains the same. the case allows us to recapitulate cancer therapy and

to consider its future. how has your treatment and prognosis shifted in the last 4000 years and what happens to her later in the new millennium? first, ever go backwards in ti time. they had a name for ellis, a hieroglyph that we cannot pronounce that you provide a diagnosis but there is no treatment he says. closing the case. in 500 b.c. in her own court, she describes the most primitive form of them a second which is performed by her greek slave. 200 years later, topographies identify the tumor as giving her ellis a name. incidentally, this is a dereliction of the name cancer because hippocrates unimagined cancer as a crabbed buried underneath the skin, the blood vessel spread out like the legs of a crabbed under the sand. right from its moment of in session cancer is a metaphorical disease. a metaphoric idf cancer permeates this illness.

a thousand years flash by and it is person or body at the tumor keeps growing, relaxing, invading and metastasizing. medieval surgeons understand little about the disease but each is only after cancer with knives and scalpels. some offer, these are real documents drawn from historical text. holy water, grab pace, chemicals as treatments. 1778, and john hunters london, the cancer is assigned a state. early localized breast cancer or late breast cancer. for the former, early breast cancer, hunter recommends a local operation. and for the latter he recommends remote sympathy. when she reemerges in the 19 city she encounters a new surgery in 1890. her breast cancer is treated with the most definitive therapy thus far, radical mastectomy with a large removal of deep

chest muscle and the collarbone. in early 20 century, finally, the treatment, i go through the story of the in the book, it turns out to be essentially a failure. it takes 90 years, 90 years before patients and doctors can begin to convince themselves to really put the idea of radical breast surgery to test. and when it is put to test 90 years after its invention, 500,000 people treated later, it turns out to be no different from non-radical surgery. in the early 20 century oncologist tried to obliterate the tumor using local x-rated by the 1950s another generation of surgeons learned to combine the two strategies. the cancer history locally with a simple mastectomy, or a lobectomy followed by radiation. in the 1970s new therapeutic strategies emerge. the charges filed by the accommodation of chemotherapy, her tumor test positive again

recapitulate things that wisconsin and about. her tumor has positive for the antigen receptor. in 1986, her tumor is further discovered to be too amplified, surgery, tamoxifen and she is treated with target therapy using herceptin. the shifting landscape of trials allow a direct comparison between the state and five nbc and then in 1990 but surgery, chemo to be, hormonal therapy and targeted therapy have likely added anywhere between 17 and 30 years to its survival. diagnosed at 40, she can result be expected to celebrate her 60th birthday. in the mid 1990s, the management of the breast cancer takes another turn. her diagnosis at an early age and her ancestry raises the question whether she carries a mutation, again these are terms of introduced in the book.

her genome is sequenced an indication is that she enters and an intense a string program to the tumor and unaffected breast to her two daughters are also tested, found positive, there offered either intensive screening or tamoxifen to prevent development of invasive breast cancer. for the daughters, the impact of screening might be dramatic. a breast mri might identify a small lump in one daughters, might be found to be breast cancer and surgical removed in its early pre-invasive stage. the other daughter might might choose to undergo alpha like a bilateral mastectomy, having excised her breast and she might live out her life without breast cancer that each sense corresponds to a seminal trial. it basically as an oncologist would know each one of those senses refers back to a very major single clinical trial that proves or disproves a particular way of the management of brc1

positive, breast cancer but that that's what i hope in a way understandable in somewhat humanized. move to the future now, in 2050, she will arrive at the breast oncology senate with a flash i can end the entire sequence of the cancer genome identifying every mutation and every gene. the mutations might be organized to key pathways, and agra might identify to contribute growth and survival for cancers, therapies might be targeted against these to prevent a relapse of her tumor after surgery. she might begin with one combination of targeted drugs can expect to switch to second dr. winter cancer mutates into a chicken when the cancer mutates again. she will take some form of medicine. this into belief is progress, but before become too dazzled by her survival, it's worthwhile putting into perspective, give

her pancreatic cancer and five nbc and the progress is unlikely to change. if she develops gallbladder cancer, that is not amenable to surgery, her survival changes only marginally over city. even breast cancer shows a market outcome. it first tumor had metastasized, or to negative and responded to standard chemotherapy, that her chances of survival would have been changed since the time of hunter's clinic. gifford cml, or hodgkin's disease in contrast and her lifespan might have increased 30 or 40 years. part of the unpredictability about the trajectory of cancer in the future is that we do not know the biological basis for this pic we cannot yet fathom for instance, what makes pancreatic cancer or gallbladder cancer so markedly different from cml or the breast cancer. what is certain, however, is that even the knowledge of

cancer biology is unlikely to eradicate cancer fully from our lives. as richard suggests, we might as well focus on prolonging life rather than eliminating death. this war on cancer may best be won by redefining victory. so that's a second passage. how are we doing for time? is the time for one last passage or should we wrap up? one last passage. i'm going to read the very last passage in the book. a very short passage, and i think is the final summary of the book. this passage is, was actually probably the hardest for me to write. and, in fact, goes back to the question that john talked about, why i had written his book it was written as an answer to a question that a woman had rates. so we return to the sort of that woman.

this was an incredible woman who i treated while a fellow in boston. and she had had an abdominal sarcoma, and had relapsed into another remission, another relapse, another remission. incredible remissions by the way caused by what was then a new drug, striking remissions. and she had an unbelievable character virtue is a psychologist, and she had essentially followed the trail of this drug throughout the country moving from one clinic to the next clinic and in will result in clinical. creating her own community every time around herself. she would engage this community and ask questions and then pulled herself into the trials. she had at one point of time she was receiving therapies using one of these drugs, while living in eternal hunger she found

herself homes like this and she would move on to the next one. is almost like choose creating her own little trail all around the country. an unbelievable person. and then finally, she had had her last response and then her tumor became completely resistant and would not respond to even, even the newest ones of therapy. so, so this is the last time i see her. so i will pick up the store. the new drug, this is the last time she had a drug produced on a temporary spot. but do not work for very long. by february 2005, her cancer had spiraled out of control growing so fast that she could record its weight in pounds as she stood on the scales every week. even her paint eventually her paint made it impossible for her to walk even from her bed to the door and she had to be hospitalized. my meeting with the that meeting was not to discuss drugs and therapies. but to try to make an honest recognition between her and her medical condition. as usual she had beaten me to

it. when i entered her room to talk about the next steps, she waved her hand in the air and cut me off. articles when a simple. she told in no more trials, no more drugs. the six years of survival should be done between 1999-2005 had not been static for the news. they had sharpened, clarified and clinched a. she had severed her race relations up with her husband and intensified her bond with her brother, an oncologist. our ally, a topic of our something nurse and her closest friend. cancer break some families, in my case it did both. she realized her dream had come to an integer want to go back to alabama to die the death she is expected in 1999. when i recalled a conversation with her embarrassingly enough, the object seemed to stand out more vividly than the words. a hospital room with the sharp smell of disinfectant and answer, the unflattering overhead lights, a wooden side

table on wheels, pills, books, nail polish, jewelry and postcards. a standard issue, plastic hostile picture filled with a bunch of sunflowers by her side. as i remember she was sitting by the bed, one leg dangling casually down wearing her usual eccentric combination of close and unusual pieces of jewelry. her hair was carefully arranged. she looked formal, frozen in perfect, like a photograph of someone in hospital waiting to die. she seemed content. she laughed and she choked. she made one a nasal gastric tube seemed somehow effortless and dignified. only years later in writing this book when i finally put it to words by that meeting left me feeling so uneasy and humbled. while the gestures in the room seemed larger than life, while the object seemed like symbols and why she herself seem like an actor playing a part. nothing i realize was

incidental. the characteristics of her personality that had once seen spontaneous and in positive were in fact almost response to response appeared almost reflective to her and lifted her clothes were loose and vivid because it were decoys against the growing outline of the tumor in her abdomen. her necklace was distractingly large so as to pull attention away from the cancer. her room was topsy-turvy with bottles and pictures. the hospital room pictures filled with flowers and a car stacked to the wall because without them it would evolve into the anonymity of the other room in any other hospital. she had things are late in that precise pose because the two had invaded her spine and begun to paralyze her other leg making it impossible to sit any other way. her casualness was studied. her jokes were rehearsed. her illness had tried to humiliate her, but it had made her anonymous and seemingly humorless. she responded with a vengeance. moving always to be one step ahead of trying to outwit it.

it was like watching someone walk in a chess game. every time her disease moved imposing yet another terrifying constraint on her, she made an equally absurd to move in return. the illness acted and she reacted. it was a morbid if not again, again had taken over her life. she dodged one blow only to be caught by another. g-2 was like carol's queen, pedaling furiously just to keep in one place. she seemed that eating to capture something essential about our struggle against cancer. that to keep pace with this malady you need to keep inventing and reinventing, learning and learning strategies. she thought catch obsessively, candidly, desperately, fiercely, madly, brilliantly and zealously. jamming all the fierce energy of generations of men and women that fought cancer in the past and would fight it in future. her quest which are had taken her on a strange and limitless

journey through internet blogs and teaching hospitals, chemotherapy and clinical trials, halfway across the country through a landscape more desolate come a desperate and disquieting that she had imagined. she had to put every last morsel of her energy to the class, mobilizing and re- mobilizing her courage, summon her will and wit and imagination until the final evening she had stared into the void of a restful this and found it empty. in that haunted last night, hanging onto her life by no more than a tenuous thread, someone offer threats to strengthen dignity, it was as if she had an catholic the essence of 4000 year-old war. thank you. [applause] dr. mukherjee will take questions now. i'm going to be bringing around the microphone, so please don't

start to question and tell you have the microphone. also, because this is being filmed for tv, for privacy reasons, please don't ask any personal questions. thanks. >> by personal, unique personal medical questions. you can ask a question about me. actually, i will start if i made by asking john a question. and that is common john, tell us a little bit about how, what's happening at the national cancer, you've come here from washington. tell us a little bit about what's happening at the national cancer institute in terms of this new administration and this sort of sputnik, and what you imagine will be happening in this administration with respect to cancer. >> thank you. i first want to comment, i was most impressed by your eloquence and your ability to 20 k. i think that they been able to educate america and the world about cancer, it's really my hope that someone in a field

other than medicine will probably be the one to find the answer to cancer. just like nitrogen mustard gas was found on the battlefield. one lesson i learned that u.s. sf, very often it's the medical students, the youngest trainees who asked the most provocative questions and who move the field of medicine forward. and i really wanted to congratulate you really, as most impressed during the discussion of serendipity, and i really hope that there may be opportunity for someone here tonight to think of new answers, just like the apple slogan, think differently. there's a lot of excitement in washington, d.c., right now. it is a pitched battle to either change or repeal the affordable care act, but one area that continues to move forward is the amazing amount of work uncle trials and studies that are being undertaken at the national institutes of health and the

national cancer institute. i hope that the budget will be able to be approved and funding will be preserved to continue all the incredible work that is being performed at the national cancer institute. the institute offers tremendous hope for patients for the entire world, and it appeared that the commitment of the obama administration to discovery, innovation, will continue. so i think that for cancer patients all around the country and the world, that there are many great things get, from that institution. >> what our -- who is fighting what? >> the battles are political. they are about how we are going to change or repeal the affordable care act. and one of the -- there are many

strategies. i would turn your attention to an article from "the wall street journal" last year about the strategies to either defined, disallow, repeal or to change the legislation passed last year. it really is my hope that we can be constructive, and to move above the acrimony of the debate and identify those portions of the law which are working well and identify the ones that need to be improved, and to keep this process of health reform moving forward. >> i think it's absolutely vital. yes, questions. >> i'm doctor jordan wilber, what i want to do is make a comment. you have a fantastic book. i knew person most of the

people, and you have them right on. right on. >> thank you very much. >> thank you. >> you know, one of the things again, because of the constraints of time, i mean, to draw a character in a book like this, one of the ways he really, it really relies on lots of primary interviews aside from the archival research. a lot of primary interviews. and i, you know, i think there are about four or 500 interviews that went into the book, carried it down over time. and even for instance, painting a picture of sidney farber was to do that, was to come at different angles. what's important is that human beings are complex and even a character like farber. a lot of people didn't like them. he was, you know, he was an unpleasant character, and that's important to convey because otherwise he began to write a history that is not real. thank you for your comment.

>> have you ever been a doctor in a war? >> that's a good question. not in the sense that you might understand more. i have never been a doctor in the military forefront, but one might say that this is also a war. in the sense that when we sometimes, we fight wars between people, human beings fight each other, but sometimes we fight even more important wars against things that we can't see. and i might add that cancer is one such entity. i don't like using the word war sometimes because it feels as if then patients become soldiers. and if you don't survive, you become a loser in such a war.

so i don't like using that metaphor. but for some people that worked there for some people really imagining us in a battle against cancer is important. and in my usual approach to all this is, if that's a metaphor that works for you, use it. you know, who am i to tell you what metaphor works for you? so yes, the quick answer is i've never been a doctor in a war, but i have been a doctor and his more abstract, abstract war. and there are other wars that are also being fought right now against more abstract entities, political wars, in part of that is also part of this book and how does one fight a political war, how does one create strategy which is not only scientific strategy because one thing we know is that if we are to engage can't determine whether it be a war or not, if we were to engage cancer, the solution can't just be a scientific solution. it will never be a scientific solution. they will have to be a political

solution, a cultural solution come at all this comes into the book, eradicating tobacco is not, you know, one does not require scientific solution. one acquires the political and social solution, solving pancreatic cancer is completely different. but requires another kind of strategic element. so every piece of us, every piece of society, every piece of us as human beings is somehow engaged in this. everyone contributes i think. >> you seem to be speaking primarily of tears of cancer in the morning about prevented. it seems to be an increasing amount of search went on. vitamin d is a popular issue right now. could either one of you comment on your outlook towards the preventive efforts that are being made, and any optimism there? >> yes, i have several comments about the. there's a large section in the book that just with prevention

so make no mistake that, in fact, one of the most historically, in fact, one of the most seminal moments in the war on cancer is when this idea of fighting a war, a cure batter began to fade away, people began to really research focus on prevention. that continues today. my thoughts on prevention women. i'm not going to talk about them at great length. i'm going to say, i'm going to make two comments. one common is that it remains shocking to me that the most preventable carcinogen is still at large. who we are fighting, it's compensated battle on the hill about how to do this that or the other, about health care costs. meanwhile, the largest known carcinogen, the great irony in all this, people, talking about radon or, you know, some known

carcinogens, fully acknowledged carcinogens. that it's a little bit like we're not talking about the huge elephant in the room, which is tobacco. so, my quick answer to the question is, some of the battle against prevention is going to be political and a cultural battle. but the second point that i want to raise, which is to be very interesting as it seems that the silos of prevention and treatment and cancer biology are collapsing. in many different ways. and i think that's very encouraging. in other words, we used to think that prevention, cancer prevention, people used to live in one compartment and cancer treatment people use to live in one compartment. and others use to live in a separate compartment, but that's not the case anymore. i'll give you an example. there are many. tamoxifen is a rude example of the. is a drug that was really created originally to treat advanced stage metastatic breast cancer but turned out to have a

role in prevention. you can use tamoxifen as inappropriate population, probably focused. tools such as mammography which were originally invented as diagnostic tools to diagnose breast cancer can be used in the preventive setting. in fact, even the genomics, cancer genomes congestion at the cancer genome, cancer and cancer genes has an accord, a role in prevention, particularly on breast cancer. so there is a way in which a new molecular biology of cancer is forcing us to rethink these silos, and i think that's very good because it will allow us to rethink about prevention in a way that just does a rugged prevention to one end of the spectrum and treatment of the other end of the spectrum, and this fusion jazz already been happening for a while but it's very encouraging to me. any comments? >> i agree entirely. i'm a surgeon, and we can cure

cancer. if we can catch it in time. i know as surgeons would burn them, froze them, we use ultrasound, we've got them apart and made vaccines. if we can catch them early enough, we can cure them. to me, it's, the question is about prevention of recurrence. and what we haven't solved them you can have a tiny tumor and you can remove it and it's entirety, but months or years later you discover that it is spread all throughout the body and conversely, i've seen the largest tumors that you removed surgically, and they never recover. and so, the fundamental next step from the surgical perspective is the prevention of but tacitus and returns. ..

>> within every, within every tumor there is a kind of darwinian battle that's going on even without treatment. so within every tumor there are clones that are growing out which are resistant, for instance, escape your immune system. within every tumor there are clones that will move into other parts of your body. when you take chemotherapy, you will kill -- you might kill many of the cells, but there might be some cells that escape and, therefore, will evolve out of that. so cancer, and we talk about it as a fundamentally darwinian illness. and that's, in fact, part of the street of how unbelievably successful cancer cells are in invading because every time it's a kind of, again, like we come back to the red queen metaphor.

every time you're doing something, your cells are, the cancer cells are sort of pushing back. i shouldn't use language like that, but cancer cells are evolving, and it's much like treating a disease -- it's much like treating a bacterial illness or a disease with viruses. there's constant mutation and evolution happening. it's like the galapagos trapped inside the body. >> my question is regarding the role of the patient during therapy. for myself when i was diagnosed, my center made it very clear that it was patient-oriented and that i would have a part to play in deciding what transactions i was going to -- directions i was going to take. but the reality of it is at the time when it happens and everything moves so fast, that you really feel like you don't have a whole lot to say because you don't know very much. do you have any comments on that? >> well, my comments, in

general, that's an unfortunate situation. that's a situation that i hope we don't find ourselves in increasingly over time. i hope that, i hope that we have given the pressures of time and money that are occurring in health care, i hope that we have the time to listen to stories and figure out how to best treat not a statistical entity, but a human being. i have to say, it's very tough. sometimes it requires, it requires a kind of listening skill which i think we as doctors have forgotten. some people might not want a certain kind of treatment, and it's very hard for physicians to listen to that. we've almost por gotten that listening skill -- forgotten that listening skill. i hope that we have a way to keep ha in medicine -- that in medicine. did you have any idea? how does one -- >> well, my thought was i didn't

feel my doctor wasn't listening to me, i felt like i have not been someone who studied cancer my entire life. i knew people who had it, but i knew very little about it. to really get to a level where i could ask a question and make some definitive decisions, i would have had to have been reading up onering. so when it gets right down to it, i have to trust my doctors which, of course, i do, and i chose doctors that i trust. but i think as a patient, a patient does feel pretty much out of control. >> oh, i mean, that's fundamentally the case, right? it is the case that one feels out of control. you know, i think, i think -- i really think this is one of the fundamental challenges of medicine, how does one, how does one involve the patient in a way that's respectful of the patient's wishes but, on the

other hand, doesn't make you feel as though -- it's your job to be the expert, you know? once it becomes your job to be the expert, then in some sense the prophesy defeated itself. this is a reason behind someone to colate all the information, and there's a huge amount of information. so i think in some ways i don't know the answer. i have two general strategies. one general strategy is, ironically, at least many my personal practice -- at least in my personal practice i find that patients become more confident when you tell them that you don't know something. it's a we call peculiar -- peculiar irony as opposed to saying you know something. much like readers can detect a false note in a book in the one and a half nanoseconds, patients can detect false confidence in doctors in one and a half nanoseconds. and so, ironically, the best way

to approach, to build confidence is to be humble about what's known and not known, that's my personal practice. and the second thing, i think, is i think in some ways it is, in fact, the restoration of faith -- and, again, this is my practice -- the restoration of faith in saying let me be the person who has the information, but you give me the direction for that information. so don't spend your nights looking on the web or the blogs because that's not what will heal, what will allow the process of healing to occur. your body, you're doing enough already. there's enough on your plate already. let me be the person who has the information, who gives you the information, and ask you be that guide for that information. i think that in some way relieves patients. they don't have to be the person who's the expert all the time because no one's the expert, you know? i'm not the expert. i know a little bit more, but

i'm not the expert in your choices. that's my strategy, and, again, i think it involves the act of listening which i think is very hard to do in these times. >> yeah. i learned that web research is the kiss of death. [laughter] >> i know. it is the kiss of death, i think. >> do you think that the vast quantity of chemicals that are being used in various processes are contributing to a increase in the incidents of cancer? >> it's a tough question. i think that some chemicals may be contributing, but i think that -- but i think, on the other hand, one has to be careful about this idea of a hypercarcinogennic environment because it creates a kind of panic about the environment that i don't agree with. so my general thoughts about this is that every chemical, particularly those that reach a certain concentration in our, in our environment need to be quite rigorously tested. in fact, our testing mechanisms

are improving. we used to perform a very primitive way of testing for carcinogenic agents. it really relies on the fact that these cause mutations. not all cause mutations in bacteria. it's an important test, in fact, developed at berkeley, but it's very primitive. we have much better tests for that. but that said, i also disagree with this idea that, that, i mean, every chemical needs to be tested is exactly the right thing to say, but i disagree with this idea that, you know, we have a generally more carcinogenic environment because we need to find what those precise star sin generals are -- carcinogens are. it's a little bit like saying the water is carcinogenic. or someone says the air is producing cancer. but i have to breathe the air. you have to tell me in a very quantitative way n a realistic

sense that the dose that's available, this molecule in the air is causing cancer so i can remove that molecule. my plea is, let's be specific about the claim. what is the chemical? how can we remove it? what role do they play in normal lives? and then remove them from the environment. >> i had a question similar to that. >> yes. yes, sorriment -- sorry. >> was i supposed to start now, or am i supposed to wait? [laughter] i have a bit of an education which always makes a person dangerous. [laughter] and so my question's similar to his, but i'm interested in avoiding the paranoia that the press encourages. so i wonder if there's some sense you have about the percentages of cancers that are, basically, just what i would call natural mutations, things

that are running around living in a clean room all your life really won't cure, and what percentage -- and i'm sure these are different for each type of cancer like smoke egg we do -- smoking we do know the answer. but excluding lung cancer, is there a percentage that are natural hue teations either inherited or that come with age, and which ones might be industrial carcinogenicly-oriented? >> so that question is, as you can imagine, is an extremely difficult question to answer. it's answerable for rare cancers. so there's an old adage in epidemiology which is that large, rare risks are much easier to assess than small, common risks. so in other words, you know, if there's a sudden epidemic of liver cancer which is associated with a particular toxin, right?

those risks are very easy to determine and, therefore, you can determine the toxin. it's when you have a small increased risk in a very common form of cancer like, let's say rest cancer. to detect, it took a huge study to detect the very substantial but, nonetheless, relatively small relative risk of increase of breast cancer with hormone replacement therapy. now, again, this risk was large enough to even register on an end deem logical scale. so this was a large risk. but it takes a sophisticated kind of study to figure it out. the quick answer to your question is, unfortunately, i'm not sure we're there yet in terms of figuring out what these small, common risks are. i suspect that for some cancers we'll never be there because, you know, in the end can one really determine whether this was a very small risk created by

a carcinogen, or was this a natural mutation? for some cancers i this i it's -- i think it's going to be very, very, very difficult. >> thank you for that fascinating talk and fascinating reading. >> oh. >> you talked about how radical mastectomy was institutionalized as a treatment for breast cancer, and it took 90 years to understand that it was unnecessary and ineffective. i wonder if you can talk about any other examples of that that you've come across in your research, and in particular, are there treatments that are part of standard therapy now that ten years from now or 20 or 50 or 90 we will think of as ineffectual or unnecessary? >> i certainly hope so. [laughter] well, i mean, there are many examples. actually, i talk about these. one of the things in writing this book, and i know this was commented upon, is that i also wanted to not write a so-called

whig history in which progress leads to more progress, and one ends you want in a funny place. there are very dark moments and tack histories and stories in this book, and many of them have to do with the way medicine becomes a self-fulfilling prophesy or learns to believe in itself. radical mastectomy is one of them, believe it or not, back to breast cancer. in the 19 l 0s -- 1980s there was a strong sentiment that many researchers believed giving radical chemotherapy would cure breast cancer and so radical, in fact, it'd weep out your bone -- wipe out your bone marrow and have to replace it with your own bone marrow that had been frozen away. and it took another decade to disprove that. and part of the reason was patients didn't want to enroll themselves in the trials. so patients had become so convinced by their doctors, they'd become so convinced this

is fs the right thing to do that no one wanted to be randomize today the placebo arm of this trial. the doctor said we believe this works, you believe this works, so why go through this an.commizationsome. >> in massachusetts there was a law that was passed called charlotte's law which forbade an insurance company from not allowing bone marrow transplantation for breast cancer. it was felt as if insurance companies would skimp, which they were doing, on breast cancer therapy. there was a law that was passed. basically, it was breast cancer therapy with transplantation by law. i certainly hope this will repeat itself for many forms of therapy that we engage in today. >> i had a question on prostate

cancer. >> you might have to be loud because the mic is somewhere in the back, but i can repeat your question. >> [inaudible] >> well, i mean -- are you asking what, ultimately, causes prostate canner or why does it come in so many different varieties? >> i'm getting older. [laughter] developing prostate cancer is, you know, t very high. >> that's right. >> just wondering what's behind that large number of men -- >> i think we don't know the full answer to that question. it turns out that the prostate is one organ where malignancy develops in men at a remarkably high rate. what's very tricky about prostate cancer is that it comes in very different forms. there's one form which actually does not metastasize so easily and, in fact, you will not die with prostate cancer, and there's another form that me metastasizes and will kill you.

we've not begun to figure out how to discriminate between these two, and it's a huge problem. it is it's a problem that, again, that will make a difference in the national health care budget because for every 10,000 of the one kind that you shouldn't be treating anyway, you're treating, you know, you're piling up costs, biopsy costs, treatment costs, etc., etc., where the best thing to do is actually not do anything. that's part of the answer. in the absence of that knowledge, and this is what i talk about in the books. in the an sense of their knowledge how do we behave as an individual or a society. i think this is about 80% likelihood that your prostate cancer's going to be the treatable kind, why don't you watch and wait, right? in a culture where we don't understand enough about cancer, where the word cancer has taken

on the current metaphors and understanding, how does one communicate the complexity of that idea and who's comfortable and not comfortable with it? you know, if you go on the web, you will find 10,000 opinions about testing with a psa, right? and, again, this is of enough importance and so common that it will make a difference to the budget. because the numbers pile up. so, again, usual answer to this is -- my usual answer to this is technology, since, deeper understanding. while we are many this sort of waiting pattern trying to figure out how to discriminate between the so-called good kind and bad kind of prostate canner and relieve all of these problems that you're having in

washington. so encourage technology, encourage science. that's the best thing we can do. >> yes. >> [inaudible] >> i -- yeah, have we looked at -- do i talk about the food additives? i actually spent a little bit, i spoke a little bit in the book about estrogens and pesticides. but, you know, it's anissue that remains -- i haven't looked at it, but there's a deep interest in looking at it. in particular at pesticides and the hormones. again, this is the kind of integrated approach involving not just the old style epidemiology, but a combination of things to solve these kinds of puzzles. in general, you know, i think

especially with cardiology cardiologyiness's that generals, there's a bit of a smoking gun. people agree and disagree with that. questions in the back and maybe in front. >> i was wondering if you could comment on your evolution as a writer, a little different tact. >> in the sense of -- >> well, was this your first book? the an extraordinary book. i'm just curious how you evolved as an author. >> you know, i, my general approach to writing book or to any kind of writing that i do happens to be informed with, think my scientific work which is i like to write books that i answer questions. so if i have a question, i will

write a book. and in this case i had a very urgent question. i actually learned to write while i wrote this book, and if you are a reader of this book, in fact, you might sense as this book progresses, again, if you're a very careful reader, at least to to me it's obvious that i'm learning to write. [laughter] by the 400th page i'm a different writer than i am on the first page. now, i worked pack wards, and i tried to clean up what i had done before. and i do realize the writing it evolves, so that's one fee chuf of et. in terms of process access, you know, i'm a deeply disciplined writer in the sense that i write

some small snatches here and there. often -- i write exclusively in my bed. [laughter] i prop myself up with pillows and, you know, when i was writing all of this, often i would have the early mornings i would write when, you know, i could have -- i had a sort of -- and i think the most important thing in terms of the writing of this book and, again, if you're a writer, it becomes, i think, clear to you, this book lives at what i call its seams. and by that i mean the content was relatively easy for me to write. the the fact -- the the stitch thing finish it was the stitching together of the content. so in other words, how does one go from 1994 back to 2000 b.c. and then move forward to 500

a.d.? what are the seams, how does it fit together? sometimes that tipping is very tenuous -- stitching is very tenuous. so, in fact, the real discipline in this book, in this particular book was that sipping. how does one manage? and the answer to that is that i tried to imagine a very confident reader. i mid to say to -- tried to say to myself the kind of person who will go through my book is the kind of person i trust to move through those seams, and i will rise to the book, and they will rise to read it, and i'm not going to make some kind of compromise about it. and people who read the book, the science gets pretty dense. you know, i didn't spare the most contemporary details. i mean, we talk about, we talk about cancer genomics from 2008. so it gets really complicated. but, again, the book lives in its seams.

so those were the features that allows me to to be, you know, to write. one last comment, and that is that lot of people have asked me me -- i've been asked to rival, a friend, and so i learned to write from people who have written about medicine before me. so there was a learning process reading a lot of reading, and that raises the question -- it was a very interesting question to me, personally -- which is, was there something about indian many this book? in this particular book? the fact is that also happen to be from the subcontinent. i spent a lot of time thinking about it. and my answer to the question is i think, i think the most important thing about being indian and writing this book was

the fact that india gave me the freedom to not to i write about india. and in doing so allowed me to write about something that was entirely universal, had nothing to do finish it was almost as if i inherited a kind of writing tradition which hows me to not have to -- which allowed me to not have to write about the culture of a subcontinent but about something you and i can have a conversation about. and that freedom was important to e me politically, i'm not sure i can con vain how deeply that was -- convey how deeply that was influential to me. i thank, actually, i thank being in america for that. i also thank the political freedoms of my country. countries. yes. maybe i'll take a last couple of questions. last question maybe. two questions, yes.

>> in recent years there's been a lot of research, and it's been links to -- [inaudible] of cancer, and i was wondering why you didn't include it in your book, and do you think any fair piece will come out of this research to fight cancersome. >> this question goes back to the question of what was included and what was not included in the book. in general, i included things that have led to human therapies. i moyed to avoid finish -- tried to avoid -- o so in other words, if you really trace back everything that's in the book, whatever goes into the book really ends up in a human being somehow. perception comes out of a certain genetic understanding of cancer and becomes the drug. preventative mechanism, etc. things like an understanding of me tsa that sis, things like the

immune system, i think, are very important in the understanding of the fundamental biology of cappser but did not meet that sniff test of being able to transform into something that will impact the way we treat or deal with preventive mechanisms of cancer. when they do so, i'll be forced to write an addendum to this book. and the last question. >> when my uncle had leukemia, they told hip at johns hopkinss university that they'd done everything they could and beyond this it was something greater. how much do you think, like, either positive mental attitude or belief in some sort of spiritual thing play a role in curing -- plays a role in curing cancer, and what is your experience in all the patients that you saw? >> right. it's good that we're going to end with that question because i'm going to give a relatively provocative answer. my answer to that is i try not

to believe that the psyche has a role in causing cancer for the following reason: because i think it victimizes cancer patients. so when people say, oh, you know, there's a link between the psyche and cancer, i think it's precisely the kind of link that hands to a cancer patient whose plate is already full twice the burden of the disease. so i try to shy away from that thinking because it feels to me very negative in some ways. i know people who have had intensely positive attitudes about life, and i know plenty of people who are unbelievably depressed or have all sorts of mental illnesses who have lived perfectly healthy cancer-free lives. so this idea that the psyche causes cancer is, to me, i have a kind of allergy to this idea. now, that said, do i believe that the psyche modifies one's ability to heal?

>> yes. but there's no ark teach typal -- archetypal psyche. for someone dealing with their illness might involve entering a space that's filled with degree and depression. that might be their americaism and to force my understanding of whatever specialty is, formy understanding of what a positive attitude is, again, ends up victimizing a patient. who am i to say what your positive attitude is? you might decide you have an intense feeling of grief around your illness, right? that's your mechanism of healing. i can try to help -- i try to help people when that grief takes what i would call a kind of pathological form. but even then i try to be kind of -- i try to step back from it. and i particularly am allergic to this idea, oh, the reason

you're not getting better is because you're not thug positively enough. there are so many self-help books about cancer that say that, you know? you're not fighting hard enough. and i think i'm very allergic to that. i start off my conversation saying i'm not going to cothere. if that's where you want to be, that's your decision as a patient. i vice president that decision, but for me to say that as a doctor creates a cycle of blame that i want to avoid. thank you. [applause] >> aide around that music -- to find out more vis