wondering wait a second. if fula cassette is required to make normal blood growth, could it be that if you block folic acid you could block the growth of mulliken and blood which is leukemia? if folic acid is a factor, key factor, could one take an anti-inflation and block the growth of leukemic and so he began to fantasize about that and this was the drug that was discovered during the process of finding folic he found its opposite, and so farber wrote to him in new york and he began to inject -- farber began to inject children with these and demonstrate for one of the first times in history that emission in childhood classic beauty and invented chemotherapy. ..

>> and so then this is about page 60, i said, have no idea who this child is and i'm on page 60 and i can't find the first patient or first few of the patients with leukemia the only thing i knew about this child was that he was the years old, and that he had lived in boston, and his initials were rs, because that was all that was in the paper.

and so i began -- i was in boston. i sent out e-mail0s on list serves which said issue if you happen to know a child called rs with leukemia in the 1940s, please right to me. and months peace -- passed by, and no response whatsoever. and i kept saying, i'm on page 60. this book is going to get written. then i got rejected, and i thought -- i went on a vacation to my parents' house in india, and someone said to me, the chemist -- only one biographyer, and someone said to me, well, he lives three blocks away from my parents' house in india. so he said to talk to him. so i said, final. so i went and talked to him, and we're having a conversation and we talked for an hour about

chemistry, and et cetera, et cetera, and he said, was in boston in 1950, visiting a clinic in order to compile this biography, and i have a roster of all his patients with leukemia. and this was -- i was -- a stunning moment for me. and out of this came a series of patients' names and pictures, and that how i found robert sandler, this missing child. and in fact the boston sunday herald printed a picture of him in 1948 when he had just begun to respond to chemotherapy. this was an historic moment for medicine. but it's not searchable. at it not indexed. so i never would have discovered him. so his became a metaphor for the

writing of the book, which is that you might look for something and yet in reality you might find it's 6,000 miles away. the second metaphor was that things always come around. there's a circularity to hoyt, and i came back to boston, now armed with the name of this child, and then using the medical records and using the boston directories address book, i could find the parents' name, and then the death records, which are publicly accessible, i could find exact time he had died, where he died, where he had been buried, et cetera, et cetera. and all of a sudden the story that had vanished came alive for me, and that's how -- again, that how this book got written. so the first package is -- now

that i have given you the behind the scenes look. now the in front of the scenes look and now that i have done this legwork and found this child, how then you can construct a story, because, again, piece-by-piece, for me, all started coming together. so here's a section in which i now reconstruct the story of the child, having visited his house. seven miles south of the long wood hospital in boston, the don't of dorchester, is a typical sprawling new england some suburb between the industrial settlements to the west and the bays of the atlantic to the east. in the 19040s, irish member immigrants settled, occupying rows of houses that snaked up the avenue. part of the writing of the sentence was, now i could go

back into the hoyt of dorchester and read about the history and reconstruction, and it turns out robert sandler's father was a ship-builder so now he is linked in with the history of dorchester. it has parks parks parks and pln the river. on sunday afternoon families converged to walk or go to the zoo. a small note here, which is when i was writing all of this, i kept -- i went to robert sandler has house and i looked at where he lived, but looking out, it looks into the park, which part of it was the zoo, and i kept thinking to myself, if i was three-year-old child, what would i remember most about the zoo? i had a three-year-old daughter, and i thought, it would have to

be the animals. so it took only a couple readings to determine there were ostriches, and, again, history, so circular. i was doing one of these readings in seattle, and someone came to me and said how do you know there were out stretches -s in the zoos. and somewhere in the back of my cabinet was an article about the fact there had been ostriches at that zoo. in' 1947 in the house across from the zoo a child fell mysteriously ill with a fever that waxed and waned. robert sandler was two years old, his twin -- he had a twin, elliott -- was an active toddler in perfect health. truth being stranger than fiction, we talk in the book how

keane are activated or inactivated to start canner sir, and if you want to find a role of carcinogens and there can sometimes be a family history, we would choose two identical twins and one would develop cancer and the other one would not, and that would allow you to enter the biology, and i didn't ask for this, and there is a twin, the family has a twin, and therefore sets up the capacity for this discussion to happen down the road about the idea, what does a twin mean in terms of genetics and cancer. >> then we enter the other paper and give us a remainder how dense medical writing can be, but there's the story of human beings being told, and wherever doctors exchange clinical

papers, what they're really exchanging are stories. stories dressed up in technical language but ultimately they're exchanging stories and i'm literally restating the paper. ten days after his first fever, robert's condition worsened, his temperature climbed higher. his complexion was turned to white. his spleen was visibly enlarged. a drop of blood under a microscope revealed the identity of his illness. chromosomes condensing and uncondensing in tiny clenched and unclenched fists. sandler arrived at the hospital. andin' 1947 he was injected with paa.

content to run a trial for a drug, a toxic drug, was not required. parents are occasionally informed about a child, but children are almost never informed or consultants. the rules were set out with a consent code. the drug had little effect. sandler developed a limp, from the leukemia pressing on his spinal cord, and the leukemia burred through a bone, causing a fracture and an intense, indescribable pain win. december the case seemed hopeless. he was withdrawn, listless,

swollen and pale, on the verge of death. on september 28th, they received a new medicine, a chemical with a small range from paa. they began to inject the boy with it, hoping at beast for a minor improvement in his cancer. but the man's was marked. the white cell count which had been climbing astro -- astronomically, started to drop. the blasts flickering out and then disappearing. but new year's eve, the count dropped to one-sixth of its peak value, bottoming out at nearly a notable level. the cancer hadn't vanished. but it temporarily abated into a stalemate in the frozen boston

winter. in january he returned to the clinic walking on his own, and his clothes had become loose around his clothes. a little observation in the paper. and he says, robert's clothes have become loose around the abdomen. what an an -- an amazing choice of simple words that is this chd had become so swollen, his mother had to make new clothes, and now the cancer was receding. you don't require a medical paper to reconstruct a story that is so vivid. his appetite was immense.

and he and his twin seemed identical again. like all stories, this one also has an epilogue, and the epilogue is even more amazing than the story itself. ten days after the book was published, i got a phone call from my editor. she says i -- you need to sit down. i was writing a grant on my computer, and i sat down, and it was elliott sandler on the phone, and he had walked into a book store, never having known about this book, remembering the story of his twin, who had died at three years old, and people who have the copy of the book know that the book opens with, to robert sandler, number 1945-1948, and to those who came before and after him. he opened the book -- he lived in maine. i never would have found him. he opened the book, and he saw

his brother's name, this brother that had vanished from his life at three years old and was actually moved to tears then. and he went back and told me this amazing story, which is his mother, helen, whose picture is in the book because i found her picture from the "saturday evening post --" hell men and robert and elot and the whole family was jewish, and this is a time when -- well, still remains -- that she was a deep believer, and as many of you might know, opening a body, performing an autopsy after a death, is considered a violation of sanctity, and helen didn't want her child to be autopsies, but farver begged her to let him

open robert's body and perform a normal autopsy. and she refused. and finally he really begged her forks the sake of medical science, let me open this body up. and she said, fine do it. and she said there are do you elliott she told me this decision haunted already for decades. for decade she would think it was the wrong decision. so the finest praise i got for my book from helen sandler that the book brought her story to a close, and robert sandler found a rightful place in medical history and he decade-long haunted memory came to an end. and that was finer praise than any i have received, and perhaps the most moving thing that happened to me around the book. i think i have time for one more passage i'm going to read, and this from the end of the book.

and which takes up a very different kind of challenge. the first kind of challenge i described to you is the challenge of storymaking, which is how you pop late a book. so at it the challenge that appears in the content. a book like this also faces a different kind of challenge and that's the challenge of summary-making, which is how do you summarize 4,000 years of history. how does one tie up all of this? the quick answer is, there is no simple solution, and that's something you learn in the book. one of the challenges of the book is, is there no pat answer. i didn't want to write a book, this is how you cure cancer, like eat broccoli or some nonsense like that. so here i take up the challenge by performing a thought experiment. and i recount the story -- earlier in the book i recount

the story about a persian queen who is described in no less than about four lines, and becomes one of the earliest descriptions of what might have been breast cancer. we don't have a word for cancer in this time in writing history, it's the description of the early history of the west, focusing on greece -- sends a little message in two or three lines. he describes the idea that the queen of persia developed a ma leg nancy, a pass in her breast, and her response, intensely contemporary proas. she was so ashamed of it, she hid herself in her shame. and she wouldn't let anyone

examine her breast until a greek slave intervened and promised to cure her, and he does cure her, and he probably does so by performing what -- one of the first recorded lumpectomies. she is very grateful, and as a return favor, she tells him she will persuade her husband, the king of persia, who is invading the eastern border of persia -- she will persuade him to invade the western border of persia towards greece so that he can return back to his native greece. and this launches the greco-persian war. so here's this woman -- i'm literally quoting from history, the moment in history when the face of persia turns from the eastern face to the western face because of this illness that she

had. this launches the early hoyt -- earl -- early history of persia, and its turning to the western border. so we now, 500 pages later, return back. recall the persian queen, who likely had breast cancer. and imagine her traveling through time. she is cancer's dorian gray. her tumor remains the same. the case allows us to recap puttpit ulate. what happens to her later. firs, toss is backwardses to

2,500bc. a name for the illness that we cannot pronounce. it provides a diagnosis but know treatment. and then it's described the most primitive form of mastectomy. and later it's identified as a c rcinos and that's the derivation of the name cancer. they imagine cancer as a crab buried under the skin and the blood vessels spread out like a crab under the skin. and a thousand years flash buy, otosss' tumor keeps growing, and surgeons understand little about

the disease but chisel away with knives knives and scapels and other chemicals. in 1778, her canner is assigned a stage, early localized breast cancer. for the early localized breast cancer, hunter recommends an operation. >> when she reemerges in the 1970, she encounters a new word in history. her breast cancer is treated with the boldest and most definitive therapy, radical mastectomy and rue -- removal of the lymph nodes, in the early 20th century -- it's essentially a failure.

it takes 90 years before patient doctors can convince themes to put the idea of radical breast surgery to test, and when it's put to test 90 years later, 500,000 people treated later, turns out to be no different than the nonradical surgery. in then radiologist trying to use local x-rays, and in the 1950s, they learned to combine the strategies, tempered by moderation. the cancer is treated locally by a lumpectomy followed by radiation. and then the surgery followed by chemotherapy to diminish the chance of a relapse. the tumor tests positive for the estrogen receptor, to prevent a relapse in 1986 the tumor is discovered to by amplified, and

she is treated with targeted therapy. it is impossible to enumerate the precise impact of these interventions. the shifting landscape of trials does not allow for the therapies. but they have add 17 and 30 years to her life. in the mid-1990s, the management of breast cancer takes another turn. diagnosis at an early image and whether she carries the mutation. they enter an intensive screening program. her doctors are also tested. found positive for bsa1.

they're offered different therapies. for her doctors, the impact of screening and prophylactic might be dramatic. the other daughter might choose to undergo prophylactic mastectomy. and might live out her life free of cancer. and each one of those comes from a seminal trial. basically an oncologyist would know, it refers back to clinical trials that proves or disproves the management of the positive or neglect breast cancer, but that's what i hope in a way that's understandable and some humanized. move into the future now, in

2050, arrive with a thumb size, flash drive with her genome, and the mutations might be organized, and algorithm identifies the contributions to the growth and survival of cancer. therapies midnight might be targeted to prevent a relapse. she might begin with one combination of targeted drugs, switch to a second cocktail, and switch again when the cancer mutate again. she would likely take another medication. this is progress, but before we become too dazzled. it's worthwhile to put it in privilege. if she develops gallbladder surgery that is not amenable to

surgery, survival changes only marginally over centuries. even breast cancer as a different outcome. her chance or survive would have barclay hanged since the time of the hundred her clinic. and her life span might have increased. part of the unpredictability about cancer in the future is we do not know the biological basis. we cannot fathom what pan careerattic -- -- we might as well focus on prolonging life rather than eliminating death and this war of cancer might

best be won by identifying victory. so that the passage. is there time for one last passage or should we wrap up? i'm going to read the very last passage in the book, a very short passage, and i think it's the final summary of the book. >> this passage is -- was actually the hardest for me to write and goes back to the question about why i had written this book. and its written in answer to a question from a woman, and we return to the story of the woman. this is an incredible woman who i treated while a fellow in boston, and she had had an abdominal sarcoma and had relapsed and had another

remission -- another relapse. incredible remission caused by what was then a new drug called gleevec. striking remission, and she had an unbelievable character -- she was a psychologist and she had followed the trail of this drug throughout the country, moving from one clinic to the next, creating list serve, creating her own community everytime around herself and she would engage this community and ask questions and then pull herself into the trials. she had -- there was -- at one point she was receiving chemotherapy using one of this drugs while living in a trailer home. she found herself homes like this. and then she would move on to the next one. almost like she was creating her own trail 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 any of the newest forms of therapy. so, this is my -- the last time i see her. i'll pick up the story. the new drug produced only a temporary response but did not work very long. by february 2005, her cancer spiraled out of control, growing so fast she could record it gain in pounds by standing on the scales. eventually her pain made it impossible for her to walk from the bed to the door. so she was hospitalized. as -- when i entered her room, she cut me off. her goals were now simple. no more trials or drugs. the six years of survival she had eeked out between 1999 and 2005 had not been static frozen years. they had sharpened, clarified

her and cleanse her. she separated her relationship with her husband and her daughter, a teenagerrin' 1999 and now a mature sophomore at a boston college, had grown into her ally, her confident. cancer makes some families or breaks them. she wanted to go back to alabama to her own home to die the death she expected in 1999. when i recall that final conversation with germane, embarrassingly enough, the objects seemed to stand out more vividly than the word. the hospital room, the unflattering overhead lights, a wooden side table on wheels piled with some various thing's. a standard issue hospital pitcher filled with flowers on the table by her side. she was sitting by in the bed,

one leg dangling casually down, wearing her usual interesting combination of clothes and her hair was carefully arranged. she looked formal, frozen, and perfect, like a photograph of one in a hospital waiting to die. she seemed content. she laughed and joked. she made wearing a naso-gastric tube look did he dignified. but the objects seemed like symbols and she seemed like an actor playing a part. nothing i realized was incidental. the characterricses of her personality that had once seem spontaneous in fact calculated ...

>> her casualness was studied, her jokes were rehearsed. her illness had tried to humiliate her. it had sentenced her to die an unsightly death in a hospital room thousands of miles from home, and she had responded with a vengeance moving always trying to outwit it. it was like watching someone locked in a chess game. every time jermaine's disease moved, imposing a terrifying restraint on her, she made a move in return. the illness acted, and he

reacted. it was a game that had taken over her life. she dodged one blow only to be caught by another. she, too, was like carroll's red queen, pedaling furiously just to stay in one place. to keep pace with this malady, you need to keep inventing and reinventing, learning and unlearning strategies. jermaine fought cancer obsessively, desperately, madly, brilliantly and zealously channeling all the fierce, inventive energy of generations of men and women who had fought cancer in the past and would fight it in the future. her quest had taken her on a strange and limitless journey through internet blogs, hospitals, chemotherapy and clinical trials halfway throughout the country. she had deployed every last morsel of her energy to bequest mobilizing and remobilizing the

dregses of her courage, summoning her wit and will until that final evening she had stared into the vault of her resourcefulness and found it empty. in that haunted last night, hanging on to her life, summoning all her strength and dignity, it was as if she'd encapsulated the essence of a 4,000-year-old war. june 2010. thank you. [applause] >> hi. siddhartha is going to take questions now. i'm going to be bringing around a microphone so, please, don't start your question until you have the microphone. also because this is being filmed for tv, for privacy reasons, pleads, don't ask any -- please, don't ask any personal questions. thanks. >> i mean, we mean personal medical questions.

you can ask questions about me. [laughter] i, also, actually, i'd start, if i may, by asking john a question, and that is, john, tell us a little bit about how, what's happening at the national cancer institute. you've come here from washington. tell us a little bit about what's happening in terms of this new administration and this sort of sputnik comment and what you imagine will be happening in this administration with respect to cancer. >> thank you. excellent question. i first wanted to comment, i was most impressed by your eloquence and your ability to communicate. i really think that by being 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 battlefields. one lesson i learned at ucsf very often it's the medical

students, the youngest trainees who can the most provocative questions. and who move the field of medicine forward. and i really wanted to congratulate you. really i was most impressed during your discussion of serendipity, and i really hope that there may be the 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. there 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, clinical 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 from the entire world, and it appears that the commitment of the obama administration to discovery, to innovation will continue. so i think that for cancer patients all around the country and the world that there are many great things yet to come from that institutionment -- institution. >> and what are the battles? who's fighting what? >> the battles are political. >> yeah. >> and they're 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 defund, disallow, repeal or to change the legislation that was passed last year. et really is my -- it really is

my hope that we can be constructive and to move above the act ri moanny 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. >> thank you. i think that's absolutely vital. sorry. yes, questions. >> hi, i'm dr. jordan wilbur, an old-time pediatric encologist. i wanted to make a comment. you write a fantastic book, and i knew personally most of the people -- [inaudible] and you have them right on. >> thank you. >> right on. >> thank you so much. >> thank you very much. >> you know, one of the things, again, for the constraints, because of the constraints of time, to draw katherine in a

book like this, one of the ways you really rely on lots of primary interviews aside from the archival research, a lot of primary interviews. and, you know, i think there are about 4 or 500 interviews that went into the book carried out over time. and even, for instance, painting a picture of sidney farber was to come at him from different angles. what's important is human beings are complex. even a character like farber, a lot of people didn't like him. he was an unpleasant character to some, and that's important to convey because otherwise you begin to write a history that's 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 war. 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, when we -- sometimes we fight wars between people and 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 it works. for some people really imagining us in a battle against cancer is important. and my usual approach to all of this is if that's a metaphor that works for you, use it.

[laughter] 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 in this more abstract, abstract war. and there are other wars that are also being fought right now against more abstract entity, political wars. and part of that is also part of this book, 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 cancer whether it be war or not, if we are to engage cancer, the solution can't just be a scientific solution. it will never be a scientific solution. there will have to be a political solution, a cultural solution, and all of this comes into the book. eradicating tobacco is not, you know, one doesn't require a scientific solution. one requires a political and cultural solution. you know, solving the genome of

pancreatic cancer is completely different but requires another kind of strategic element. so every piece of us, every piece of us as society and human beings is somehow engaged in this, and everyone can contribute, i think. >> you seem to be speaking primarily of cures of cancer, and i'm wondering about prevention because there seems to be an increasing amount of research going on. vitamin d is a popular issue right now. could either one of you comment on your outlook toward the preventive efforts that are being made and any optimism there? >> well, yeah, i have several comments about that. incidentally, there's a large section of the book that deals with prevention, so let there be 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

curative battle began to fade away and people began to really, the research was focused on prevention. that continues today. my thoughts about prevention are many. i'm not going to talk about them at great length. i'm going to make two comments. one comment is that it remains shocking to me that the most preventable carcinogen is still at large. here we are fighting this complicated battle on the hill about how to do this, that or the other about health care costs. meanwhile, the largest known carcinogen, you know, there's a great irony in all of this. people come and talk to me about radon or, you know, some known carcinogens, fully acknowledged carcinogens, but 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 me, very interesting is that 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 prevention lived in one compartment and treatment lived in one compartment and others lived in a separate compartment. but that's not the case anymore. i'll give you one example. here's a drug that was really created to, originally, to treat advanced stage er-positive breast cancer, but it turns out to have a role in prevention. you can use to mock sin as a prevention appropriately identified, appropriately 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 genomics, the understanding of the cancer genome has a role in prevention, particularly on breast cancer. so there is a way in which the new molecular boig -- biology of cancer is forcing us to think about these silos in a way that just doesn't relegate prevention to one end of the spectrum and treatment to the other end of the spectrum this and this fusion has been happening for a while and is 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. as surgeons we burn them, froze them, used ultra sounds, we've cut them apart and made vaccines. if we can catch them early enough, we can cure them. to me, it's the question about

the prevention of recurrence and what we haven't solved. you can have a tiny tumor, and you can remove it in its entirety, but months or years later you'll discover that it's spread all throughout the body. and conversely, i've seen the largest tumors that you remove surgically, and they never recur. and so the fundamental next step from the surgical perspective is the prevention of metastasis and recurrence. >> viruses and bacteria evolve, and so, therefore, the war against them is never other, it's -- over, it's always a temporary victory for decades. do cancers evolve with your 5,000-year look? >> well, cancers evolve in a more microscopic sense. in other words, cancers are evolving inside the body of the human being that cancer is in. so in other words, within every,

within every tumor there is kind of a 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 all the -- 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 what, this in fact, that is part of the secret of how unbelievably successful cancer cells are in many invading because -- in invading because every time it's a kind of, again, we come back to this 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 much like treating 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 directions i was going to take. but the reality of it is at the time when it happens 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 comment 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. and it's, 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 forgotten that listening skill. i hope that doesn't, i hope that we have a way to keep that in medicine. did you have any idea? the i mean, how does one -- >> well, my thought was i didn't feel that my doctor wasn't listening to me. i felt like i have not been someone who studied cancer my entire life. i know people who had it, but i knew very little about it. to really get to the level where i could ask a question and

really make some definitive decisions, i would have had to have moved so fast i would have, you know, had to be reading up on everything. so when it gets right down to it, i trust, 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 this is -- i mean, 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, of the patient's wishes, but on the other hand, doesn't make you feel as if it's your job to be the expert, you know? this once it becomes your job to become the expert, in some sense the process has defeated itself. there is a reason behind the,

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 in my personal practice, ironically, i find that patients become more confident when you tell them that you don't know something. it's a peculiar irony. as opposed to saying you know something. it's a peculiar irony of medicine. of course, much like readers can detect a false note in a book in one and a half nanoseconds, patients can detect false confidence in doctors in one and a half nanoseconds. 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, there's a restoration of faith. and, again, this is as it relates to my practice. a 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 you be the guide for that information. i think in some way that unburdens or 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 and directions. so that's my strategy. again, i think it involves the kind of active listening which i think is very hard to do in these times. >> i've learned that web research is the kiss of death. >> i know. [laughter] it is the kiss of death, i

think. >> in 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 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 actually 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 and, in fact, our testing mechanisms are improving. we used to perform a very primitive way of testing for car sin no generallic agents relying on the fact that these chemicals cause mutations. not all cause mutations in

bacteria. it's an important test, in fact, developed at berkeley, but it's a very primitive test. we have much better with 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 carcinogens are. it's a little bit like saying, you know, the water is carcinogenic. well, that's okay, but i have to drink the water. or someone says the air is producing cancer. but i have to breathe the air. you have to tell me in 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 these kinds of claims. what is the chemical?

how can we remove it? what role does it play in normal lives, you know? and then remove them from our environment. >> i had a question similar to that. >> sorry. >> was i supposed to the start now, or am i supposed to wait? [laughter] i have a bit of education which always makes a person dangerous. 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 live anything a clean room -- live anything a clean room all your life really won't cure. and i'm sure these are different things like smoking we do know

the answer. but excluding lung cancer, is there a percentage that are just natural mutations 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, i mean, 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 many this a very common form of like, let's say

breast 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. this was a large risk, but it takes a sophisticated kind of study to figure it out. so the quick answer to your question is, unfortunately, i'm not sure we're there yet in terms of technology, 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 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, or unnecessary? >> i certainly hope so. [laughter] well, i mean, there are many examples. actually, i talk about these. i mean, one of the things in the 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 up in a sunny place. in fact, there are very dark histories and stories in this book, and many of the dark stories have to do with the way

medicine becomes a self-fulfilling prophesy or learns to believe in itself. radical mastectomy is one of them that, believe it or not -- back to rest cancer -- in the 1980s there was a strong sentiment that many researchers believed that giving radical chemotherapy would cure breast cancer and so radical that, in fact, you'd wipe out your bone marrow and have to replace it with your own bone marrow that had been frozen away, a transplantation for breast cancer. and it took another decade to disprove that. and part of the reason was that patients department want to enroll -- didn't want to enroll themselves in the trials. so patients had become so convinced that, by their doctors, they'd become so convinced this was the right thing to do that no one wanted to be randomize today the placebo arm of this trial. and the doctors said to them we believe this works, and you believe this works, so why go