>> she said now that robert sandler has found a place, a rightful place in history, it was as if her decade-long haunted memory had come to an end. i think that's in some ways finer praise then any that i have personally received. i think i have time for one more passage that i'm going to read, and this is from the end of the book in which takes up a very different kind of challenge. the first kind of challenge that i described to you is the challenge of storing making which is how do you populate a book. the challenge that appears in the content. a book like this also faces a very 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, how does one tie up all of this? the quick answer is there is no

simple solution. that's something you learn in the book. one of the challenges of this book is there's no path answer. i did not want to write a book where i said this is how you cure cancer. or nonsense like that. and so here i take up that challenge by actually performing an experiment. and i recount the story earlier 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. again, we don't have a word for cancer in this time. it's the description of the early history of the west focusing on greece. since a little bit of a message, about two or three lines that he describes his idea that the queen of persia developed a

malignancy, a swelling in her breast, a mass in her breast and some people have translated it. and her response, intensely contemporary prose, her response was she was so ashamed of it that she hid herself in her shame. remember, 1950 and fannie calling of "the new york times." she hid herself in her shame and she would let anyone examine her breast. until a greek slave intervened and promises to cure her, and he does care. and he probably does so by performing one of the first recorded mastectomies or lumpectomy's of breast cancer. atossa 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 in

towards greece so that he can return back to his native greece. and in doing so this launch is the greco persian war figures this woman, and i should quote him, literally quoting from history. this is the moment in the history when the faith of persia as a work turns from eastern phase to the western face because of this illness that atossa has. he dedicates 455 but, of course, this launch is the early history of the west, the greco persian war and 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 greco persian wars. so we now, 500 pages later, return back, recalled atossa, the persian queen, who likely had breast cancer 500 b.c.

imagined traveling through time, appearing and reappearing in one h. after the next. as she moves to the arc of history, her tumor frozen in stage and behavior remains the same. atossa's case allows us to consider its future. how has your treatment and prognosis shifted in the last 4000 years and what happens to atossa later in the new millennium? first, there's a name for her illness, a hieroglyph we cannot pronounce pick up about the diagnosis and there is no treatment, he says, closing the case. in 500 b.c. in her own quart atossa self prescribes a primitive form of mastectomy was performed by her greek slave. 200 years later, it was identified the tumor as getting her illness and name. autocracies imagine cancer as a

crab buried under the skin and the blood vessels spread out like the legs of a crab under the sand. rife in this moment of inception cancer is a metaphorical disease. the metaphorical ideas of cancer permit this illness. 1000 years flashed by. the tumor keeps growing, relapsing, invading and metastasizing. medieval surgeons understand little about the disease but the chisel away with knives and scalpels some offer -- these are real documents drawn from historical test. frog legs, holding water, grab pace, tim nichols as treatment. in 1778 and john hundreds london, her cancer is assigned a stage, early localized breast cancer or late. for the former, hunter recommends a local operation. and for the latter here recommends remote sympathy.

when atossa reemerges in 19th century she encounters a new world of surgery. in 1890 atossa's breast cancer is treated with the most boldest therapy so far. radical mastectomy. in early 20 century, by the way, that treatment i go to the story of that in the book, turns out to be an essentially afghani. it takes 90 years, 90 years before patients and doctors began to convince himself to really put the idea of radical breast surgery to test. when it is put to test that years after its invention, 500,000 women treated with it later, it turns out to be no different am not radical surgery. in the early 20 century they tried to obliterate the tumor using local x-rays. they learn to combine the two strategies also tempered by moderation. atossa's cancer stricken locally with a simple mastectomy or love

acme followed by radiation. in the 1970s new therapeutics strategies emerge. her tumor tests positive soaking wet recapitulating this in the book. in 1986 her tumor is further discovered to be too amplified. she is treated with targeted therapy. it is impossible to emulate the precise impact of these interventions. the shifting landscape of trials allow direct comparison to atossa's state until fate in five and a pc. but -- diagnosed at 40, say, atossa can reasonably be expected to celebrate her 60th birthday.

in the 1990s the management of atossa's askance it takes an aggressive turn to her diagnosis at an early age and ancestry, there's a question of whether she carries a mutation. atossa's genome is sequenced and, indeed, indication establishing interest and intent to screen program to take the appearance of the tumor and unaffected breast. her two daughters are also tested, i'm positive, there offered either intensive screening or tamoxifen to prevent the development of breast cancer. for her daughters the impact of screen might be dramatic. a breast mri might identify a small lump in one daughter, it might be found to be breast cancer and surgically removed in early pre-invasive stage. the other daughter might choose to undergo prophylactic bilateral mastectomy, having excised her breast preemptively she might live out her life. incidentally, each one of the senses corresponds to a similar clinical trial.

basically as an oncologist would know, it refers back to very major single group of trials that proves or disproves a particular point of management of breast cancer. but that's why hope in a way understandable and somewhat humanized. moving to the future now, in 2050, atossa will arise at her clinic with thumb sized containing the full sequence of her cancer genome. the mutations might be organized into key areas. therapies might be targeted to prevent a relapse of the tumor after surgery. she might begin with one culmination of targeted drugs, expect to switch to a second cocktail with a cancer mutate and switch again when the cancer mutates again. she will likely take some form

of medicine for the rest of her life. this is progress. but before become too dazzled by atossa survival is worthwhile to take it into perspective. if atossa's pancreatic cancer in 500 b.c. and prognosis is unlikely to change by more than a few months and 2500 years. if atossa develops gallbladder cancer, that is a matter of three, her survivor -- survival changes only marginally. if atossa student had metastasized bar was too negative, i responded to stand chemotherapy, then her chances of survival would have buried -- terry kain since the time of hunter's clinic. part of the unpredictability of the trajectory of cancer in the future is that we do not know the biological bases.

we cannot yet fathom for instance, what makes pancetta cancer so markedly different from cml, or atossa's breast cancer. what is certain, however, is that even the knowledge of canceled biology is unlikely to eradicate cancer fully from our life. as richard suggests and has atossa epitomizes, we might as we'll focus on prolonging life and eliminating death. so that's the 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 it's 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 talk about why i had written this book. it was written as an answer to a question that a woman had raised, and so we return to the story of that woman. this is an incredible woman who i treated while a fellow in boston. she had had an abdominal sarcoma and had relapsed and had another emission, another relapse, another remission. incredible remissions by the way caused by what was then a new drug called -- striking remission. she had come was an unbelievable character pictures as a coach as yet essentially followed the trail of this drug throughout the country moving from one click to the next clinic and will result in clinical trials, creating list, creating her own community every direct result of shrinkage is commute and ask

questions and then pulled herself into the trials. she had at one point in time she was a -- using one of these drugs while living in a trailer home. she found herself homes like this and should move onto the next one. it was almost like she's great her own little trail all around the country. unbelievable person. and then finally she had had her last response and then her tumor became completely resistant and would not respond to even the newest forms of therapy. so, so this is the last time i see her. so i will pick up the story. the new drug, this is the last time she took him produce a temporary response that didn't work for very long. by february 2005, her cancer spiral out of control growing so fast that she did record its weight in pounds as she stood on the scales every week. even her pink eventually to think that it impossible for her to walk, even from her bed to the door and she had to be

hospitalized. my meeting with her that he was not to discuss drug to do but try to make an honest translation between her and her medical condition. as usual she had beaten me to it. when it entered her room to talk about the next steps, she waved her hand and cut me off. her goals when a simple. no more trials, no more drugs. to six years of survival that she ge capital in 1999-2005 had not been static frozen years. they had clinched a. should sever relationship with her husband and intensified her bond with her brother and oncologist. her daughter, teenager in 1999, and now a sophomore at boston college had grown into her ally, a confidant, her sometimes nurse and her closest friend. catch a break some families and makes him, she said. in my case it did both. she realized her life it come to an end. she want to go back to alabama to die the death she expected in 1999. when i recalled a conversation

with her am embarrassingly enough, the object seemed to stand at more vividly than the words. a hospital room with sharp smell of disinfectant and hand soap, the unflattering overhead lights, a wooden sidetable. a standard issue plastic hospital picture by with a bunch of sunflowers perched on the table by her side. she was sitting by the bed one leg dangling casually down wearing her usual eccentric and interesting 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 the hospital waiting to die. she seemed intended she laughed and she joked. she made when a nasogastric tube seems effortless and dignified. only years later in writing this book i finally put into words why that meeting left me feeling so an easy and humble.

the gestures in that room seemed larger than life, an object seemed like symbols, and why she herself seem like an actor playing a part. nothing was incidental. the characteristics of her purse not that it was a spontaneous and in positive were in fact copulate and almost responsive to responses. her clothes were loose and vivid because they were decoys against the glowing outline of the tumor in her abdomen. her necklace was distractingly large size to the full attention away from her cancer. her room was topsy-turvy with bottles and pictures. the hospital room filled with cards. without that it would evolve into the anonymity of any of the room in any other hospital. she had tangled her leg and that precise angle because the two had invaded her spine and begun to paralyze her other leg making it impossible to sit any other other way. her casualness was studied. her jokes were rehearsed. her illness to try to humiliate

her and made her anonymous and seemingly humorless. she had responded with a vengeance. moving always to be one step ahead of trying to out wit it. it was like watching someone locked in a chess game. every time her disease moves come impose yet another terrifying constraint on her, she made an equally assertive move in return. illness acted and she reacted. it was a morbid have not again, again that it taken over her life. she dodged one blow only to be caught by another. she, too, was like the bread queen. she seemed that even to capture something essential about our struggle against cancer. that to keep pace with this malady need to keep inventing and reinventing, learning and unlearning strategies are she fought cancer obsessively, desperately, fiercely, madly, brilliantly and zealously.

and challenging all the energy of generations of men and women that fought cancer in the past and would fight any future. her quest for a caretaker on a strange and limitless journey through internet blogs in teaching hospitals, chemotherapy and clinical trials, halfway across the country to a landscape more desolate, desperate and disquieting anything she imagined her she deployed every last morsel of her energy to the quest, mobilizing and re-mobilizing her courage, summon her will and wit and imagination until the final evening she had stared in to the fault of her resourcefulness and found it empty. in that haunted last night, hang onto her life by no more than a tenuous thread, summoning all her strength and dignity as she willed herself to the privacy of her bathroom. it was issued and captured the essence of 4000 year old war. june, 2010. thank you. [applause]

>> hi. doctor will take questions do. i will be bring around a microphone so please don't start your question until you have a microphone. also, because this is being filmed for tv, for privacy reasons, please don't ask any personal questions. thanks. >> by personal, winning personal medical questions that you can ask questions about me. [laughter] actually, i would 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 cancers. you've come here from washington. 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.

an excellent question. i first wanted to, as most impressed by your eloquence and your ability to communicate. i think that by being able to educate the american and the world about cancer, it's really my hope that someone in the 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, very often it's the medical student, the youngest trainees ask the most provocative questions, and to 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 opportunity for someone here tonight to think of new answers, just like the slogan, think differently. there's a lot of excitement in washington, d.c., right now. there is a pitch battle to

either change or repeal the affordable care act, but one a 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 for the entire world. and it appears 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 yet to come from that institution. >> 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 -- there are many strategies, i would turn your attention an article from "the wall street journal" last year about the strategies to either defined, disallow, repeal or to change the legislation that was 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. spent i think it's absolutely vital. >> i'm doctor george wilber, old

time oncologist. what i want to do is make a comment. you write a fantastic book. [inaudible] you have them right on. >> thank you. >> thank you. 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 you, it relies on lots of primary interview. aside from the archival research, a lot of primary interviews. i think there are about four or 500 interviews that went into the book, carried on overtime. and difference in painting a picture of sidney farber, to do that, too, came from different angles. and what's important is that humans 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 is not real. thank you for your comments. >> 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 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 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 as in a battle against cancer is important. in my usual approach to all this is, if that's the 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 in this more abstract, abstract were. 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, how does one fight a political war, how does one create strategy which is not only scientific strategy because the one thing we know is if we are to engage

cancer, if we are to engage cancer, yeah, the solution can't just be a scientific solution. it will never be a scientific solution. it will have to be political solution, and all this comes into the book. eradicating tobacco is not, one does not require scientific solution. one requires a political and social solution. solving the genome of pancreatic cancer is completely different. it requires another kind of strategic element. so every piece of us, every piece of us as a society, every piece of us as human beings is somehow engage in this. >> you seem to be speaking primarily of terms of cancer but i'm wondering about prevention. there's an increasing amount of research going on. vitamin d is a big piker issue right now. i'm wondering and even what you

could comment on the outlook towards the preventive efforts are being made, and any optimism there? >> several comments about that. there's a large section in a book which deals with prevention. and, 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, nature begin to fade away and people begin to really, researchers is focus on prevention. that continues today. my thoughts and prevention army. 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 to this. people, talk to me about radon or, you know, some known carcinogen. it's a look-alike were not tied with 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, it seems that the silos of prevention and treatment and cancer biology are collapsing. in many different ways. i think that's very encouraging. we used to think that prevention, cancer prevention people we used to live in one compartment and cancer treatment people used to live in one compartment. and other live in a separate compartment, but that's not the case anymore. i'll give you one example.

tamoxifen is a very good example of the. is a drug that was really created, originally to treat advanced stage metastatic er positive breast cancer. but it turns out to have a role in prevention. you actually as tamoxifen as a kind of agent and the appropriate population, a properly identified appropriate focused, tools such as mammography which rendered as diagnostic tools to diagnose breast cancer can be used in the preventative setting. in fact, even the genomics, cancer genomics, the understanding of the cancer genome has an important preventative, as a role in preventing, particularly on breast cancer. so there is a way in which the 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 doesn't really get

prevention to one of the spectrum and treatment to the other end of the spectrum. it's very encouraging to me. any comments? >> i'm a surgeon, and we can cure cancer if we can catch it in time. as surgeons we burned them, froze them, use ultrasound, cut them apart and made vaccines. if we can catch them early enough, we can cure them. to me, it's the question is 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 discover it spread all throughout the body. and conversely i've seen the largest tumors being removed surgically and they never recur. and so the fundamental next step from the surgical perspective is the prevention of metastasis and returns. -- returns.

>> viruses and bacteria evolve, and so, therefore, the war against them is never over. so as a temporary victory, for decades, the cancers evolve with your 5000 euros? >> well, cancer evolves a more microscopic sense catches are evolving inside the body of the human being at the cancers and. so in other words, within every tumor there's a kind of darwinian battle that's going on, even without treatment. so within every tumor there are clones that are rolling 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, you might kill any of the cells, but there might be some cells that escape. and, therefore, will it evolve out of that. so cancer, and we talk about

this, is fundamentally a darwinian illness. and that is, in fact, part of the secret of how unbelievably successful cancer cells are. in invading because every time it's a kind, again, we come back to this metaphor, every time you're doing something, you are cells, the cancer cells are sort of pushing back, or shouldn't his labors like that, but cancer cells are evolving. and it's much like treating a disease, it's much like treating a bacterial illness, are much like treating a disease with viruses, 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 second made very clear it was patient oriented and that i would have a part to play in deciding what direction 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 to have any comments. >> my comment in general, that's an unfortunate situation. that's a situation that hope we'll find ourselves in increasing over time. 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 i have to say it's very tough. sometimes 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.

it's almost as if we've forgotten that listening skill. i hope that doesn't, i hope that we have a way to keep that in medicine. do you have any idea? >> my thought was i didn't feel that my doctor wasn't listening to me. i thought, like i have not been someone who studied cancer my entire life, i knew people who had, i knew very little bit 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 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 when i chose doctors that i trust. but i think as a patient, a patient has to pretty much out of control. >> i mean, that's fundamentally the case, right? it is the case that one feels out of control. you know, i think this is, i

really think this is the fundamental challenges of medicine. how does one involve the patient in a way that's respectful of the patient's wishes? but on the other hand, it doesn't make you feel, it's your job to be the expert. you know, once a because your job to be the expert, then in some sense the process has defeated itself. there is a reason behind someone to collate all the information. there's a huge amount of information. i think in some ways, i don't know the answer. i have to general strategies. one general strategy is ironically, 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, 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 have nanosecond. patients can detect false confidence in doctors in one and have nano seconds. and so ironically, the best way to approach, to build confidence, to be humble, or 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 related to my practice. a restoration to 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, will allow the process of getting to occur. you doing enough already. let me be the process the information, and you be the guide for the information. i think some ways that unburden

release patients. they'll have to be the person is the expert all the time. because no one is the expert, you know? i'm not the expert. i know more but i'm not expert in your choices. so that's my strategy. but again, i think it involves the active list in which i think is very hard to do in these times. >> yeah, i learned that web research is the kiss of death. [laughter] >> it is the kiss of death i think. >> do you think the vast quantities of chemicals that are being used in various processes are contributing to an increase in the incidence of cancer? >> it's a tough question. i think some chemicals may be contravening. but i think, but i think on the other hand one has to be careful about this idea of hyper carcinogenic 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 environment, need to be quite rigorously tested. in fact, our testing methods are included in we used to perform a very primitive way of testing for carcinogenic's agent that it relies on the fact that these chemicals cause mutation that not all carcinogens directed calls vacation. it's an important test developed at berkeley, but it's a very primitive test equipment better test for that. but with that said, i also disagree with this idea that, i thank him every chemical needs to be tested, is exactly the right thing to say. but i disagree with this idea that we have a generally more carcinogenic environment because when he defined what the precise carcinogens are bigoted little

bit like saying the water is carcinogenic. that's okay but have to drink the water. or summits is that there is causing cancer, but i have to breathe the air by catatonia very, very quantitative way, you have to come in a realistic sense that the dose that is available, this molecule in the air is causing cancer so i can remove that molecule. so let's be specific about these kind of claims. what is the chemical, how can we remove it, what role does it play in normal lives? and then remove them from our environment. >> i had a question similar to that. was i supposed to start that when exposed to wait? i have a bit of education which always makes a person dangerous. so my question, 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 running around, living in a clean them all your life really won't cure, and what percentage -- i'm sure these are different for each type of cancer, like smoking we do know the answer, but for excluding lung cancer, is there a sense of the percentage that are just natural mutations, either inherited or that comes with age, and which ones might be international carcinogenic oriented? >> so, that question, as you can imagine, is an extreme difficult question to answer. is answerable for rare cancers. there's an old adage in epidemiology which is the large

rare risk are much easier to assess that small common risks. so in other words, you know, if there's a sudden epidemic of liver cancer, which is associate with a particular toxin, 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 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. again, this risk was large enough to even register on epidemiological scale pics of 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 are there yet in terms of technology, in terms of figuring out what the small

common risks are. i suspect that for some cancers we will never be there because in the end, can one really determine whether this was a very small risk by a carcinogen or was this a natural mutation? for some cancers i think it will be very, very, very difficult. >> thank you for that fascinating talk and fascinating reading. 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 you came across in your research? and in particular, are there treatments that are part of standard therapy now that 10 years from now or 20 or 50 or 90, we will think of as ineffectual or unnecessary? >> i certainly hope so.

well and then, there many examples. i talk about these. one of the things in writing this book, and i know this was commented upon, was i also wanted to not write a so-called wiggy history in which progress needs to do more progress m1 seems up in a sunny place. to a very dark moment in his book and very dark stories in this book. many of the dark stories have to do with the way medicine becomes a self-fulfilling prophecy, or learned to believe in itself. believe it or not, back to breast cancer in the 1980s. there was a strong sentiment that many researchers believe that giving radical chemotherapy would cure breast cancer. and so radical that it would wipe out your bone marrow and have to replace it with your own bone marrow that had been frozen a way.

and it took another decade to disprove the. and part of the reason was that patients didn't want to enroll themselves in the trials. so patients have become so convinced by their doctors, they become so convinced this was right thing to do that no one to be randomized as a placebo for this arm of the. the doctor said we believe this works and deeply this work to why go through this randomization? in massachusetts, this would be interesting, massachusetts there was a law that was passed called charlottes law, which forbade an insurance company from not allowing a -- so in other words, because it was felt as if the insurance companies would skip, which they were doing, on breast cancer therapy, there was a law that was passed. basically breast cancer therapy mandated by law.

there are examples after examples. i'm sure this will repeat itse itself. >> the. [inaudible] >> you have to be loud. i can repeat your question. [inaudible] >> well, i mean, are you asking what ultimately causes prostate cancer or why is prostate cancer coming in from a different variety? which of those? [inaudible] >> that's right. [inaudible] >> i think we don't know the full answer to that question. it turns out the prostate is one organ where malignancy develops in men at a remarkably high rate. what's very tricky about prostate cancer is that prostate

cancer comes in very different forms. there's one form which actually does not metastasize it easily and, in fact, you will not die of prostate cancer, but with prostate cancer. there's another form that metastasizes and will kill you. we've now begun to figure out how to discriminate between these two things. it's a huge problem. it's a problem that is again off the magnitude that will make a difference. it's a can from no make a difference in health care budget, national health care budget. because for every 10,000 of the one kind that you shouldn't be treating anyway, you are treating, you know, you're putting up costs, biopsy costs, et cetera, were the best thing to do is not do anything. that's part of the answer but, of course, there's a cultural part of the answer. in the absence of that knowledge, and this is were i talked with in the book, in the absence of knowledge, how do we behave as individuals or as a society, how does one tell a man

that i'm not sure but it's likely, i think, there's about 80% likelier prostate cancer would be the one kind, why don't you watch and wait. in a culture where we don't understand enough about cancer, in a culture where the word cancer has taken on the current metaphors, the current understandings, how does one communicate the complexity, that idea and who's accountable and who is not comfortable? if you go on the web, you will find 10,000 opinions about testing with apsa, right? and again, this is a thing of importance and so, in 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 science, deeper understanding, while we are in the waking banner try to figure out,

hopeless and any audience will tell us five years later how to discriminate between us good and bad kind of cancer and relieve all these problems that you're having in washington. so encourage technology, and courage science. that's the best we can do. [inaudible] >> have we looked at, to talk about the food additives? ipaqs are spent, i spoke a little bit in the book about exogenous estrogens and pesticides. but, you know, it's an issue that remains -- there's a deep interest in looking at it but in particular exogenous hormones. and again, i think this is the kind of integrated approach

involving not just the old style epidemiology, that a combination of molecular biology, cancer genetics and epidemiology would be required to do all these kinds of things. in general, you know, i think is special with exogenous estrogens there's a bit of a smoking gun there. i don't of people agree or disagree with that. >> this questions in the back and maybe in the front. >> i was wondering if you could comment on your evolution as a writer a little different tack. >> in the sense of -- >> was this your first book? it was an extraordinary book. i'm just curious how you devolve as an author. >> you know, my general approach

to writing this book, or to any kind of writing that they do, happens through my scientific work, which is i like to write books that answer questions. so, if i have a question i will write a book. in this case i had a very urgent question. in terms of writing this particular book, i actually learned to write while i wrote this book. and if you are a reader of this book, in fact, you might sense that as the book progresses from the second 200 page, to the 400 page, it's quite obvious and learn to write as i'm doing this. by the 400 page i'm a different writer than i am as from the first page. now, i worked backwards and to try to clean up, i tried to clean up what i had done before. again, that still remains energy relies in the writing itself evolves. so that's one feature of it. in terms of profits, you know, i

talk about, i've spoken to others already about this. it's been written about. i am a deeply disciplined writer, in the sense that i write, i write small parts here and there. often i write exclusively in my bed. i probably self up with pillows, and when i was writing all of this, often i would have early mornings i would write when, i had 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, what i call it seems. and by that i mean the content was relatively easy for me to write. 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 580? what were the scenes? out of this fit together. sometimes that stitching is very tenuous. so if, in fact, a real discipline in his book, in this particular book, was that stitching, how does one manage. and the answer to that is that i tried to imagine a very confident reader. i tried to say to myself the kind of person who will go through this book is the kind of person i trust to move through those scenes. and i will rise to the book and they'll rise to read. i'm not going to make some kind of compromise. so i for people to read the book, it gets into pretty -- the science gets pretty dense. i didn't spare most contemporary

details. we talk about, we talk about cancer genomics from 2008, so this gets really complicated. but again it lives, the book lives at it seems. so those were the features that allowed me to the, you know, to write. one last comment, and that is the author people have have asked me, i mean, i've been asked, i have a friend, and so i learned to write from people who have written about medicine before me. so there is a learning process, a lot of reading. and that raises the question about it is a very interesting question to me personally, which is, was there something about being indian in this book, in this particular book? and the fact is i happen to be

from the subcontinent. and i spent a lot of time thinking about. sometimes i was thinking about it even today. and my answer to the question is, i think, i think the most important thing about being indian in writing this book was the fact that india gave me the freedom not to write about india. and in doing so, allowed me to write about something that was entirely universal, had nothing to do, but it was almost as if i inherited a kind of writing tradition, which allowed me to not have to write about the local politics or the culture of the subcontinent. but write about something you and i can have a conversation about. that freedom is very important to me personally. it's the cultural freedom, political freedom. i'm not sure i could convey how deeply that was influential to me. and since i didn't feel constrained. i thought i could write about something that's relatively universal. and i should thank being in

america for that. i should also think the freedom for my country. yes, maybe i'll take the last couple of questions maybe. >> in recent years there's been a lot of research, and has been linked to cancer. as wondering why you didn't include it in your book. and do you think it will come out of this research to fight against cancer? >> so again, this caution prospective course of what was included and not included in the book. in general and for things in the book, scientific things and above that have led to human therapy. i try to avoid -- so in other words, if you really traced back everything that is in the book, what ever goes into the book really ends up in a human being, somehow. percept and comes out of it certain understanding of cancer

and cancer drug. a preventive mechanism, tamoxifen, et cetera. things like our understanding of damascus is, like the immune system, i think are very important in understanding of the fundamental biology of cancer but did not need the sniff test of being able to be transformed into something that will impact the way we either treat her the way we deal with in preventative mechanisms of cancer. when they do so, i mean, i would be forced to write an addendum to this book. and last question. >> when my uncle had leukemia, they told him at johns hopkins university that they've done everything they could, and beyond this it was something greater. how much do you think, like either positive attitude or belief in, you know, some sort of spiritual thing, plays a role in curing cancer? and what are your experiences

and all the patients using? >> it's good that we're going to end with that question because i'm going to give a relatively provocative answer. my provocative answer to that is, i try not to believe that the psyche has a role in causing cancer. for the following reasons. 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 is precisely the kind of thing that happens at cancer patient is played is already full. twice the burden. so i try to shy away from that kind of thinking because it feels to me very negative in some ways. i know plenty of people who haven't had intensive positive attitude about life for that interval cancers but i know plenty of people who are unbelievably depressed or have all sorts of mental illnesses who have lived healthy cancer

free lives. so this idea that the psyche causes cancer to me, i have kind of an allergy to this idea. now, that said, do we believe that the psyche modifies one's ability to heal? yes. now, but there's no archetype of psyche. someone might use greek to heal. someone might use depression to heal. for someone, dealing with their illness might involve entering a space that is full of grief and depression. that might be the mechanism. and to force my understanding of what ever spirituality is or force my understanding of what a positive attitude is, again, i think ends up into a patient. who am i to say what your positive attitude is? you know, your decision. you might decide that you're intensely, you have an intense feeling of grief around her illness, right? that's your mechanism of healing. i can try to help. i tried to help people when that

grief takes what i would call a kind of pathological form. but even then i tried to be, i try to step back from it. and i particularly am allergic to this idea that the reason you're not getting better is because you're not thinking positively enough. i think actually that's part of the reason i wrote this book. there are so many self-help books out there about cancer that say that. unit, you're not giving better enough, you're not doing the right thing, you're not fighting hard enough. i think i'm very allergic to the. i start on my conversation saying i'm not going to go there. if that's where you want to be, that's your decision as a patient that i respect that decision but for me to say that as a doctor i think it creates a kind of cycle of blame that are really want to avoid. thank you. [applause]