The Emperor of All Maladies: A Biography of Cancer (75 page)

The Italian memoirist Primo Levi, who survived a concentration camp and then navigated his way through a blasted Germany to his native Turin, often remarked that among the most fatal qualities of the camp was its ability to erase the idea of a life outside and beyond itself. A person’s past and his present were annihilated as a matter of course—to be in the camps was to abnegate history, identity, and personality—but it was the erasure of the future that was the most chilling. With that annihilation, Levi wrote, came a moral and spiritual death that perpetuated the status quo of imprisonment. If no life existed beyond the camp, then the
distorted logic by which the camp operated became life as usual.

Cancer is not a concentration camp, but it shares the quality of annihilation: it negates the possibility of life outside and beyond itself; it subsumes all living. The daily life of a patient becomes so intensely preoccupied with his or her illness that the world fades away. Every last morsel of energy is spent tending the disease. “
How to overcome him became
my obsession,” the journalist Max Lerner wrote of the lymphoma in his spleen. “If it was to be a combat then I had to engage it with everything I had—knowledge and guile, ways covert as well as overt.”

For Carla, in the midst of the worst phase of her chemotherapy, the day-to-day rituals of survival utterly blotted out any thought of survivorship in the long run. When I asked a woman with a rare form of muscle sarcoma about her life outside the hospital, she told me that she spent her days and nights scouring the Internet for news about the disease. “I am in the hospital,” she said, “even when I am outside the hospital.”
The poet Jason Shinder wrote, “Cancer
is a tremendous opportunity to have your face pressed right up against the glass of your mortality.” But what patients see through the glass is not a world outside cancer, but a world taken over by it—cancer reflected endlessly around them like a hall of mirrors.

I was not immune to this compulsive preoccupation either. In the summer of 2005, as my fellowship hurtled to its end, I experienced perhaps the singularly transformative event of my life: the birth of my daughter. Glowing, beautiful, and cherubic, Leela was born on a warm night at Massachusetts General Hospital, then swaddled in blankets and brought to the newborn unit on the fourteenth floor. The unit is directly across from the cancer ward. (The apposition of the two is hardly a coincidence. As a medical procedure, childbirth is least likely to involve infectious complications and is thus the safest neighbor to a chemotherapy ward, where any infection can turn into a lethal rampage. As in so much in medicine, the juxtaposition between the two wards is purely functional and yet just as purely profound.)

I would like to see myself at my wife’s side awaiting the miraculous moment of my daughter’s birth as most fathers do. But in truth I was gowned and gloved like a surgeon, with a blue, sterile sheet spread out in front of me, and a long syringe in my hands, poised to harvest the maroon gush of blood cells from the umbilical cord. When I cut that cord, part of me was the father, but the other part an oncologist. Umbilical blood contains one of the richest known sources of blood-forming stem cells—cells
that can be stored away in cryobanks and used for a bone marrow transplant to treat leukemia in the future, an intensely precious resource often flushed down a sink in hospitals after childbirth.

The midwives rolled their eyes; the obstetrician, an old friend, asked jokingly if I ever stopped thinking about work. But I was too far steeped in the study of blood to ignore my instincts. In the bone-marrow-transplant rooms across that very hallway were patients for whom I had scoured tissue banks across the nation for one or two pints of these stem cells that might save their lives. Even in this most life-affirming of moments, the shadows of malignancy—and death—were forever lurking on my psyche.

But not everything was involuting into death. Something transformative was also happening in the fellows’ clinics in the summer of 2005: many of my patients, whose faces had so fixedly been pressed up against the glass of their mortality, began to glimpse an afterlife beyond cancer. February, as I said before, had marked the midpoint of an abysmal descent. Cancer had reached its full, lethal bloom that month. Nearly every week had brought news of a mounting toll, culminating chillingly with Steve Harmon’s arrival in the emergency room and his devastating spiral into death thereafter. Some days I dreaded walking by the fax machines outside my office, where a pile of death certificates would be waiting for my signature.

But then, like a poisonous tide receding, the bad news ebbed. The nightly phone calls from the hospitals or from ERs and hospice units around Boston bringing news of yet another death (“I’m calling to let you know that your patient arrived here this evening with dizziness and difficulty breathing”) suddenly ceased. It was as if the veil of death had lifted—and survivors had emerged from underneath.

Ben Orman had been definitively cured of Hodgkin’s lymphoma. It had not been an effortless voyage. His blood counts had dropped calamitously during the midcycle of chemotherapy. For a few weeks it had appeared that the lymphoma had ceased responding—a poor prognostic sign portending a therapy-resistant, fatal variant of the disease. But in the end the mass in his neck, and the larger archipelago of masses in his chest, had all melted away, leaving just minor remnants of scar tissue. The formality of his demeanor had visibly relaxed. When I last saw him in the summer of 2005, he spoke about moving away from Boston to Los Angeles to join
a law firm. He assured me that he would visit to follow up, but I wasn’t convinced. Orman epitomized the afterlife of cancer—eager to forget the clinic and its bleak rituals, like a bad trip to a foreign country.

Katherine Fitz could also see a life beyond cancer. For Fitz, with the lung tumor wrapped ominously around her bronchus, the biggest hurdle had been the local control of her cancer. The mass had been excised in an incredibly meticulous surgery; she had then finished adjuvant chemotherapy and radiation. Nearly twelve months after the surgery, there was no sign of a local relapse. Nor was there any sign of the woman who had come to the clinic several months earlier, nearly folded over in fear. Tumor out, chemotherapy done, radiation behind her, Fitz’s effervescence poured out of every spigot of her soul. At times, watching her personality emerge as if through a nozzle, it seemed abundantly clear why the Greeks had thought of disease as pathological blockades of humors.

Carla returned to see me in July 2005, bringing pictures of her three growing children. She refused to let another doctor perform her bone marrow biopsy, so I walked over from the lab on a warm morning to perform the procedure. She looked relieved when she saw me, greeting me with her anxious half-smile. We had developed a ritualistic relationship; who was I to desecrate a lucky ritual? The biopsy revealed no leukemia in the bone marrow. Her remission, for now, was still intact.

I have chosen these cases not because they were “miraculous” but because of precisely the opposite reason. They represent a routine spectrum of survivors—Hodgkin’s disease cured with multidrug chemotherapy; locally advanced lung cancer controlled with surgery, chemotherapy, and radiation; lymphoblastic leukemia in a prolonged remission after intensive chemotherapy. To me, these were miracles enough. It is an old complaint about the practice of medicine that it inures you to the idea of death. But when medicine inures you to the idea of life, to survival, then it has failed utterly. The novelist Thomas Wolfe, recalling a lifelong struggle with illness, wrote in his last letter, “I’ve made a long voyage and been to a strange country, and I’ve seen the dark man very close.” I had not made the journey myself, and I had only seen the darkness reflected in the eyes of others. But surely, it was the most sublime moment of my clinical life to have watched that voyage in reverse, to encounter men and women
returning
from the strange country—to see them so very close, clambering back.

Incremental advances can add up to transformative changes.
In 2005, an avalanche of papers
cascading through the scientific literature converged on a remarkably consistent message—the national physiognomy of cancer had subtly but fundamentally changed.
The mortality for nearly every major
form of cancer—lung, breast, colon, and prostate—had continuously dropped for fifteen straight years. There had been no single, drastic turn but rather a steady and powerful attrition:
mortality had declined by about 1 percent
every year. The rate might sound modest, but its cumulative effect was remarkable:
between 1990 and 2005, the cancer-specific
death rate had dropped nearly 15 percent, a decline unprecedented in the history of the disease. The empire of cancer was still indubitably vast—
more than half a million American men and women
died of cancer in 2005—but it was losing power, fraying at its borders.

What precipitated this steady decline? There was no single answer but rather a multitude. For lung cancer, the driver of decline was primarily prevention—a slow attrition in smoking sparked off by the Doll-Hill and Wynder-Graham studies, fueled by the surgeon general’s report, and brought to its full boil by a combination of political activism (the FTC action on warning labels), inventive litigation (the Banzhaf and Cipollone cases), medical advocacy, and countermarketing (the antitobacco advertisements).

For colon and cervical cancer, the declines were almost certainly due to the successes of secondary prevention—cancer screening. Colon cancers were detected at earlier and earlier stages in their evolution, often in the premalignant state, and treated with relatively minor surgeries. Cervical cancer screening using Papanicolaou’s smearing technique was being offered at primary-care centers throughout the nation, and as with colon cancer, premalignant lesions were excised using relatively minor surgeries.

For leukemia, lymphoma, and testicular cancer, in contrast, the declining numbers reflected the successes of chemotherapeutic treatment. In childhood ALL, cure rates of 80 percent were routinely being achieved. Hodgkin’s disease was similarly curable, and so, too, were some large-cell aggressive lymphomas. Indeed, for Hodgkin’s disease, testicular cancer, and childhood leukemias, the burning question was not how
much
chemotherapy was curative, but how
little:
trials were addressing whether milder and less toxic doses of drugs, scaled back from the original protocols, could achieve equivalent cure rates.

Perhaps most symbolically, the decline in breast cancer mortality epitomized the cumulative and collaborative nature of these victories—and the importance of attacking cancer using multiple independent prongs. Between 1990 and 2005, breast cancer mortality had dwindled an unprecedented 24 percent. Three interventions had potentially driven down the breast cancer death rate—mammography (screening to catch early breast cancer and thereby prevent invasive breast cancer), surgery, and adjuvant chemotherapy (chemotherapy after surgery to remove remnant cancer cells).
Donald Berry, a statistician in Houston
, Texas, set out to answer a controversial question: How much had mammography and chemotherapy
independently
contributed to survival? Whose victory was this—a victory of prevention or of therapeutic intervention?
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