The Emperor of All Maladies: A Biography of Cancer (36 page)

Scientists, too, withdrew from the war—in part, because they had little to contribute to it. The rhetoric of this war implied that its tools, its weapons, its army, its target, and its strategy had already been assembled. Science, the discovery of the unknown, was pushed to the peripheries of this battle. Massive, intensively funded clinical trials with combinations of cell-killing drugs would be heavily prioritized. The quest for universal causes and universal solutions—cancer viruses among them—would be highly funded. “We will in a relatively short period of time make vast inroads on the cancer problem,” Farber had announced to Congress in 1970. His army was now “on the march,” even if he and Mary Lasker had personally extricated themselves from its front lines.

The act, then, was an anomaly, designed explicitly to please all of its clients, but unable to satisfy any of them. The NIH, the Laskerites, scientists, lobbyists, administrators, and politicians—each for his or her own reasons—felt that what had been crafted was either precisely too little or precisely too much. Its most ominous assessment came from the editorial pages of the
Chicago Tribune:
“A crash
program can produce only one result
: a crash.”

On March 30, 1973, in the late afternoon
, a code call, a signal denoting the highest medical emergency, rang through the floors of the Jimmy Fund Building. It sounded urgently through the open doors of the children’s clinic, past the corridors with the cartoon portraits on the walls and the ward beds lined with white sheets and children with intravenous lines, all the way to the Brigham and Women’s Hospital, where Farber had trained as an intern—in a sense retracing the trajectory of his life.

A group of doctors and nurses in scrubs swung out toward the stairs. The journey took a little longer than usual because their destination was on the far end of the hospital, up on the eighth floor. In the room with tall,
airy windows, they found Farber with his face resting on his desk. He had died of a cardiac arrest. His last hours had been spent discussing the future of the Jimmy Fund and the direction of the War on Cancer. His papers were neatly arranged in the shelves all around him, from his first book on the postmortem examination to the most recent article on advances in leukemia therapy, which had arrived that very week.

Obituaries poured out from every corner of the world. Mary Lasker’s was possibly the most succinct and heartfelt, for she had lost not just her friend but a part of herself. “
Surely,” she wrote, “the world will never be the same
.”

From the fellows’ office at the Dana-Farber Cancer Institute, just a few hundred feet across the street from where Farber had collapsed in his office, I called Carla Reed. It was August 2005, a warm, muggy morning in Boston. A child’s voice answered the phone, then I was put on hold. In the background I could hear the white noise of a household in full tilt: crockery, doorbells, alarms, the radio blaring morning news. Carla came on the phone, her voice suddenly tightening as she recognized mine.

“I have news,” I said quickly, “good news.”

Her bone marrow results had just returned. A few nodules of normal blood cells were growing back interspersed between cobblestones of bone and fat cells—signs of a regenerating marrow reclaiming its space. But there was no trace of leukemia anywhere. Under the microscope, what had once been lost to cancer was slowly returning to normalcy. This was the first of many milestones that we would cross together, a moment of celebration.

“Congratulations, Carla,” I said. “You are in a full remission.”

*
It would run in the
New York Times
on December 17.

PART THREE
 
“WILL YOU TURN
ME OUT IF I CAN’T
GET BETTER?”

Oft expectation fails
, and most oft there

Where most it promises; and oft it hits

Where hope is coldest, and despair most sits

—William Shakespeare,
All’s Well That Ends Well

I have seen the moment of my greatness flicker

And I have seen the eternal Footman hold my coat, and snicker,

And in short, I was afraid.

—T. S. Eliot

You are absolutely correct
, of course, when you say that we can’t go on asking for more money from the President unless we demonstrate progress.

—Frank Rauscher, director of
the National Cancer Program,
to Mary Lasker, 1974

In science, ideology tends to corrupt
; absolute ideology, [corrupts] absolutely.

—Robert Nisbet

Orthodoxy in surgery is like orthodoxy in other departments
of the mind—it . . . begins to almost challenge a comparison with religion.

—Geoffrey Keynes

You mean I had a mastectomy for nothing
?

—Rose Kushner

Farber was fortunate to have lived in the right time, but he was perhaps even more fortunate to have died at the right time. The year of his death, 1973, marked the beginning of a deeply fractured and contentious period in the history of cancer. Theories were shattered; drug discoveries stagnated; trials languished; and academic meetings degenerated into all-out brawls. Radiotherapists, chemotherapists, and surgeons fought viciously for power and information. The War on Cancer seemed, at times, to have devolved into a war
within
cancer.

The unraveling began at the very center of oncology. Radical surgery, Halsted’s cherished legacy, had undergone an astonishing boom in the 1950s and ’60s. At surgical conferences around the world, Halsted’s descendants—powerful and outspoken surgeons such as Cushman Haagensen and Jerome Urban—had stood up to announce that they had outdone the master himself in their radicalism. “
In my own surgical attack on carcinoma
of the breast,” Haagensen wrote in 1956, “I have followed
the fundamental principle that the disease, even in its early stage, is such a formidable enemy that it is my duty to carry out as radical an operation as the . . . anatomy permits.”

The radical mastectomy had thus edged into the “superradical” and then into the “ultraradical,” an extraordinarily morbid, disfiguring procedure in which surgeons removed the breast, the pectoral muscles, the axillary nodes, the chest wall, and occasionally the ribs, parts of the sternum, the clavicle, and the lymph nodes inside the chest.

Halsted, meanwhile, had become the patron saint of cancer surgery, a deity presiding over his comprehensive “theory” of cancer. He had called it, with his Shakespearean ear for phrasemaking, the “centrifugal theory”—the idea that cancer, like a malevolent pinwheel, tended to spread in ever-growing arcs from a single central focus in the body. Breast cancer, he claimed, spun out from the breast into the lymph nodes under the arm (poetically again, he called these nodes “sentinels”), then cartwheeled mirthlessly through the blood into the liver, lungs, and bones. A surgeon’s job was to arrest that centrifugal spread by cutting every piece of it out of the body, as if to catch and break the wheel in midspin. This meant treating early breast cancer aggressively and definitively. The more a surgeon cut, the more he cured.

Even for patients, that manic diligence had become a form of therapy. Women wrote to their surgeons in admiration and awe, begging them not to spare their surgical extirpations, as if surgery were an anagogical ritual that would simultaneously rid them of cancer and uplift them into health. Haagensen transformed from surgeon to shaman: “
To some extent,” he wrote
about his patients, “no doubt, they transfer the burden [of their disease] to me.” Another surgeon wrote—chillingly—that he sometimes “
operated on cancer of the breast solely
for its effect on morale.” He also privately noted, “I do not despair of carcinoma being cured somewhere in the future, but this blessed achievement will, I believe, never be wrought by the knife of the surgeon.”

Halsted may have converted an entire generation of physicians in America to believe in the “blessed achievement” of his surgical knife. But the farther one got from Baltimore, the less, it seemed, was the force of his centrifugal theory;
at St. Bartholomew’s Hospital in London
, a young doctor named Geoffrey Keynes was not so convinced.

In August 1924, Keynes examined a patient
with breast cancer, a thin, emaciated woman of forty-seven with an ulcerated malignant lump in her breast. In Baltimore or in New York, such a patient would immediately have been whisked off for radical surgery. But Keynes was concerned about his patient’s constitutional frailty. Rather than reaching indiscriminately for a radical procedure (which would likely have killed her at the operating table), he opted for a much more conservative strategy. Noting that radiation therapists, such as Emil Grubbe, had demonstrated the efficacy of X-rays in treating breast cancer, Keynes buried fifty milligrams of radium in her breast to irradiate her tumor and monitored her to observe the effect, hoping, at best, to palliate her symptoms. Surprisingly, he found a marked improvement. “
The ulcer rapidly heal
[ed],” he wrote, “and the whole mass [became] smaller, softer and less fixed.” Her mass reduced so rapidly, Keynes thought he might be able to perform a rather minimal, nonradical surgery on her to completely remove it.

Emboldened by his success, between 1924 and 1928, Keynes attempted other variations on the same strategy. The most successful of these permutations, he found, involved a careful mixture of surgery and radiation, both at relatively small doses. He removed the malignant lumps locally with a minor operation (i.e., without resorting to radical or ultraradical surgery). He followed the surgery with radiation to the breast. There was no stripping of nodes, no cracking or excavation of clavicles, no extirpations that stretched into six or eight hours. Nothing was radical, yet, in case after case, Keynes and his colleagues found that their cancer recurrence rate was at least comparable to those obtained in New York or Baltimore—achieved without grinding patients through the terrifying crucible of radical surgery.

In 1927, in a rather technical report to his department, Keynes reviewed his experience combining local surgery with radiation. For some cases of breast cancer, he wrote, with characteristic understatement, the “extension of [the]
operation beyond a local removal
might sometimes be unnecessary.” Everything about Keynes’s sentence was carefully, strategically, almost surgically constructed. Its implication was enormous. If local surgery resulted in the same outcome as radical surgery, then the centrifugal theory had to be reconsidered. Keynes had slyly declared war on radical surgery, even if he had done so by pricking it with a pin-size
lancet
.