The Emperor of All Maladies: A Biography of Cancer (63 page)

But was the flat line of cancer mortality truly inanimate? Physics teaches us to discriminate a static equilibrium from a dynamic equilibrium; the product of two equal and opposite reactions can seem to sit perfectly still until the opposing forces are uncoupled. What if the flat line of cancer mortality represented a dynamic equilibrium of counterbalanced forces pushing and pulling against each other?

As Bailar and Gornik probed their own data further, they began to discern such forces counterpoised against each other with almost exquisite
precision. When cancer mortality between 1970 and 1994 was split into two age groups, the counterbalancing of forces was immediately obvious: in men and women above fifty-five, cancer mortality had increased, while in men and women under fifty-five, cancer mortality had decreased by exactly the same proportion. (Part of the reason for this will become clear below.)

A similar dynamic equilibrium was apparent when cancer mortality was reassessed by the
type
of cancer involved. Mortality had decreased for some forms, plateaued for others, and increased for yet others, offsetting nearly every gain with an equal and opposite loss. Death rates from colon cancer, for instance, had fallen by nearly 30 percent, and from cervical and uterine cancer by 20. Both diseases could be detected by screening tests (colonoscopy for colon cancer, and Pap smears for cervical cancer) and at least part of the decrease in mortality was the likely consequence of earlier detection.

Death rates for most forms of children’s cancer had also declined since the 1970s, with declines continuing over the decade. So, too, had mortality from Hodgkin’s disease and testicular cancer. Although the net number of such cancers still represented a small fraction of the total cancer mortality, treatment had fundamentally altered the physiognomy of these diseases.

The most prominent countervailing ballast against these advances was lung cancer. Lung cancer was still the single biggest killer among cancers, responsible for nearly one-fourth of all cancer deaths. Overall mortality for lung cancer had increased between 1970 and 1994. But the distribution of deaths was markedly skewed. Death rates among men had peaked and dropped off by the mid-1980s. In contrast, lung cancer mortality had dramatically risen in women, particularly in older women, and it was still rising. Between 1970 and 1994, lung cancer deaths among women over the age of fifty-five had increased by 400 percent, more than the rise in the rates of breast and colon cancer
combined
. This exponential upswing in mortality had effaced nearly all gains in survival not just for lung cancer, but for all other types of cancer.

Alterations in the pattern of lung cancer mortality also partially explained the overall age skew of cancer mortality. The incidence of lung cancer was highest in those above fifty-five, and was lower in men and women below fifty-five, a consequence of changes in smoking behavior since the 1950s. The decrease in cancer mortality in younger men and
women had been perfectly offset by the increase in cancer mortality in older men and women.

Taken in balance, “Cancer Undefeated” was an article whose title belied its message. The national stalemate on cancer was hardly a stalemate, but rather the product of a frantic game of death in progress. Bailar had set out to prove that the War on Cancer had reached terminal stagnancy. Instead, he had chronicled a dynamic, moving battle in midpitch against a dynamic, moving target.

So even Bailar—
especially
Bailar, the fiercest and most inventive critic of the war—could not deny the fierce inventiveness of this war.
Pressed on public television, he begrudgingly conceded
the point:

Interviewer: Why do you think they’re going down a little bit, or plateauing?

Bailar: We think they have gone down perhaps one percent. I would like to wait a little bit longer to see this downturn confirmed, but if it isn’t here yet, it’s coming. . . .

Interviewer: Dr. Bailar?

Bailar: I think we might agree that the cup is half-full.

No single strategy for prevention or cure had been a runaway success. But undeniably this “half-full cup” was the product of an astonishingly ingenious array of forces that had been deployed against cancer. The vaunted promises of the 1960s and 1970s and the struggles of the 1980s had given way to a more grounded realism in the 1990s—but this new reality had brought its own promises.

Sharply critiquing the defeatism of Bailar and Gornik’s assessment, Richard Klausner, the director of the NCI, pointed out:

“
‘Cancer’ is, in truth, a variety of diseases
. Viewing it as a single disease that will yield to a single approach is no more logical than viewing neuropsychiatric disease as a single entity that will respond to one strategy. It is unlikely that we will soon see a ‘magic bullet’ for the treatment of cancer. But it is just as unlikely that there will be a magic bullet of prevention or early detection that will knock out the full spectrum of cancers. . . . We are making progress. Although we also have a long way to go, it is facile to claim that the pace of favorable trends in mortality reflects poor policies or mistaken priorities.”

An era of oncology was coming to a close. Already, the field had turned away from its fiery adolescence, its entrancement with universal solutions and radical cures, and was grappling with fundamental questions about cancer. What were the underlying principles that governed the root behavior of a particular form of cancer? What was common to all cancers, and what made breast cancer different from lung or prostate cancer? Might those common pathways, or differences for that matter, establish new road maps to cure and prevent cancer?

The quest to combat cancer thus turned inward, toward basic biology, toward fundamental mechanisms. To answer these questions, we must turn inward, too. We must, at last, return to the cancer cell.

PART FIVE
 
“A DISTORTED VERSION
OF OUR NORMAL SELVES”

It is in vain to speak of cures
, or think of remedies, until such time as we have considered of the causes . . . cures must be imperfect, lame, and to no purpose, wherein the causes have not first been searched.

—Robert Burton,
The Anatomy of Melancholy
, 1893

You can’t do experiments to see
what causes cancer. It’s not an accessible problem and it’s not the sort of thing scientists can afford to do.

—I. Hermann,
cancer researcher, 1978

What can be the “why” of these happenings
?

—Peyton Rous,
1966, on the mystery
of the origin of cancer

It is the spring of 2005—a pivot point in the medical oncology fellowship. Our paths are about to divide. Three of us will continue in the clinic, with a primary focus in clinical research and in the day-to-day care of patients. Four will explore cancer in the laboratory, retaining just a minor presence in the clinic, seeing just a handful of patients every week.

The choice between the two paths is instinctual. Some of us inherently perceive ourselves as clinicians; others primarily as scientists. My own inclinations have changed little since the first day of my internship. Clinical medicine moves me viscerally. But I am a lab rat, a nocturnal, peripatetic creature drawn to the basic biology of cancer. I mull over the type of cancer to study in the laboratory, and I find myself gravitating toward leukemia. I may be choosing the laboratory, but my subject of research is governed by a patient. Carla’s disease has left its mark on my life.

Even so, in the fading twilight of my full-time immersion in the hospital, there are disquieting moments that remind me how deeply clinical medicine can surprise and engage me. It is late one evening in the fellows’ room, and the hospital around us has fallen silent save for the metallic clink of cutlery being brought up for meals. The air outside is heavy with impending rain. The seven of us, close friends by now, are compiling lists of patients to pass on to the next class of fellows when Lauren begins to read her list aloud, calling out the names of those in her care who have died over our two-year fellowship. Suddenly inspired, she pauses and adds a sentence to each name as a sort of epitaph.

It is an impromptu memorial service, and it stirs something in the room. I join in, calling out names of my patients who have died and appending a sentence or two in memory.

Kenneth Armor, sixty-two, an internist with stomach cancer. In his final days, all he wished for was a vacation with his wife and time to play with his cats.

Oscar Fisher, thirty-eight, had small-cell lung cancer. Cognitively impaired since birth, he was his mother’s favorite child. When he died, she was threading rosaries through his fingers.

That night I sit alone with my list, remembering the names and faces late into the evening. How does one memorialize a patient? These men and women have been my friends, my interlocutors, my teachers—a surrogate family. I stand up at my desk, as if at a funeral, my ears hot with emotion, my eyes full of tears. I look around the room at the empty desks and note how swiftly the last two years have reshaped all seven of us. Eric, cocksure, ambitious, and smart, is humbler and more introspective. Edwin, preternaturally cheerful and optimistic in his first month, talks openly about resignation and grief. Rick, an organic chemist by training, has become so infatuated with clinical medicine that he doubts that he will return to the laboratory. Lauren, guarded and mature, enlivens her astute assessments with jokes about oncology. Our encounter with cancer has rounded us off; it has smoothed and polished us like river rocks.

A few days later, I meet Carla in the infusion room. She is casually chatting with the nurses, as if catching up with old friends. From a distance, she is barely recognizable. The sheet-white complexion I recall from her first visit to the hospital has warmed up several degrees of red. The bruises in her arm from repeated infusions have vanished. Her children are back in their routine, her husband has returned to work, her mother is home in Florida. Carla’s life is nearly normal. She tells me that her daughter occasionally wakes up crying from a nightmare. When I ask her if this reflects some remnant trauma from Carla’s yearlong ordeal with illness, she shakes her head assertively: “No. It’s just monsters in the dark.”

It has been a little more than a year since her original diagnosis. She is still taking pills of 6-mercaptopurine and methotrexate—Burchenal’s drug and Farber’s drug, a combination intended to block the growth of any remnant cancer cells. When she recalls the lowest points of her illness, she shudders in disgust. But something is normalizing and healing inside her. Her own monsters are vanishing, like old bruises.

When her blood counts return from the lab, they are stone-cold normal. Her remission continues. I am astonished and exalted by the news, but I bring it to her cautiously, as neutrally as I can. Like all patients, Carla smells overenthusiasm with deep suspicion: a doctor who raves disproportionately about small victories is the same doctor who might be preparing his patient for some ultimate defeat. But this time there is no reason to be suspicious. I tell her that her counts look perfect, and that no more tests are
required today. In leukemia, she knows, no news is the best kind of news.