The Emperor of All Maladies

Emperor“Hope is a funny thing. You have to base hope on something.” “In medicine, you always want to believe.”

Sometimes the truth is difficult to confront. Who wouldn’t rather reside in a happy place in our minds that makes us feel like everything is going to turn out splendidly than engage uncomfortable or undesirable realities? If only merely putting on a pair of yoga pants suddenly made excess weight and cholesterol dissolve without the sweat, soreness, exhaustion, and discipline of real exercise and healthful diet. If only we could just wish that our lazy, credit-stealing boss was less of a tool and he would become better without having the awkward, status-quo-disrupting conversations to actually make it happen. If only all of our financial, relational, ecological, and other mistakes of human nature would sort themselves out well without any of the ugly, painful consequences. If only we were not mortal creatures and could live forever.

Science and technical innovation are perhaps the most optimistic and hopeful human endeavor of our lifetime, and nowhere has belief and reality collided more than in the area of cancer research and treatment. The quotes at the lead are two of many poignant ones from the excellently crafted recent PBS documentary series Cancer: The Emperor of All Maladies, based on the book of the same name by Siddhartha Mukherjee. Through the all-encompassing history therein, it is apparent that the crucial questions at the core of any discussion about cancer are: What do we really know? What can we now do to address it? We always want to believe that we have the right answers and that we know how things will turn out, but cancer has challenged our understanding of our bodies and our world in ways that few other things have. As Mukherjee states early on in the first part of the series, “to imagine that we will find a simple solution doesn’t do justice to the complexity of the problem.”

Over the course of human history, medical experts of all kinds have run the gamut of nearly every possible explanation for cancer’s causes and viable cures. Is it punishment from the gods? Is it black bile run amok? Is it from a virus, genes, or chemicals? Is there something in the apothecary for it: boar’s tooth, fox’s lung, or crab’s leg? Can’t it just be cut out? Maybe an intravenous combination of some potent synthesized chemicals will wipe it all out? Can’t our immune system do this on its own?

It all is, or at least should be, rather humbling: humbling in both the sense of being humbled—lowered or destroyed—and to be humble—not arrogant, honestly assessing one’s power and understanding. Our bodies are humbled by this debilitating, complex disease that attacks from within: the very constituent parts of our bodies that keep us alive and healthy will under different circumstances kill us. And also, the mysteriousness of cancer and our feeble inability to fully perceive and treat it, despite many and varied efforts of trial and error, should remind us of the limitations of our understanding of the world and our capacity to control it in directions of our own will. Somehow there has been little humility of the latter sort despite the persistence and even increase in cancer’s ravaging humiliation of the former. We always want to believe. We want to believe there’s nothing we can’t understand and course correct it the way we want it to go.

With little or no truthful understanding of cancer’s genetic origins and unpredictable, metastatic spread, we spent decades administering more is better therapies. More cutting: notably the radical mastectomy—barbaric removal of not only a breast with malignancy, but the entire musculature and other tissue below it. More drugs: ever-increasing doses and combinations of chemotherapy—pushing patients closer to the brink of death from treatment than the cancer had itself. One of the most heart-wrenching personal stories shown in the documentary is a young boy who receives aggressive chemotherapy for his leukemia, only to develop a second cancer from the chemo and later die from graft-versus-host after a failed transplant to try to treat the second, medically caused cancer.

Is it better to do something than nothing? What lengths are we willing to go to before we have a better understanding of what’s going on?

Though we now have more accurate concepts like genes, mutations, and pathways rather than humors, we’re not necessarily this close to cancer being fully manageable—as much of the rhetoric of researchers, popular news sources, and some physicians would suggest. After things like smoking, obesity, radiation, viruses, and sunlight, the other 40% of the causes of cancer are not yet known. Prevention and early detection can go a long way, but we’re still seeing through a glass darkly about how the switch is flipped on for a huge set of cancers, and have not found low side-effect treatments that will cleanse and heal the body of the majority of cancers. A few bright spots like the drug Gleevec, a once-a-day pill especially for a form of leukemia, and some immunotherapies—different versions of empowering a body’s own immune system to fight the cancer itself—are exactly that—just a few bright spots in the strive for full cures for all cancers.

Importantly, the documentary spends a meaningful chunk of time near the end exploring the importance of palliative care. It’s difficult to watch as some patients are told there is nothing medical science can do to help them. They will have weeks or maybe months before cancer ends their life. The conversation shifts beyond even a glimmer of hope in this or that treatment to be tried to what is a good death? Eventually, mortality and bodily fragility catch up, and medicine—however advanced and powerful—reaches the limits of its ability to restore. There is no medical expert in eternal life. But doctors still have an important role to play in helping people live out the last days of their lives as well as possible.

As we continue the worthy fight of trying to subvert cancer’s enigmatic power, we need to perpetually ground ourselves in a posture of humility. Too often, medicine (like many other scientific disciplines) has told stories about what cancer is and how it can be defeated that amounted to false hope—acting in overconfidence, and worsening bodily health beyond the destruction of cancer alone. The fight requires ingenuity, patience, a willingness to be dead wrong, collaboration, an emphasis on sustaining the highest level of well-being of patients, honesty, and a tempered optimism, rather than buoyant expectation, that perhaps one day we just might get it all figured out. It’s not a given, though. It’s not inevitable, it won’t happen overnight, and it won’t be without setbacks. Hope has to be based on something. The way to that something—to truth—requires a humble approach. The limits of: what we know, what we don’t, and what we’re willing to subject people to. Our power to investigate, learn, and understand is as personal and finite as our vulnerable bodies.

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