When Doctors Get Disheartened
By Syed Amir, PhD
Bethesda, MD
During the past decade, several highly acclaimed, popular books have been published in the US on a subject that will touch the lives of all of us at some time, disease and the dying process, especially the devastating effect of cancer on its victims and their families. These have won numerous prestigious literary awards, and quickly climbed on the best-seller list. A distinguishing feature is that their authors are renowned physicians-scientists of Indian origin, blessed with exquisite writing talents.
The first book, written by Dr Siddhartha Mukherjee, the Pulitzer-Prize winning author of The Emperor of All Maladies released in 2010, is a brilliant exposition on the origin, pathobiology, and progression of cancer, and emerging strategies for its treatment. The second, Dr Atul Gawande’s exceedingly popular and oft-quoted book, Being Mortal was published in 2014. The author, a surgeon- oncologist, provides a highly personal and touching account of his many interactions with his patients, including his own father, who faced imminent mortality with surprising levels of acceptance and equanimity.
Of all the recent cancer-related books, the most emotionally powerful is a brief, highly applauded memoir, When Breath Becomes Air, authored by Dr Paul Kalanithi, a brilliant neurosurgeon, who had just completed his medical training at Stanford University, and was looking forward to a successful career in medicine, when he found himself battling the stage IV metastatic lung cancer, transforming him from a doctor to a patient. He provides an exceedingly moving account of his day-to-day struggle with the progressively debilitating disease, the text laced with his metaphysical ruminations about the nature of life itself. Kalanithi died at the young age of 37 before he could finish his book. His memoir, completed by his wife, also a doctor, was published posthumously.
Recently, the corpus of popular biomedical books on cancer has been enriched by the addition of The First Cell, written by a well-established Pakistani-American, oncologist and scientist, Dr Azra Raza, Professor of Medicine at Columbia University, who graduated from Karachi’s Dow Medical College. Her research focuses on myelodysplastic syndrome, a form of cancer in which bone marrow does not produce enough functioning blood cells.
Arguing that all strategies that have been pursued by doctors have so far shown scant success, she espouses a new approach to fight the dreaded disease. Raza contends that the “Current landscape (of knowledge) is worse than it was in the 1970s. Even today, 95 percent of experimental trials (of new drugs) continue to fail. The 5 percent that succeed, extend life of patients by a few months at the cost of millions of dollars.” It is disappointing that some 70 percent of drugs approved for cancer treatment during the last fifteen years have shown no benefit or improvement when tested in patients; many, paradoxically, proved to be harmful.
She cites some grim statistics to underscore the urgency of finding a cure. In 2018, 18 million new cases of cancer were diagnosed worldwide; potentially half of these patients will die of the disease. It is estimated by the American Cancer Society, as cited by the author, that by the year 2030, the number of patients will climb to 21.7 million, 13 million of them dying of the disease. Furthermore, the cost of treatment is staggering. A drug that extends the life of pancreatic cancer patients by a mere twelve days, costs $26,000. Is it wise to invest so much money for so little return, one wonders? During the year 2018, some 166,000 scientific papers were published, addressing some aspect of cancer, but, in the judgment of the author, the results reported in the great majority of cases could not be duplicated by others, making their usefulness questionable.
Human cells divide to create new cells; in the duplication process, errors occur, and a few aberrant cells are generated. Usually they are destroyed, but some escape and proliferate. The longer people live, greater are the opportunities that aberrant cells will be created and survive to lead to cancer. Raza recommends a new paradigm for cancer diagnosis and prevention. She believes that current methodologies are incapable of cancer detection at an early stage where it would be amenable to therapeutic intervention. She proposes that our primary emphasis should be on the detection of the first abnormal or cancerous cell in the body and to eliminate it. She proposes that we should be looking in the body fluids, urine and blood, for biomarkers, signature of specific cancers, dealing with them before they can gain a foothold and establish themselves. At this time, a disproportionately huge amount or resources are directed at cancer treatment when it might be too late to achieve a successful outcome.
Raza has been personally touched by the devastation of the disease, as her husband, Harvey Preisler, a renowned cancer researcher himself, ironically came down with leukemia and died after a five-year battle with the disease. She narrates, in heartbreaking detail, the difficult time the family went through and her heightened awareness of the anguish her patients experience in their struggles. She writes; “Cancer is what I had been treating for two decades, yet until I shared a bed with a cancer patient, I had no idea how unbearably painful a disease it could be.” Raza recounts the final phase of her husband’s illness and the complications he suffered when his body was ravaged by other opportunistic infections. His end came in the loving arms of his wife, surrounded by close family.
The author introduces the reader to a number of her patients whom she got to know well and each one of them had a unique story of anguish and sorrow. They become familiar characters to the reader. While discussing deep intricacies of DNA genetics and cancer cell proliferations mechanism, the author also talks about her close-knit family, her sisters, a brother and mother, all of whom provided strong support and succor in time of need. Pakistani readers will appreciate her references to her native city, Karachi, to which she still seems to have some emotional bonds.
The First Cell is embellished with quotations of Western authors, such as Emily Dickinson, Shakespeare, ancient Greek philosopher, Heraclitus, and iconic Urdu poets, such as Ghalib and Iqbal, indicative of the diversity and breadth of the author’s interests and scholarship. In addition to being a famed oncologist, she has abiding interest in classical Urdu poetry, having authored, in collaboration with her friend, Sara Suleri, a treatise, Ghalib: Epistemologies of Elegance, an interpretation of Ghalib’s selected poems.
The First Cell is an excellent source of information about the current status of cancer research, its future and potential new avenues of research that can be appreciated even by those without background in medicine. However, while the author listed multifarious challenges we face in the fight against the disease, she offered no definitive, pragmatic approaches to overcome them.
(The writer is a former assistant professor, Harvard Medical School and a retired health scientist administrator, US National Institutes of Health)
