“Cancer is what happens when some part of ourselves wants to live forever. The body is more a confederation of cells agreeing to act in concert than a single organism. When a cell refuses to die and transmits that obdurate life force to its neighbours, we get cancer – death brought on by the striving for immortality.”
One cannot claim to speak on behalf of anyone else, let alone a distinct majority, but for the slightly literary inclined, it is becoming increasingly difficult to maintain a regiment in regard to potent dosages of the written word. But where you might find yourself faltering, you can count yourself lucky to be, if you are in the company of good people – my friend M, who is more than familiar with my various anchors, nudged me lightly in the direction of this book. She did so sincerely and perhaps slightly tactfully, to a good extent – and after inhaling its contents, I could not be more thankful for her contribution to my little catalogue.
Not meaning to sound reductive in the least, The First Cell: and the Human Costs of Pursuing Cancer to the Last by Dr Azra Raza reads like a several hours long Ted Talk, but far, far more intimate. Equal parts memoir and equal parts research diary, the prolific cancer specialist at Columbia University in New York writes in incredible affection, depth and reverence, the accounts of some of her most resplendent patients.
Omar, Per, Lady N, Kitty C, JC, Andrew and her own husband, Harvey make up the sentinels upon which she builds her foundation. These are not her stories; these stories are theirs, ones which she merely retells through the personal proxy she possessed with them at some point. These are her clinical anecdotes recounted in perfect, vivid and precise detail, each carrying a grim moral: Implicitly and often explicitly, Raza does not hold back in her view, which to me personally, reads as the most genuine form of respect to the reader, as she does not simplify or dull any account; instead she endorses the need of how a more intelligent and better organized research program and an honest self-appraisal by the community of cancer scientists might have saved far more lives.
“How many more Omars and Andrews will it take?” she laments, referring to two of her patients who died, diagnosed far too late with no good options for cure. For a change, Raza lends her voice to the aggrieved and coming from a lofty perch, her strengths bound in the experience as a researcher and an empathic clinician shine through; she infers heavily throughout her narrative how difficult cancer research truly is particularly how rare breakthroughs are whereas missteps are aplenty. Ideas are simple; humans and their biology are definitely not.
The First Cell: And the Human Costs of Pursuing Cancer to the Last hopes to convey how we have mismanaged time and money barking up the wrong tree by continuing to use outdated experimental models (animals, cells, and the entire 20th-century repertoire of discovery). Raza goes on to state how current cancer research is addressing the wrong end of the problem — late-stage disease, when the cancer has already become too large and perhaps has already spread, when patients are their most sick and immuno-compromised, when even the most wonderful new miracle drug will be unlikely to work.
She points out the billions spent on research to find and target a single mutated gene or a faulty signaling pathway at a time when a seasoned tumor has evolved into a chaotic mass of malignant cells reproducing in multiple clones with varying genetic and cellular derangements. In this approach, researchers study human tumors as static entities in tissue culture or injected into mice whose immune systems and microenvironments are in no way comparable to the cancers seen in mostly elderly patients.
Better to find the cancers sooner when the actual number of cancer cells is still small. Therapies will then have a better chance of being effective: with a lower risk of genetic mutations that expound drug resistance or spotty penetration of medications into bulky growths. Attacking the disease when the cells show only an earlier intimation to cause trouble would be a far cheaper, less toxic, and decidedly more effective, she writes. Raza decries the “protocol of surgery, chemotherapy, and radiation—the slash-poison-burn approach to treating cancer” that has remained unchanged for decades.” It is a compelling argument, one with a long history and public support.
Anything but one dimensional, Raza in her book does not simply wax on about the plight at hand; she demonstrates her point and sharpens her criticism through her series of patients that she has treated through the years. We meet several people, each with their unique and difficult cancers. No one cancer is the same, so neither is her cast of characters or their respective stories.
Each chapter leads us, some not so gently, to their ultimate death. Of particular poignance is the story, woven throughout the book, of her husband, oncologist Dr. Harvey Preisler, who died of an aggressive lymphoma in the year 2002. It is instances like these where there most heartbreaking of introspections take place, as they do in real life, in comfortable moments of silence and within the illusion of comfort and control. Post diagnosis, lying in bed awake with her terminally ill husband, she thinks:
“What does time mean to people who are running out of it? How does a man hearing the footsteps of death approach closer every day negotiate the themes of dying, loss, pain, grief, the withering sense of waste, the unbearable, crushing sadness of things that will be left undone? Cancer chipping away at the body relentlessly in slow, steady excruciating blows: the lucid, sharp, coherent mind forced to reside in an aching, skeletal corpus, documenting each ignominy with sensorial precision.”
And with a resounding tranquility she articulates some of the most heartwrenching set of words ever strung together, an illustration of her internal incomparable calamity:
“Soon I would be speaking in rooms forever depleted of his voice, I would be breathing air that would no longer contain his breath.”
Very rarely has someone been able to quantify so accurately the earth-shattering ramifications of the diagnosed terminal illness of a loved one.
As an ongoing homage to her peers at some point later in the book, Raza expounds upon the work of some of today’s leaders in the field of early diagnostics. She praises the likes of Sanjiv Sam Gambhir, chairman of the Canary Center at Stanford for Cancer Early Detection, for his work in using radiologic scans to see the first signals of cancer. She also highlights the great success of colonoscopy screening in reducing mortality from colon cancer. And she describes the enormous promise of DNA detection in the bloodstream.
Her approach may be inspired in part by her own research on a pre-cancer syndrome that can develop into acute myeloid leukemia. She describes her efforts in that area as well as new research aimed at finding blood or tissue biomarkers of those first cancer cells. Her explanation of the science and her brief history of cancer research would be enough to recommend this volume to general readers, but it is in the case histories of cancer patients she has treated, including her late husband’s, where Raza’s eloquence is on full, and might I add, spectacular display. With elegant literary references and a compassion that deeply personalizes her interactions with patients and families, she engages readers in a commitment to finding a better path forward.
Alternatively, she avoids a deep discussion on the frailties of the same research including early detection, such as the notoriously inaccurate scientific work of Elizabeth Holmes and Theranos, with their claims of a simple finger-prick diagnosis. Nor does she take on the many problems created by early detection, including the uncertainty in how best to manage unclear results. Why the elusiveness? One could suggest that at the end of the day, Raza is sincerely mindful of her approach to the writing and her narrative is as much introspective as it is beneficial. She is after all; a robust member of this fraternity and their shortcomings are merely a preview to her very own. If one were to take it in pure diagnostic terms; the first step to solving a problem is acknowledging that there IS a problem. Her ultimate resolve however is evident throughout the entirety of her prose.
“I feel incredibly fortunate every day for the opportunity my profession provides – bearing witness to some extraordinary lives, enjoying unparalleled, intimate glimpses into the most noble aspects of humanity. In the presence of such grace, all one can do is to be grateful.”
In the end, according to Raza, cancer remains an often-fatal disease not merely as a result of bad-faith governance or corporate avarice or individual narcissism, (though there is plenty of each and there is a lot to be said about these in isolation). Rather the reasoning is simple if not reactively overwhelming: that cancer, in the present age, is an impossible problem for the state of current science to fix.
Dr Raza, if ever you get the chance to come across this – please know that your sensitivity, your passion, your clarity and your command are the very virtues with which one day we will win this war against cancer. Thank you, Dr Raza for your contributions. And thank you M, for this book.