Throughout my career as a neurosurgeon, I have worked closely with oncologists. Many of my patients have cancer of the brain — one of the deadliest of the near-infinite number of cancers. I have always viewed my oncological colleagues with complicated, contradictory feelings. On the one hand, I’m in awe of their work, which can be so emotionally demanding. On the other, I suspect they don’t always know when to stop.
There’s an old joke in medical circles: “Why should you never give an oncologist a screwdriver?” The answer: “Because they will open the coffin and carry on treating the patient.”Azra Raza, an oncologist at Columbia University, vividly illustrates this tug-of-war in her book “The First Cell: And the Human Costs of Pursuing Cancer to the Last.” It is, in many ways, a cry of protest against the disease that killed her husband (also an oncologist) and, over time, most of her patients. When it comes to cancer, Raza knows firsthand how hard it is to reconcile compassion with science and hope with realism.She asks hard questions: “Why are we so afraid to tell the stories of the majority who die? Why keep promoting the positive anecdote? Why all this mollycoddling?” She says the time has come to think about the “ghastly toxicities of therapies” that often achieve so little. And she intersperses an impassioned argument about the ineffectiveness of current cancer medicine — at least for most patients with metastatic disease — with descriptions of the suffering of her husband and some of her patients (who are identified by first name, with photographs). By describing this suffering, Raza says, she hopes to jolt people into looking for a new paradigm in the so-called war on cancer.Raza documents the failure of chemotherapy to help the great majority of patients with metastatic disease, and the immense cost and suffering involved. She castigates pharmaceutical companies (as have many others) for concentrating on drugs that often fail and at best achieve, on average, a few extra months of life. She quotes research that in the United States, over 14 years, “42.4 percent of the 9.5 million cancer cases had lost all of their life savings within two-plus years.”Raza also accuses research scientists and her fellow oncologists of “unshakable hubris, convinced as we are that we possess the power to untangle the intricacies of as complex a disease as cancer.” She dismisses much current research with the comment that it is “pure arrogance” to think the problem “can be solved by a few molecular biologists”; research, she says, should be based on studying humans, not mice. She goes on to say: “Our lives are at stake. Our future is at stake.”Cancer is overwhelmingly a disease of old age, even though ads for cancer charities invariably show pictures of children and young women. It is worth noting that most of the patients whose stories Raza recounts are relatively young as well. She writes, “An effective treatment for cancer can only be developed essentially after we understand how life works, how we age, since aging and cancer are two sides of the same coin.” Fine words, but the reader can be forgiven for feeling that they smack of the same hubris afflicting those molecular biologists, toiling away in the lab with their mouse models.So what is the answer? Raza suggests the first cancer cell that gives rise to a tumor is like a grain of sand that precipitates the collapse of a sand pile. Research, she says, should concentrate on finding these early changes, before an actual tumor develops. There is research going on along these lines, but Raza argues that its funding is insufficient compared with the resources being poured into new drug development.A “quantum leap” is required, and this will involve “genomics, transcriptomics, proteomics, metabolomics; indeed, panomics.” It will also involve smart bras and special toilets — real-life technologies in various stages of development, she assures us. I am in no position to know whether these technologies represent a paradigm shift in the treatment of cancer, or whether they are akin to the magical thinking that geoengineering will save us from the unfolding apocalypse of climate change, or to the gullibility that gave rise to the Theranos scandal.At the heart of “The First Cell” is the problem of knowing when to stop treating patients who have incurable cancer, especially in the elderly. Raza recounts the case of “Lady N.,” whose cancer becomes untreatable (not just incurable) after years of chemotherapy. She is placed on a ventilator and treatment continues until her 101-year-old mother pleads for it to be stopped. Raza writes, “What I know beyond a shadow of a doubt is that to intubate her … was the worst possible thing to do to her.” She tells us that she was forced to give the patient the choice of ventilation “by the law, of course.”.I sympathize with Raza. I’ve had patients with slowly evolving brain tumors. I got to know them well; we became friends. I had guarded conversations about their future — trying to provide hope, but not too much hope. On several occasions, I operated yet again when I should not have done. This was not because the law dictated that I give my patients a choice, but because it was so unbearably painful to spell out the truth to them.Often, there is a little fragment of hope, if only for a few more weeks of life, as medicine is almost always about probabilities rather than certainties. Patients hope they will be statistical outliers, one of the minority who “do well.” This can all to easily lead to a folie à deux between doctor and patient. And in a country like the United States — with its optimistic culture and commercially driven health care system — this all too human weakness can, and does, lead to grotesque overtreatment of very sick people.”The First Cell” raises many profound questions but fails to provide clear answers. What is abundantly clear is how deeply Raza cares for her patients. Her diagnosis of the ills from which cancer treatment suffers strikes me as accurate, but her solutions seem infused with the same unrealistic optimism she identifies as the cause of so much suffering. Time will tell, but as they say, America is the land where death is optional.Henry Marsh is a neurosurgeon and the author of “Do No Harm” and “Admissions.”THE FIRST CELLAnd the Human Costs of Pursuing Cancer to the LastBy Azra RazaIllustrated. 368 pp. Basic Books. $28.