by Syed Tasnim Raza
When I was a young attending surgeon on the faculty in the Division of Cardiothoracic Surgery, one of the things I got frequently called for was management of malignant pleural or pericardial effusions. Once a patient develops malignant pleural or pericardial effusion the median survival is only two months, so I would do things that would relieve the acute symptoms and perhaps try to prevent fluid from reaccumulating, but nothing drastic or major. One evening in late October, one of the nurses who had known me called to say that her father was being treated for lung cancer but had to be admitted with a large pleural effusion and that she and her father’s Oncologist would like me to manage it. I met the fine 72-year old retired banker, and while he was short of breath even as he talked, he was in a very upbeat mood. I decided to insert a chest tube to drain the pleural fluid and relieve his symptoms. As I was doing the procedure at the bedside the patient mentioned to me that his oncologist has assured him that once his fluid is out he will start him on a new regimen of chemotherapy and he should expect to live for a few more years. I was disturbed to hear the false hope he was being given.
Later on, his daughter asked me what I thought of his prognosis and I asked her if I should be honest. She said yes, please. I explained to her that I was concerned by the false hope the oncologist had given her father, that he may indeed live many more years, but the chances are he will not see Christmas in the following year, and at least he should be prepared for such an outcome. The next day the patient asked me directly and I gave the same answer, in other words one should hope to live long and beat the odds, but always be prepared for the alternative. After he was discharged and went home, he organized a big Thanksgiving dinner for his extended family, including his three sisters he had not seen in many years. He died in mid-December of that year. I went to his funeral and his daughter and wife hugged me and thanked me profusely for being so honest and what a wonderful Thanksgiving he had before he died. And he was able to say goodbye to his loved ones. In my own practice I have felt that it is good to give patients hope, but it should be realistic and honest.
In her remarkable book “The First Cell,” Azra (full disclosure: Azra is my younger sister) has been brutally honest at every level.
President Nixon declared “War on Cancer” in 1972, but as shown in this book there has been little improvement in the prognosis of most cancers. The only decline in the death rates from cancer we have seen are due to early diagnosis from routine screening and the ability to treat cancers at such an early stage. Yet we hear of new miracle cures, transformational new drugs and so on frequently, followed by the same disappointments. No one in the leadership of those treating cancers are willing to accept their failure and continue to give false hope to the patients. If we really are serious about winning the war on cancer we need to start by exactly what this book does. Take stock of where we are. What have we learnt from the billions of dollars spent on research in the cancer field and how to go forward? The book informs us that 95% of the new drugs tried for treating cancer don’t make it through the FDA approval and the 5% that do get approved have increased the survival by a few months only. Azra correctly asks if it is not time to acknowledge our failure and try some new venues of research. To think outside the box. To make a 180 degree turn.
‘The First Cell’ is really three books in one but they are intertwined and weaved together perfectly, so that they read well. The first book describes the science of cancer, and it is beautiful. The highly complex nature of cancer cell, its differences from the normal cell, its relationship to the ‘ageing cell’ (the Replicative Senescence) and the cancer cells’ ability to maintain the length of telomeres and thus keep dividing unlike the ageing cell. All this and more has been explained in very simple terms so people like me, who are not familiar with cancer can understand and appreciate it. There is of course much more, the Oncogenes, proto-Oncogenes, the surveillance function of the tumor suppression gene p53, and how cancer cell overcomes this function.
The second book is the highly emotional and detailed stories of several patients with cancer, including Azra’s own beloved husband Harvey Preisler and her daughter Sheher’s best friend, Andrew. These and other stories of cancer patients really put things in perspective. They lay out the human and emotional price of cancer, how it affects families for life. They also point out why it is so important for oncologists to have compassion. To suffer and see one’s loved one dying of cancer with intense pain and other indignities is not easy and on top of it if the families feel that the oncologists did not ‘care’ it becomes so much worse for them to live with. I am sure there would be some explanation, but it was very disturbing to read that the oncologist who saw Andrew and recommended treatments at the New York Special Hospital never saw Andrew again even though he was hospitalized for four months and he and his family went through living hell.
Azra herself shows what an exemplary oncologist would do. She would become friends with her patients, would sit with them talking about their lives, their emotions, their aspirations. She would invite them to her home, visit them in their homes and maintained long term friendships, all the while treating them for their cancers. These stories really make the book very powerful in its message. As Azra states one of every two men and one of every three women will develop cancer in their lifetimes, and many will die of the disease after much pain and suffering. With compassion will come the urgency of finding answers to the riddle of cancer and to reduce the suffering and treat the deadly disease.
The third book is the literary treat and the pleasure one gets out of references to poetry, literature and lessons learnt from the classics that Azra explains throughout the book. Her command on Urdu poetry and on the Western canon is impressive on its own but the way she has related these lessons to the story she is telling is much more impressive.
Perhaps, I am losing myself in the beauty of the book and have not mentioned the main thrust of her book, which is a challenge to the scientific community particularly the leadership of the cancer enterprise to come down from their high horses, accept and acknowledge the failure of cancer treatments thus far and find other ways to treat it. She describes in detail about the ‘Tissue Repository’ that she has developed where she has collected thousands of blood samples over the last 30 years from patients she has treated for cancer. Their serial blood samples before and after treatment can shed light to the effects of medicines and changes in the gene expressions and other scientific methods, which may lead to developing better drugs. Azra has shown in the book why trying new drugs to treat cancers will not make a difference, but the thrust should be on detecting it early where treatment may be more effective. Currently early detection means screening mammograms, chest x-rays and other tests to pick up cancers. But by the time cancer is visible on an imaging study it is already too late to cure it. What Azra is suggesting is to detect cancer at the cellular level using a tube of blood and eventually a drop of blood, or even implantable devices that may pick up mutations in cells that may suggest cancer developments and treat the first cell that becomes cancerous. She discusses at some length how to improve surveillance for early detection of cancer in every human being. That may be the best hope for cure of this scourge.
This book is a must read for all physicians and everyone who has been effected by cancer personally or in their loved ones and by those who have even remote interest in cancer. It should be required reading for those in cancer research and for those in the medical bureaucracy who are in positions of power to make decisions where the research funding goes.
I recommend it highly.