With Budd Mishkin
An intimate look at cancer from a doctor deep in the trenches. The soulful memoir is called “Cancerland.”
Franziska Michor, professor of computational biology at the Dana-Farber Cancer Institute and a professor at Harvard University.
From The Reading List
Excerpt from “Cancerland” by David Scadden
Raised to believe I had a responsibility to serve others, I imagined working as a small-town physician would be a dream, and so I applied to medical school. There I discovered both the limitations of what medicine could offer to patients and, despite how much I had to learn, how little was really known about the workings of the body. The revolutionary ability to understand the body and diseases at the level of molecules, molecular biology, was just beginning. Figuring out how things work at a fundamental level, such as individual molecules and cells, was just electrifying. I didn’t think I had the ability to contribute at that level, but it was clear medicine would be transformed by it, and I wanted to be a part of making it happen.
I knocked on the door of Adel Mahmoud, a fabulous physician and scientist, and an inspiring teacher. He was working on how a dreaded parasite, Schistosoma mansoni, could outwit the immune system and cause the devastating liver diseases he had seen growing up in Egypt. He welcomed my clumsy presence in his lab. I spent whatever hours I could steal from my classes and rotations in his lab mostly making a mess but loving the chance to connect with solving a real problem. Nothing was more compelling than discovering for the sake of relieving misery. It drives me to this day. I added nothing to the lab’s effort, I am sure, but it gave me a passion for trying to figure things out. Trying to understand a process to gain some dominion over it so that, just maybe, it could be tamed to help people I knew needed it. I left medical school for the postgraduate training program I thought was the most rigorously committed to using science for patient care in the country, the Brigham and Women’s Hospital at Harvard Medical School. It was tough, demanding, and unbelievably rewarding. Nothing was accepted on the basis of “because that is the way we do things.” People, from interns to the most senior faculty, were expected to defend their decisions based on either scientific study or logical deduction from what science could offer. It is now called evidence-based medicine and is a commonplace, but the Brigham stood out then as it does today for baking that into the culture and into every patient care discussion.
One day, I got a call from my parents. My mother had advanced cancer. I was an intern and pretty frayed by the every-other- or every-third-night-on-call schedule. Thirty-six hours on, twelve off would now be considered torture. I was struggling to keep up with the patients under my care and still tie my shoes. My family was a cushion of comfort and stability I knew I could rely on. That was now gone. Not even the bright light of my mother was without jeopardy. I couldn’t take time off, but a friend told me of the hospital toll-free line so I could check in often. That nearly got me fired: it turns out toll-free was anything but. I finally got my mother to have surgery at the Brigham. It was wrenching to be there as family and intern, but at least I could stay close to what was unfolding.
The paucity of options for my mother made my decision about training for me. I had to go into cancer care. But as I read more and got involved more, it seemed that clinical oncology research was largely focused on mixing and matching different combinations of poisons. There was a paucity of science beyond pharmacology. Hematology and the study of blood cancers were, in contrast, increasingly driven by the emerging field of molecular biology. Indeed, hematologists had almost invented what we now call precision medicine in blood banking and transplantation, where lab analysis of specific blood features could indicate compatibility or danger. In cancer, blood cancers were being recognized as distinctive because of specific genetic abnormalities. It seemed that figuring things out was closest to having an impact on people through the study of the blood, so I chose both hematology and oncology as my subspecialties within internal medicine.
The choice of specialties was also affected by a sense that when confronting cancer, people are their neediest and their most authentic selves. It is a time when connection to others is intense, but real and simple kindness resonates long. The darkness of the diagnosis dissolves veneers while putting deep values in sharp relief. For patients, their loved ones, and my fellow caregivers, cancer largely sweeps away what distracts us so much of the time and reveals the very essence of what it means to be human. In this state, we are revealed, and in the vast majority of cases, what can be seen is inspiring. Given the options of science and medicine, I chose both. The decision led me to a forty-year devotion to the problem of cancer as it presents itself in our lives, in our laboratories, and, given its wider implications, in its social context. In this time, I have marveled at astounding advances in our understanding and felt intensely grateful to be working in this era of discovery. I have also been required, by experience, to accept that today’s promise is often tomorrow’s disappointment and that the processes that produce health and illness are incredibly complex. A telling example can be drawn from my own area of research. Where once we thought it was enough to know that our bone marrow is responsible for the production of blood cells, we now appreciate that the marrow and the adjoining cells engage in a complex dance that enables cell production. The niche that makes up this specialized environment wasn’t widely recognized until about 1980, and we are still learning about how it works. The complexity of different body systems helps to explain why laboratory advances and even experimental successes with animals do not necessarily translate into therapies for people with cancer. But we should not be discouraged by the fact that seeming leaps forward turn out to be smaller steps toward understanding. All the science that has gone before has brought us to a place where, as we develop more sophisticated understanding of disease, we can begin to imagine more sophisticated methods of treatment.
Today’s research efforts bring together more teams comprising different kinds of scientists, including chemists, cell biologists, physicists, and engineers, than were ever seen in laboratories of old. Today, we even include experts in so-called big data analytics and information technology on our teams because these disciplines help us to understand profoundly complex systems and manage knowledge.
The current state of science and medicine finds us tantalized by possibilities. Cancer therapies that rely on engineered viruses and immune cells improved in the laboratory have been successful in small trials. Research has produced vaccines that can prevent certain kinds of malignancies, such as cervical cancer and liver cancer, by creating immunity against so-called oncoviruses, including human papillomavirus and the hepatitis B virus. Others, which have been approved to treat metastatic prostate cancer and melanoma, appear to be effective against active disease. The genetic variety found in cancers suggests that we may never find a silver-bullet vaccine to stop all malignancies. However, rapid advances in the technology that sequences genes offer hope that custom-made immunotherapies could be within reach.
More promise is coming from work on stem cells, including some of the projects in my own lab, and from investigations into the naturally occurring immune processes that keep mutations from developing into cancer. These and other developments, including technologies that allow for more precise surgery, radiation therapy, and chemotherapy agents, have yielded big headlines in the press. When a program such as 60 Minutes tells viewers about brain cancer cured with attenuated polio viruses, as it did in 2015, excitement ripples through entire communities of people concerned with cancer.
Everyone hopes that we have arrived at a point where effective, less-toxic treatments and even cures for a host of cancers are at hand. Huge industries are emerging to support research into the treatments of the future, and the people who run clinical centers stress that they offer the very latest—custom-tailored treatment is the term of art—to patients who come seeking care. No one wants to miss out, and as a consequence, we are beginning to see a flood of advertising by hospitals and companies that make medical technologies. In New York City, you can even tune your radio to hear weekly hour-long broadcasts by a radiation oncologist who pitches his treatments as an effective therapy for patients who have been told by other doctors that they have no options.
With so much talk about potential breakthroughs and so much publicity touting options for care, a bubble of expectation is ever present. The pressure of this bubble is felt by every person who has an interest in cancer, which means all of us. We live in a time when molecular science is moving at an extraordinary pace, revealing the innermost secrets of how the body works, and our discoveries are giving us good reason to hope. The people, places, and ideas that energize these hopes are exciting to behold. However, we must balance our hope with understanding, lest we become diverted from the course that will serve us best.
Excerpted from CANCERLAND: A Medical Memoir by David Scadden, M.D. with Michael D’Antonio. Copyright © 2018 by the authors and reprinted by permission of Thomas Dunne Books, an imprint of St. Martin’s Press.
Kirkus Reviews: “‘Cancerland’ by David Scadden” — “Stories of loss and hope from distinguished Harvard oncologist Scadden. Having spent much of his career on the cancer battlegrounds, the author writes with authority that cancer is an “immutable fact of life.” When Scadden was growing up in the 1950s, he was confused and traumatized by the cancer deaths of three people he knew. As a medical student at Case Western Reserve University, the author encountered his first patient cases, which prepared him for a livelihood built on a delicate combination of medical precision and compassionate humanity. Scadden shares poignant and moving anecdotes of his patients as a student earning a real-world medical education—e.g., learning about childbirth from a gracious pregnant woman or delivering a devastating prognosis to a lymphoma victim. The author’s account of the personal pain of watching his own parents navigate cancer treatments leads into a probing discussion on how far early formative therapies have evolved, including how his work with stem cell research has branched out to encompass a wide array of afflictions.”
It’s no stretch to say that everyone knows someone who has been affected by cancer. Dr. David Scadden knows the pain firsthand. He watched his mom battle cancer, and then his dad, while treating his own patients. Now he’s written what he calls a medical memoir titled “Cancerland,” including the pain of diagnosis, the joy of survival and, always, the search for a cure.
This hour, On Point: Cancer. Where we’ve been, where we’re going.
— Budd Mishkin