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Surescripts
Suppose that jazz saxophone giant John Coltrane couldn’t die, as the moral philosopher Todd May imagines. With eons of time stretched out before him, perhaps even Coltrane would eventually stop practicing new scales and techniques after late-night gigs, as was his habit, and join his fellow musicians to drink, smoke and socialize. Immortality guarantees tomorrow, and tomorrow after that, ad infinitum, transforming Coltrane’s drive and passion into apathy and boredom. Immortality, in other words, drains the life from his days.
But share this argument with someone diagnosed with cancer—or with Coltrane himself, who died of liver cancer at 40 in 1967, at the height of his fame—and this philosophical exercise becomes cold comfort. So, too, for those of us working to optimize the use of health information in delivering care to patients, who see how scientific and technological innovation can speed time to therapy for those who need it most.
We can accept May’s argument against immortality and still conclude that if time is all we have, cancer puts time (and our innate desire for more of it) into sharp focus. A young mother with a suspicious lump in her breast nervously asks her doctor, “Did we catch it in time?” An elderly man with metastatic lung cancer growls, “How much time do I have left, do you suppose?” To a greater or lesser degree, time is an ever-present concern for each of us. And if we reject immortality, as May does, we see that time fuels drive and passion in our lives. It lends meaning to our ephemeral reality.
But at the level of reality where you find the cancer cell, the ordinary rules of mortality break down. Siddhartha Mukherjee’s Pulitzer-winning The Emperor of All Maladies is an attempt to make sense of a disease that lives forever. Mukherjee writes: “One of the most provocative examples of a cancer cell’s behavior … is its immortality.” He muses about the mechanism that “allows a cancer cell to keep dividing endlessly without exhaustion or depletion generation upon generation.” Unfortunately, Mukherjee cannot describe how this mechanism works. This is not his failing: no one knows.
Ovarian cancer took my grandmother’s life at 70, which brings us back to time: Since my grandmother’s death, my widowed nonagenarian grandfather has lived for a second lifetime—over two decades—in his house west of Chicago, the house in which they raised their family and the house in which my grandmother died. For all of our talk about immortality, two decades is an eon of time in human terms, time enough for Coltrane to continue pushing the boundaries of modern jazz on his saxophone, or for my grandmother to paint and play her electric organ and enjoy life with my grandfather.
In Maladies, Mukherjee traces cancer’s millennia-long reign over us, from the ancient Egyptian surgeon Imhotep and his early observations of cancer as “bulging tumors … hard and cool to the touch,” to our present-day understanding of cancer’s genetic anatomy. Perhaps more troubling than the conundrum of cancer’s immortality is the notion that it’s part of who we are, not a foreign viral microbe, but “stitched into our genome,” as Mukherjee writes. We accumulate genetic mutations in our cells, especially as we age, and malignancy proliferates. This may be as “natural” for us as anything else we encounter in the natural world, but the subtext is that we aren’t much closer to a universal cure for cancer than we were four thousand years ago, when Imhotep first described it.
And we feel the sweat on our palms as we wait for our lab results. Or we feel the crush of anxiety as we see paperwork prioritized over patient care, undermining the innovation and delivery of the latest cancer medication with weeks-long delay.
Among the defining characteristics of war are duration and intensity, and in the war on cancer, though we haven’t discovered a cure (engineered is perhaps more precise), we have won many significant battles. In a July 2019 New Yorker piece, Mukherjee describes the scientific and technological innovation of CAR-T therapy, a promising form of immunotherapy involving white blood cells that are genetically reprogrammed to attack cancer. As a “living drug,” CAR-T is markedly different from traditional therapies. Like cancer, living drugs don’t die; they remain active within the patient’s body. In a sense, the drug is the patient.
This is personalized, bespoke medicine, made from the patient’s own cells, and in some cases appears to provide a bona fide cure.
However: “We don’t entirely know how to regulate, or even conceptualize of, this new generation of drugs,” Mukherjee writes. With immunotherapy, we are learning how to take cancer down a peg or two, but as an experimental therapy, patients and their clinicians get caught in red tape, underscoring the need to streamline and automate specialty prescribing. And it’s costly, which drives our need for new approaches to reimbursement and patient access.
We’re back yet again to time: As these life-changing drugs go to market, it’s our job to get them into the hands of those who need them, from today’s John Coltrane to every child’s grandmother. And every child.
Over the past 300 years—roughly the lifespan of industrial civilization so far—we’ve inched from cancer as a death sentence toward cancer as a manageable, chronic condition. If we can get there, that may be more than enough. Like May, Mukherjee appears to reject immortality and argue in favor of time: “[W]e might as well focus on prolonging life rather than eliminating death,” as he writes near the end of Maladies. To that end, he offers an encouraging aphorism: “Death in old age is inevitable, but death before old age is not.”
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