Thursday, April 2, 2015

Cancer: The Emperor of All Maladies (Florentine Films/PBS, 2015)

by Mark Gabrish Conlan • Copyright © 2015 by Mark Gabrish Conlan • All rights reserved

The last three nights I’ve been following an interesting if sometimes frustrating mini-series on PBS called Cancer: The Emperor of All Maladies, produced under the auspices of Ken Burns and his production company, Florentine Films, even though Burns actually had nothing to do with making it. The people who did were veteran movie producer Laura Ziskin, who acquired the film rights to a book by cancer researcher and clinician Dr. Siddhartha Mukherjee called The Emperor of All Maladies: A History of Cancer; and Barak Goodman, who actually wrote and directed the resulting film. A movie about cancer — documentary or dramatic — would seem one of the chanciest projects a filmmaker could take on, mainly because the subject virtually invites tear-jerking, and also there are so many vested interests in the “cancer industry,” including pharmaceutical companies (Genentech, one of the leading enterprises working on molecularly elaborate and outrageously expensive cancer drugs, is one of the principal sponsors), dedicated clinics (the Cancer Treatment Centers of America, which makes enough money it advertises regularly and extensively on commercial TV, is the other lead sponsor), nonprofits like the American Cancer Society, the Leukemia and Lymphoma Association and Stand Up to Cancer (all also present on this show’s ultra-extensive sponsor list) and individual clinicians and researchers, it’s hard to imagine a treatment of the subject that won’t step on some people’s toes. Needless to say, this being PBS, the history of cancer presented by Cancer is an exclusively mainstream one — even though the Cancer Treatment Centers of America’s own TV ads stress that they offer “complementary” therapies in addition to the Big Three of mainstream cancer treatment (surgery, radiation and chemotherapy), no hint of any alternative therapies is shown on this program.

The film, narrated by Edward Herrmann (a final credit dedicating the film to people no longer living — presumably after cancer-related deaths — lists both Herrmann and producer Ziskin among the in memoriams), stretches out the history of cancer over six hours and intersperses the historical information with stories of modern-day cancer patients and their families (and as one who’s worked with and for people with disabilities for over 30 years now some of these scenes seemed all too familiar to me, particularly those anxious moments as the family members and significant others wait in the waiting room for the doctors’ pronouncements and then, once the doctors speak, parse out what they had to say and what that means in terms of whether, and how long, the person they care about who’s undergoing this excruciating crisis is going to live), which is pretty much where the tear-jerking comes in. I had a number of observations about the show, of which the first and most obvious is that cancer is our modern age’s version of the Big Scare, taking the social role that plague, smallpox, tuberculosis and polio had for previous generations — indeed, as one doctor on the show mentions in passing, an observation I’ve heard elsewhere as well, it’s because modern medicine has been so good at either eradicating or controlling these ancient horrors that more people have lived long enough to get cancer. The film traces the history of cancer as a medical issue back to the ancient Egyptians — it showed a papyrus manuscript in hieroglyphics that lists various human afflictions and their appropriate treatments, and it includes a clinically accurate description of cancer and under “treatment” the heartbreaking words, “There is none.” It’s also an interesting story in that it showcases not only the way overall fashions in the medical industry in general shape the treatments for a particular disease. In the 19th century the inventions of antisepsis and anesthesia expanded the repertoire of surgical operations possible, and as a result surgery became the cutting edge of medical treatment and just about anything was thought to be curable by some sort of operation or other (even mental illness; a friend of Sigmund Freud named Dr. Wilhelm Fliess was convinced that mental illness was caused by an abnormally shaped nose, and so he performed plastic surgery on mentally ill patients hoping that by adjusting the shapes of their noses, he could bring them back to sanity). At the end of the 19th century, when radioactivity was discovered, it was considered a cure-all and elaborate machines to beam X-rays and other nuclear beams into cancer patients were devised, hoping this would cure their cancers. Later, in the 20th century, the emphasis in medical practice shifted to prescription drugs, and so starting in the 1940’s cancer researchers and oncologists started looking at chemicals that would poison cancer cells while leaving normal cells alone.

The other point this film makes especially eloquently is that cancer is maddening precisely because it’s a disease of such contradictions: it originates not from outside the body but inside it, when a group of ordinary cells somehow goes haywire and reproduces with maddening speed, causing illness, pain and death; and all too many of the treatments for cancer, including both radiation and chemo, can themselves cause cancer. The film gives surprisingly short shrift to environmental causes of cancer — they’re not mentioned at all in episode one, “Magic Bullets” (named after Dr. Paul Ehrlich and his famous statement that the key to curing disease lay in developing drugs whose molecules would act as “magic bullets” against the agents causing disease), and they’re brought up in episode two, “The Blind Men and the Elephant,” mainly as one of the three potential causes of cancer (along with viruses and genes) which oncologists were arguing about in the mid-20th century, literally in opposite camps — one cancer researcher recalls that in the 1960’s at cancer conventions the environmentalists, the virologists and the geneticists would be in separate rooms and would never talk to each other. I’ve long believed that cancer would turn out to be one of those “all of the above” chronic diseases Western medicine, with its foci on the ideas that every illness has one and only one cause; that disease comes in from outside the body rather than within it; and the appropriate way to treat it is therefore to wipe out the outside agent either by poisoning it with drugs, burning it out with radiation or cutting it out with surgery, is singularly ill-equipped to deal with. (I feel the same way about AIDS, despite the AIDS mainstream’s “success” in following what is essentially Pat Paulson’s strategy for ending the Viet Nam War: declare victory and get out. From the moment I first heard about AIDS and started learning about it, I was convinced the various diseases lumped together under the “AIDS” label had more than one cause and that real treatment would have to be tailored to each individual and what was making them, personally, sick. Now, given regimens of drugs that are either more effective or simply less toxic than the original ones from the 1980’s and 1990’s, the pharmaceutical industry and the AIDS establishment have proclaimed AIDS — or rather, “HIV disease,” as they self-referentially call it — a “chronic, manageable illness” that can never be outright “cured” but can be “managed” with regular doses of toxic and frightfully expensive drugs. Of course, since they now “diagnose” “HIV disease” just as a positive result on an antibody test for the presumed virus, a lot of people on these drug regimens aren’t actually sick at all, so of course they live longer than patients in the late 1980’s who weren’t given drugs until they were actually ill.)

Perhaps the most interesting part of the “Magic Bullets” episode was the account of how cancer activists pioneered the whole idea of marketing a disease — though they had an example before cancer became a major national concern, a road map laid out by Eleanor Roosevelt and her colleagues in the March of Dimes against polio (obviously a personal issue for Eleanor Roosevelt since her husband had it!). The American Cancer Society was organized largely by a philanthropist named Mary Lasker, and her portrayal here drips with irony — her husband, Albert Lasker, was 18 years her senior and had made his money as an advertising executive masterminding, among other things, the successful ad campaign for Lucky Strike cigarettes; he later died of cancer, and Mary Lasker is shown here being interviewed on the Person to Person TV show by Edward R. Murrow, cigarette in hand — Murrow contracted smoking-related lung cancer and died in 1965. Lasker and the doctors she consulted with realized they needed to put a human face on the disease to open the wallets of America, and so they identified a patient with childhood leukemia and changed his awkward immigrant name, Einar Gustafsson, to “Jimmy,” featuring him prominently in their promo films and even naming the cancer research and treatment hospital they built in Boston “The Jimmy Fund Clinic.” (The Jimmy Fund Clinic building still exists and “Jimmy” himself lived to be 65, a rare success story in the early days of cancer treatment.) The second episode, “The Blind Men and the Elephant” — a reference to the famous poem by 19th century British writer John Godfrey Saxe about the blind men who felt different parts of the elephant and thereby came up with very different ideas of what an elephant was like (a wall, a spear, a snake, a tree, a fan, a rope) when “each was partly in the right/And all were in the wrong” — dealt in part with the dispute over whether cancer’s “true” cause was environmental, viral or genetic. The show portrays the “War on Cancer” launched by President Nixon with a funding bill passed by sweeping bipartisan margins in the U.S. Congress (before our modern days when the two major parties are so riven by ideological splits — though, as Eric Alterman notes in the current Nation, that’s largely because the Republicans have a coherent ideology and the Democrats don’t — it’s virtually impossible to get bipartisan agreement on anything, except maybe military spending), and though the program doesn’t make the point as explicitly as I would have liked, it was basically the viral faction of the cancer establishment that got to spend the money under this bill … and came up with a lot of exciting lab discoveries on how to cause cancer but almost no advances in how to treat it.

By the end of the “War on Cancer” (or at least the initial funding push for it, which dried up in 1986) the focus began to shift to gene-related explanations for cancer, which had a certain “Well, duh!” aspect to it — if you have a disease whose hallmark is the uncontrolled division of cells whose control mechanisms have gone haywire, it’s logical to think that genes, which after all are what give instructions to the cells on how to behave and what to become, including when and how often to divide, would have something to do with it. Ironically, the first two episodes of the program deal with the expectations raised by groups like the American Cancer Society and researchers (whose own papers are frequently far more qualified and uncertain than the versions that get filtered through the mass media and end up in the public consciousness) that the breakthrough which will “cure” cancer (itself a misnomer because “cancer” is a catch-all name for a multitude of different phenomena and it’s almost infinitesimally unlikely that there will ever be a definitive one-size-fits-all “cure” for it — a fact that the scientists interviewed in this film seem sporadically aware of and then appear to forget) is just around the corner, and only give us a few years and a few tens or hundreds of millions of dollars more and we’ll end cancer once and for all — when the end of this movie seems to be heading in that very direction, with the rise of gene therapy and immunotherapy as the cutting-edge treatments for cancer and some audible concern that a Republican-led Congress intent on cutting back all non-military spending is going to lead to lower funding for cancer research just when we’re on the one-yard line. (What makes this especially ironic is that one of the show’s principal sponsors is David Koch, who when he isn’t buying PBS sponsorships and thereby insulating himself from criticism on public television — the New York PBS affiliate did a documentary critical of him and he was able to use his membership on the PBS board and his financial influence to have it quashed — he’s giving money to the very political candidates who are defunding domestic spending in general and scientific research funding in particular because they see scientists as a bunch of atheistic crazies propounding dangerous, heretical notions like the theories of evolution and human-caused climate change.)

The big problem with using the human immune system as a front-line defense against cancer, of course — and like many of the scientific complexities, it’s touched on here but not really engaged — is that the whole point of the immune system is to determine “self” (this is part of me, and therefore I will defend it) from “non-self” (this is something from outside of me, and therefore I will hunt it down and kill it), and since cancer cells are by definition “self” (they come from your own body and are like all your other cells except for the mutation that makes them cancerous) an immune-based cancer therapy is only going to work if it can somehow fool the immune system into thinking your cancer tumors are “non-self.” The day before PBS started airing this show, CBS’s 60 Minutes ran a laudatory episode about researchers who are deliberately infecting cancer patients with polio virus (genetically modified so it supposedly no longer has the ability to cause polio) in hopes they can get the tumors sufficiently ridden with polio that the immune system will read the polio-infected tumors as “non-self” and kill them. Transplant patients, of course, have the other problem; their bodies’ immune systems read the transplanted organs as “non-self” — as essentially a gigantic infection — and therefore the doctors treating them have to give them drugs that deliberately suppress the immune system; this would not ordinarily seem to be a problem in cancer therapy, but this show depicted one young patient who was given a new immune system grown from his sister’s bone marrow, and despite their genetic similarities his body rejected it big-time and they had to give him massive doses of a drug called interleukin-6 to get his body to stabilize and stop attacking itself.

If there were any people in this show whom I would consider heroes, in episode two it was Dr. Bernard Fisher, who in the 1960’s challenged the medical orthodoxy that the only way to treat breast cancer was with a “radical mastectomy” — removing not only the entire breast but also the lymph nodes and the muscles supporting them — my mom has told me she remembers from her own work as a nurse seeing women who’d had this operation and their arms hung limply on their sides because there were no muscles there to hold them up — and he insisted that for most women a simple “lumpectomy,” removing just the tumor instead of the whole breast, would be sufficient. He got trashed by his colleagues and virtually read out of the cancer establishment (like so many of my other scientific heroes, including nuclear physicist John Gofman, read out of his profession for insisting that nuclear power plants were inherently unsafe; and cancer researcher Peter Duesberg, who was a key figure in the discovery and identification of oncogenes — cancer-causing genes — in the 1970’s until he first questioned whether oncogenes were a significant factor in human cancers and then got definitively anathemized for daring to suggest that the retrovirus HIV was not the cause of AIDS) until his work was discovered by women activists in the nascent second-wave feminist movement in the early 1970’s and they pushed the cancer establishment to reconsider and stop unnecessarily mutilating women in the name of a crack-brained theory about how cancer spread that was being disconfirmed by the facts. In episode three it was Dr. Suzanne Cole, who fascinated me if only because she continued to work the experimental oncology wards while she was visibly pregnant — which fascinated me because there she was, showing off the beginnings of a human life while dealing with people who were very likely at the ends of theirs.

Among the fascinations of Cancer: The Emperor of All Maladies were the political pressures brought to bear on researchers, clinicians and especially pharmaceutical companies — the third episode shows footage of demonstrations led by ACT UP, a group formed to agitate for people with AIDS who turned their attention to cancer (especially once the Lesbian community fixated on breast cancer as “their” disease and claimed that Lesbians were at higher risk for it than heterosexual women — which turned out to be true, at least to an extent, though less because there was something inherent in Queer women that made them more vulnerable to breast cancer; rather, it was that medical care for women was focused almost exclusively on their role in reproduction, so women who by nature or choice weren’t engaging in potentially procreative sex didn’t get the kinds of screenings that would have allowed for early detection of breast, cervical or ovarian cancer) and targeted drug companies that were pricing cancer treatments out of the financial reach of most patients. (There’s an interesting aside on this program about just what a financial catastrophe cancer can be, especially in the United States, with our much-vaunted “freedom” from a government that guarantees health care as a human right and pays for it collectively with tax money, while people in developing countries who get cancer often don’t have access to treatments at all.) What’s also interesting about it is that, precisely because the social expectation is that cancer is virtually always fatal, doctors feel entitled to experiment on their patients and give them incredibly toxic and unproven drugs on the ground that if the drugs don’t work they’re just going to die at about the same time they would have otherwise, while if they do there’s always a chance of establishing for future patients that they work. Though hampered by the “official” auspices under which it was produced — as Celia Farber noted, journalists reporting on science tend to be far more deferential to their sources than ones writing about other things, mainly because science journalists seem all too aware that the people they’re writing about are Big Experts in the field and they themselves know comparatively little about it — Cancer nonetheless raises interesting questions about how we know what we think we know about health and disease, and whether a multifactorial phenomenon like cancer will ever yield to the mainstream allopathic paradigm of one disease, one cure, one treatment.