The Emperor of All Maladies

GENESIS

I.

On Monday, Carla had a headache.

“Take an aspirin,” her doctor told her breezily. It was just stress, then. “April had arrived so fast,” she thought, chasing the day along... lilacs for Sarah's birthday, mulch for the garden, and the big clean was next weekend. Carla had always looked forward to spring. The pictures from Sarah's first birthday, three years ago, showed mother and daughter in matching floral dresses, their smiles both bursting into bloom. Why, now, did she feel hers wilting?

When Alfie found her napping for the third time, his indulgence took a hint of concern. “Are you sick? You're so tired recently...” Full of apologies and reassurances, she hurried, half dressed, to help prepare dinner. But her plate was already cold and the dishes put away.

“What time is it?”

“8:30.”

“Why didn't you wake me earlier?”

He hesitated. “I was worried you were sick. I thought I should let you rest.”

“It's nothing, Alfie. Just a virus,” she reassured him, scoldingly.

It was Friday when she found the bruise. It wrapped all the way around her leg, a black python. She nearly screamed when she saw it.

“What's wrong?” And, “Oh my god, Carla – what happened?”

“I don't know, I don't know, I didn't hit it. It doesn't hurt,” she protested, numbly.

The second doctor looked at the bruise, and looked at Carla, and scribbled a series of acronyms on a notepad. “Get these done today.”

“What do you think it could be, Doc?” asked Alfie, with an edge in his voice.

“We'll see what the tests show,” she replied evasively. “We'll give you a call when they are through.”

It was Sunday and she was in the garden with Sarah when the phone rang. Sarah with a fistful of lilacs, waiting for her Mommy to come back and play. The doctor on the other end of the line saying something she didn't understand, and to come. Come now.

II.

Thus begins Siddartha Mukherjee's magisterial magnum opus, The Emperor of All Maladies. The author is on the seven o'clock train to the Massachusetts General Hospital when Carla's life flashes before her eyes and across his pager. New patient, 30 F, leukaemia, on the 14th floor. Please see as soon as you arrive.

Mukherjee's ambition is nothing less than a biography of cancer. His prose sweeps across centuries: from the ancient sands of Egypt in 4000 BC, where a slave is ordered to cut off his queen's cancerous breast, through the sterile, gleaming halls of the National Cancer Institute, six millenia later, where chemicals named vincristine, cyclophosphamide, and rituximab seep with clockwork precision into bruised veins. But a vast panorama is nothing without a human subject to take it all in.

And so we find Carla, wide-eyed, her thirty years a backdrop to the six thousand, as if projected on a screen. Sarah is gazing at her, not understanding, wanting her to come back to the garden tea party. Tears in Carla's eyes, she steps away from her daughter, into the image – a waste land of IV lines, beeping machines, chemotherapy, transfusions, and white-clad masked people who speak a language she can't comprehend.

“Leukaemia,” explains one masked lady, “is a cancer of the immune system – the white blood cells. Your blood stream is full of cancerous white cells. The chemotherapy will kill the bad white cells, but also the good ones, so you will be very vulnerable.”

White cells, she thinks, like lilacs. The lilacs are blooming. She shudders. It's April, April, the cruellest month. Dull roots stirred by spring rain.

“Any infection can be life threatening when you don't have an immune system to protect you. You need to tell your family and friends to keep their distance, if they have so much as a sniffle. Flowers? Yes, they can bring flowers, but we'll keep them outside, in a separate room. The dirt can carry bacteria.”

The waste land stretches out for miles in every direction. “Do you have any questions?” Yes – like all cancer patients, she has two.

The first is “how long have I had this for?” And it's a question about guilt. Could I have known earlier? What could I have done to prevent this?

The second is “how long have I got?” And it's a question about forgiveness.

Can I be saved?

III.

The answer, of course, is simple: time is an illusion.

There was never any sin to be absolved. Look up – your body came from stardust; our destinies were written there long before any of us were born. If you look to the horizon on a clear night sky, with a bit of imagination, you can trace it all out. It's written in the stars. Cancer, a Crab. When the ancients ripped it from the breast of their queen, they saw how deeply its claws had pierced her flesh.

And as above, so below: we are slaves to the whims of the stars. Justice has no power against cancer, it strikes the righteous and the evil ones with indifference. No sin, no forgiveness, no past, no future. Time is an illusion, Carla. Your thirty years are six thousand. Every moment is a century. Yes, weep, but don't weep for the past that will never return or the future that never was. Weep with joy for the moment. Weep for the world you won.

And, Carla, look up, and I'll show you something more than your shadow at evening rising to meet you. If time is an illusion, then, like the old Pilgrim – can we come unstuck in time?

EXODUS

I.

On Tuesday, Carla had a nosebleed.

They were gassed for the first time at Ypres. Two of his buddies went down, screaming, clawing at their face, as if they might rip out their own eyeballs. Johnny pressed the wet muslin gauze into his face, soaked with urine and sweat. Silently, he recited Our Father, each word a tombstone, each second passing like an hour. Martin was the luckier of the two – he'd been standing right in front of the canister and caught the full force of it; he was dead in moments. Tommy's unholy screams and gurgles as his lungs dissolved took a long time to subside.

“You were ranting and raving like a madman when they carried you out of there,” Jim told him later. They were lying side by side on two cots in the infirmary that smelled of sawdust. It was late at night and Johnny could see the full moon through an open window that let the damp breeze roll in. He often remembered this moment, later, when he thought of Jim. The sawdust and the sweat and the cool breeze and Jim's brown eyes. He left the window open on his wedding night, and lying next to Sophie, her hands caressing his hair, he could close his eyes and let the air waft him back to the infirmary and their love that never was.

It was two years later, with Sophie pregnant, when the nosebleeds started. The first time it happened, waking up with his head stuck to the pillow in dark blood, he had a flashback to the sodden year after the war. How many times had he woken up in a sticky puddle... That was before Sophie swearing to leave him and the tears and the promises. But he'd been dry now for over a year. This was new.

It wasn't until the fifth time, after two hours when the bleeding wouldn't stop, that he let her drag him to the hospital, her waddling ungainly, him with a bloody ice pack pressed to his face. He wished, then, he'd warned her before she decided to marry him – war leaves scars on you inside and out.

II.

Sidney Farber wore formal suits to his medical school classes. His classmates found him arrogant and nicknamed him Four-Button Sid, so he took his meticulous and conscientious nature down to the basement of the Boston Children's Hospital. There he specialised in pathology. He wrote wondrous prose about the tumours he saw under the microscope, garbed in precise technicality. Stiff and formal on the outside, perhaps, but these attributes were the gleaming train tracks that he drove with a flourish right into the heart of the cancer cell.

Farber came of age in the antibiotic era when anything seemed possible in medicine. Syphilis, that potent symbol of the wages of sin, had been cured by Salvarsan – a name chosen by its creator, Paul Ehrlich, to sound like “salvation.” The demons that had ravaged mankind for millenia – tuberculosis, pneumonia, cholera, smallpox – were all beating a hasty retreat. But Farber's cool eye was focussed on a more distant horizon. If bacterial cells could be beaten, why not cancerous ones?

In 1919, after the Great War, a pair of American pathologists had examined the bone marrow of soldiers like Johnny, scarred from mustard gas, and found a waste land. Scorched earth, just like in Ypres. The nitrogen mustard hadn't killed him as quickly as his fellow soldiers, but it had burned itself into his soul.

The bone marrow produces three different kinds of cells: red cells, white cells and platelets. It is the garden of the body, shooting forth life. Without red cells, anaemia: it starts with pallor and fatigue and progresses to shortness of breath. Without white cells, a vulnerability to infection – a cough quickly becomes pneumonia and stokes the fires of septicaemia. Without platelets, bruising, and spontaneous bleeding. Johnny was very pale as they took his temperature, his wife threading her fingers through his, one hand on his forehead, stroking his hair.

III.

Chemotherapy, then, is simple: it kills that which grows.

All progress must first come from struggle. War shapes our history. The nitrogen mustard that burned away Johnny's life was reshaped, in the hands of Farber and his colleagues, to be the first chemotherapy agents that burned away leukaemic cells. That which destroys can also cure. They published in 1948 a watershed paper in the history of cancer – children with leukaemia, treated, sent into remission (however briefly) by their new chemicals. Aminopterin and mustine, the very first salvos of the war on cancer. Johnny was still a soldier when he died, fighting in a different kind of trench.

Sidney Farber was Abraham, the first patriarch, of cancer therapy. He made the covenant, set off on the right path, and his descendants inherited the Earth. They went on to discover tens, hundreds of cancer-fighting chemicals. Anti-metabolites, anti-folates, alkylating agents... the list goes on. The chemicals that Carla is having infused into her, in the Massachusetts General Hospital in 2004, were first forged after the two great wars in 1948.

But Johnny never got to see why he had been saved above Martin in that moment on the battlefield. As he burned up in the hospital bed, his bedsheets soaked with blood, he saw Jim beckoning to him from their distant quiet room with a smell of sawdust. Please, relief, relief, he prayed. For it seemed, then, as though he had been spared by a distant and cruel God, who thundered down “Through your blood shall you live! Through your blood shall you live!”

NUMBERS

I.

On Wednesday, Carla had a fever.

“You'd better rest up and get better before the ball game tomorrow,” Sammy's Dad told him jovially. It was the first game of the Baltimore Orioles after the spring break, and Sammy had been looking forward to it for months. “Bob Boyd! Dad, Bobby just hit a home run!” he'd shouted, running to his Dad, the radio exploding with excitement. He'd tracked that 1962 season with the diligence of an accountant and the enthusiasm of an evangelical.

After he retreated to his room, though, the house grew awfully quiet. His mom went into check on him around dinner time, and found him fast asleep, his forehead hot, his breathing regular. She tucked him in, tiptoed out, and switched off the lights. “Sammy doesn't want dinner today,” she told her husband. “Aw, poor kid,” he replied absent-mindedly, not looking up from the newspaper.

It was in the early hours of the morning that his plaintive cries rang out. “Mom? Mommy? I don't feel well.” She hurried to him, bleary eyed, ready for reassurance, a glass of milk, rocking him to sleep in Mommy's arms. But she found him wide awake, scalding to touch, with his Winnie the Pooh pyjamas covered in vomit stained with blood.

II.

Emil Freireich didn't mind the blood. Emil Freireich was bloody-minded. He strode through the halls of the National Cancer Institute in Bethesda like Moses through the Red Sea, parting the waves behind him. Children shuddered in his wake. One lay, very pale and motionless, his mother's eyes glistening, one hand on his drawn cheeks, the other grasping helplessly at his hand. Another rolled on her side, arms and legs akimbo. The parents held a hand apiece while a grim doctor prepared a crucifixion, a thick bone marrow biopsy needle to be hammered into her hip. A priest swayed against a wall, eyes closed, murmuring “All things bright and beautiful; all creatures great and small.”

Freireich had inherited the doctrine of chemotherapy from Farber, but he didn't settle for reading psalms to dying children. He preached bloodfire. If a little chemotherapy could produce a short remission, lasting a few months, perhaps a bit more than that could produce remission for many months, and a lot more several years, and so on until cure.

To his colleagues, this was blasphemy; Freireich was playing God. No one before him had dared to cure leukaemia, least of all with these toxic chemicals that were as likely to kill as to save. “It's best to tell these patients to go to Florida and enjoy life,” said a senior haematologist on the hospital board, Dr Carl Moore. “If they have too many symptoms, a little nitrogen mustard, but the smallest dose possible. Anything more aggressive than that is unethical.”

By the time Freireich met him, Sammy's fevers had settled with antibiotics, and his bleeding with platelet transfusions. Freireich explained the next steps to his parents, who sat in shock, wide-eyed, tight-lipped. One chemotherapy drug would be given, and then another, attacking the cancer from as many angles as possible. The cancer cells would die, but the healthy cells in the bone marrow too. Sammy could suffer life-threatening infections, anaemia, blood loss. He could bleed anywhere, including into his brain, which was lethal. He would have to be almost killed to be reborn.

“What do you think about all this, sport?” asked his father. The joviality forced, this time.

A reply came from deep within the rumpled bedsheets. “I just want to go home, Daddy.”

III.

The regimen was four drugs: vincristine, amethopterin, mercaptopurine, and prednisone. Appropriately for the blood-sucking, life draining effect it had on its patients, it went by the acronym VAMP.

Sammy lay in the hospital for the whole of the first cycle, pale and nauseous. Messages from friends and family piled up by his bedside - “Thinking of You, Sport!” - but he didn't have the energy to read them. “Please, Daddy,” he begged. “Just take me home. I want to go home.” “Be brave, Sammy,” his father pleaded with him, choking.

After Sammy's second cycle, the nurse brought a surprise to his room. “For a very, very brave little boy,” read the card, signed by all the ward staff. They plugged in the portable television and let the black-and-white ballgame crackle to life. She smiled as she saw Sammy sit up and grin.

“Bobby! Bobby's on first!”

Freireich never gave up. In 1965, together with his colleague Emil Frei, he published a now legendary paper “Progress and Perspectives in the Chemotherapy of Acute Leukaemia,” announcing that he had developed a successful treatment. Today, the cure rate is more than 90 percent. No parent has to feel that same fear, today, when they see bloodstains on Winnie the Pooh pyjamas.

“A line drive to deep left field,” read the announcer. “That's a double! Another run for the Orioles. Five to five, bottom of the 8th, folks. We're going to take an ad break – don't go anywhere.”

But Sammy is going somewhere – slipping into a dream. The nurse sees him convulse, foam at the mouth, and runs to his bedside. She knows what this means.

“Emergency call, bed 14,” the call goes out over the paging system. “Intracerebral haemorrhage,” she says to the doctors who come running. “Call his family. I'll draw up the morphine.”

And so it ends like this, with his mother laying her head on his chest, a guttural shriek emerging from her mouth, a trickle of blood running from the corner of his. The announcer, forgotten, shouts “Boyd! Bobby Boyd, rounding the bases. A sacrifice fly, in the bottom of the 9th, to win it for the Orioles. That's it, ladies and gentlemen! That's the ball game! He's going home!”

CHRONICLES

I.

On Thursday, Carla had a cough.

I meet her in clinic in the afternoon. The referral says “lung mass. ?malignant.” I scroll through pages of notes – a CT scan, a biopsy result, past medical history, smoking history. All of it rendered in medical jargon, designed to safely insulate us medicos from the reality it represents.

For Amanda, this is the worst day of her life. For me, it's a Thursday.

“Can we do an operation?” demands her husband. “To cut it all out?” No, I explain wearily. The pincers are too deep in the flesh. Once cancer has spread from one organ to another, it is metastatic, stage four, incurable. It will move inexorably to further organs. Treatment is palliative. We can slow this monster, even shrink it, but never kill it.

She is crying now. I make an empty gesture with a box of tissues. “I'm glad I don't have your job,” says her husband, sympathetically. I don't reply, not because he doesn't understand, but because he does.

I sketch out a plan – blood tests, DNA tests, a CT scan of the brain, with chemo to start in the next two weeks. She thanks me as she leaves. What for, I wonder.

II.

In emergency departments, all the sufferings of humankind are written in misspelled bullet points and three-letter acronyms. Hemingway once wrote a short story in six words: “for sale: baby shoes. Never worn.” Clearly, he never worked in ER: awfully long-winded. If “Anna Karenina” were summarised by an emergency physician, it would read “28 F vs train. Hx: home w partner ?suicdal intent”

“Oncology on call?” is the first question the ER doctor asks me, cheerfully. When I respond in the affirmative, he asks if I can admit his patient. Beeping machines play in the background, giving his story a musical lilt. “67 year old lady, background lung cancer on chemo, presents with shortness of breath. CT shows a large right sided pleural effusion. On blood thinners, need to withhold, wondering if we can admit under you guys for drainage tomorrow.”

Simple enough. I pepper him with questions. What chemo? When did she last have it? What's her platelet count? He scrolls through her file and answers, although I can tell his mind is already elsewhere – looking across to Fast Track where a triage nurse has scribbled “33 M, carpenter, nail vs hand.” Diligently, he adds “X-ray, refer plastics, check tetanus status pls”

I see Amanda after the fluid is drained and she can breathe again, without oxygen. She wants to travel overseas to see her son and asks, hesitantly, if this is OK. Of course it is, I reassure her, we'll work around it. Delay chemo a week if we have to. Family is most important. See Florida. See the mountains, where you feel free. Enjoy your life. Enjoy your time.

III.

A year passes before I get the second call. It's another Thursday. The voice on the other end is more circumspect. “Your lady – she had a seizure, witnessed by family. Post ictal and drowsy in the department. We loaded her with Keppra and gave eight milligrams dex. The CT brain is back, I'll, uh, just read you the report: multifocal metastatic disease both infra and supra-tentorial, with surrounding vasogenic oedema and mass effect.”

It's a lot of words to say she's going to die.

In hospice, flowers are allowed. The vase next to her bed is filled with lilacs. Family take it in shifts to sit with her through the day and sleep by her side during the night. Whether she hears anything they say in those last days, no one knows. We direct a fan at her face to make her breathing easier. Breathe, Amanda, Shantih. Shantih. Shantih.

So it goes. She was born in January, married in February, bore children in March. But April came, always bloody April. The cruellest month. It was all an illusion, and the illusion broke. And she is waking up, waking up to see her sons and daughters, angels each and every one of them, sitting around her in resplendent glory. HURRY UP PLEASE IT'S TIME, they say in chorus. And so she ascends. Her body, riddled with cancer, is full of holes – but she plucks the lilacs from the vase and fills each one. No more holes. She is whole. She is holy. HURRY UP PLEASE IT'S TIME. There is no sadness, only light, only joy.

Her mother is here, saying, Father will be here soon. Amanda, Amanda, you're here. We made it. She threw her arms around her shoulders and pressed her face in her neck. All we have to do is wait for him now.

JOB

I.

On Friday, Carla was in pain.

Pain exists in a space that wishes only for its extinction. And here, Ahmed was in that space, a land not his own. Strange symbols filled the streets, shimmering, blue horizon stretched in all directions. The dead tree gives no shelter, the dry stone no sound of water. There is shadow under this red rock (come in under the shadow of this red rock) and I will show you hope in a handful of dust.

“Where does it hurt?” He gazed up at her, not comprehending, bewildered to see this young woman with her hair falling around her shoulders. At home he had seen only three women without their hijab – his wife and mother, may Almighty Allah grant them Jannah, and his sister Aaliyah. But Aaliyah had her hair bound up on the day she cried and swore and told him to leave.

“Go where?”

“Just go!” she hissed. “It's not safe for you. It's not safe for any of us with you here. How can you not understand? How can you be so selfish?” And she wept, and beat at his chest with her fists; ashamed, he pushed her away.

“Mr. Al-Maliki,” the doctor was saying loudly, “do you have any pain? Pain? Do you understand what I'm saying to you?”

“Pain!” He understood this word. “Pain, yes, pain” - and here he contorted himself and gestured with a balled hand to his lower back and hip.

“Mr. Al-Maliki, there are bone lesions on your CT scan. We don't know exactly what's causing them, but we're going to do another scan and some blood tests and then organise a biopsy.”

“No English,” he shrugged back at her. Grappling for words, he tried “My friend, he is here soon. Maybe he help.”

II.

Hope in a handful of dust. In April, poppies bloom.

Many patients ask how they are going to die. They want reassurance that their final moments will not be the claws of a crab turning into the claws of a demon and tearing them from this earth. That the pincer will not throttle them and leave them gasping for air, unable even to ask for an end to their torment.

After enough years on this earth, enough time under the shadow of the red rock, the fear of suffering outweighs the fear of death. These two snakes have always been intertwined, but the bite of one rages through the veins, while the other offers relief into a peaceful slumber.

The word “palliative” comes from the Latin “palliare,” meaning “to cloak.” A cloak woven out of poppies. Morphine is a drug to wash away the sins of the world. Even Job, that avatar of man unjustly treated by the gods, glowering from the ashes, his skin covered in sores – even he could be soothed. His wounds could be covered. As Jesus said: to him who asks for your tunic, give to him your cloak also.

III.

Through half-slit eyes, Ahmed watched Khaled breathe. The two men, comrades in exile. He was wrapped comfortably in his cloak. An hour earlier, he'd watched Khaled yell at a timid nurse, shouts of incomprehension, as every nerve in Ahmed's body felt like it was aflame and he'd been wracked with febrile groans. Now he was warm and drugged and sleepy.

Pain, you are just like me, he thought, a stranger in a strange land. Words fail to convey it. The standard tools are useless - “how bad is your pain, Mr Al-Maliki? On a scale from one to ten, where ten is the worst pain you've ever experienced?” Imagine saying such a thing to Job – he would have snarled. As if such a desolate feeling could be described in a number.

Closing his eyes, he prayed without words. He prayed for deliverance from this place. He prayed for Aaliyah, and his family, and Khaled, and that Allah would protect them and forgive his indiscretions. But most of all, he prayed to be free from pain. That space would melt and time would unravel and he could just drop into the sea and dissolve. The Drowned Man, he thought, drifting into a pool of sleep. I am he. These are pearls that were his eyes.

THE GOSPELS

I.

On Saturday, Carla couldn't sleep.

“Can I be saved?” she'd asked Dr. Mukherjee. On that first day, on Monday, they'd spoken for an hour. He outlined the plan – first, they'd give her heroic doses of chemotherapy, wiping her bone marrow to all but a glimmer. This was known as the induction phase, and included multiple lumbar punctures to administer chemotherapy through the base of her spine. Then, she'd enter the consolidation phase, with ongoing high doses of chemotherapy to kill any residual cells. This would last a little more than one year. Finally the maintenance phase, where low dose methotrexate would be given for two years.

“Your chances,” he told her, “are 30 percent.” She took this in, her eyes narrowing. “30 percent? This means I can be cured?” “It does,” he replied.

And he left the room. A whoosh of air blew him outwards and sealed Carla in.

II.

It's two am in Massachusetts General Hospital. An orderly is humming, wheeling a food trolley down a basement corridor. An IV line is making a twinkling sound – tissued, the nurse declares, and sets up to resite the cannula, the bleary eyed patient rolling to and fro. And Carla is still wide awake.

30 percent.

(The distant sound of a tap dripping.)

A life, reduced to a number. She pictures Alfie's grief-stricken face when he hears she has relapsed, and there's nothing further they can do. She pictures the calls to her parents - “Mom? Are you there? It's me, Carla. Listen, the doctors gave me some bad news...” She pictures her room at home, and this room in the hospital, filled with flowers, filled with the desperate love that knows its own extinction, knows pain will immediately follow. She pictures herself drowning in it. She pictures Sarah growing up, braces, plaits and ribbons in her hair. She pictures her talking to boys as a teenager, “Oh, I never really knew my Mom. She died when I was really young.”

And suddenly, a new feeling. Anger. 30 percent. Who gave her this number? What cruelty, what caprice, was this, that God should play dice with her life in this way? She resolved, then, that she would live or die, but do it on her own terms. 30 percent. Whether it was 50 percent, or 15 percent, or 1 percent, it made no difference to her. She would fight. If it was written in the stars, if this was her time, she would go gracefully to her grave.

But she still couldn't sleep.

(“It's the steroids,” an intern told her. “Try an Ambien. I'll write it up.”)

She smiled and nodded, and he left the room.

Forty years, she thought. We have wandered in the desert since 1965. Freireich, Moses, told us he would lead us to the promised land. And yet here we are, still in the desert, in the waste land, with our bald heads and sunken eyes and dressed in these blue robes like crazed monks, still wandering, still searching. For what? Who will sustain us? The holy manna comes in sterile packs labelled HYDROXYDAUNORUBICIN and DO NOT TOUCH – VESICANT – AVOID CONTACT WITH SKIN OR EYES.

“This is not fucking milk and honey,” was her last thought before she finally slipped into slumber.

III.

When Mukherjee started his book, he thought he knew how it was going to finish – with Carla's death. He thought that was how it would end. But like all good authors, his characters come to life, and then do whatever it is they like. And so she walked across his heap of broken images, her feeble thirty years projected against the ancient enemy, the Emperor of All Maladies. As old as humanity itself. The skulls of millennia rolled at her feet. She stumbled, gasped, then quickly righted herself. And kept walking.

He didn't expect that.

In 2005, he called her. A year had passed since she first started treatment. She greeted him tightly, with that terrible anticipation of what could follow.

“It's good news,” he says quickly. “You're in remission.”

He thought she wouldn't even survive the induction chemotherapy. He was wrong. In 2009, five years exactly after he looked down the microscope into her bone marrow specimen and saw lilacs blooming, he drove to her house with a bouquet of flowers. She sat looking at them, numb and speechless.

Five years without a relapse. The five-year anniversary, in leukaemia, is synonymous with a cure.

As she poured him a glass of water, he asked her how she thought she survived it. She glanced, instinctively, towards the room where Sarah was playing. “I had no choice,” she answered.

REVELATIONS

I.

On Sunday, Carla went to church.

There's a New York joke: what's the difference between Sloan-Kettering and Shea Stadium? At Sloan-Kettering, the mets always win.

Ha ha, you say. What?

You see, “mets” is an abbreviation for metastases, a solid cancer which has spread from one organ to another.

It's a dirty joke, because it conceals a dirty truth. For all the Old Testament fire and brimstone of Farber and Freireich, none of it – none of the hundred different chemotherapies – has proven curative against solid tumours. Breast, lung, colon, pancreas cancers. Chemotherapy can shrink the tumour, can wilt the garden, but it will always grow back. Always. Just a matter of time. Even today, a stage four cancer is a death sentence.

But Mukherjee published his book in 2010. Three years later, a remarkable paper was published, entitled “A Novel Therapeutic Approach for the Treatment of Advanced Melanoma.” Hidden in the figures, graphs, and medical jargon was a remarkable thing – a cure for stage four melanoma. “Long term follow up,” the authors say carefully, “show that 24% survived at least two years, and in phase II studies, a proportion survived at least five years.”

Five years?? That's a cure. The Emperor has no clothes.

The key is called Keytruda, an immunotherapy. It activates the patient's own immune system to fight the cancer. Not only is this more effective, it – usually – has less severe side effects. Don't burn down the garden, boys, send in the troops with machetes and trim those weeds. It doesn't work for every melanoma, much less every cancer. But for many, many patients, it has given them something indispensable – hope. They too can be saved. In the end, we are all Carla, and every day is Sunday.

II.

In 1968, Steve Rosenberg was a surgical resident at Brigham Hospital in Boston when he found a mistake in the chart.

“It says this guy had metastatic gastric cancer 12 years ago,” he told his attending, puzzled. “We sent him home to die. But he's just here for a routine gallbladder surgery. No sign of cancer anywhere in his body.”

80 years earlier, another surgeon named William Coley was combing the tenements of Manhattan, looking for a man he knew only as “Mr Stein.” A record at the hospital had caught his eye – this man had had an inoperable sarcoma of the neck; doctors told him he would soon die. Then he developed a mild skin infection, and when the infection cleared up, the cancer miraculously did too.

Both these men had glimpsed the light, briefly. Such cases of cancer in spontaneous remission are exceedingly rare, but well described. Miracles do occur. Many are called, but few chosen.

Coley and Rosenberg heeded the call. Both became pioneers in their own right in cancer immunotherapy. Coley was the first – in the 1890s, he experimented with injecting cocktails of bacteria that would later be called “Coley's toxins,” into tumours, with the hope of stimulating an immune response. Rosenberg, for his part, remains the director of the National Cancer Institute today, at 84 years old. The Nobel Prize in Medicine was awarded in 2018 to his colleagues James Allison and Tasuku Honjo for their development of cancer immunotherapy. Most of us now, in oncology, think these men glimpsed something real.

Out of darkness, there shall shine a great light.

III.

It ends like this.

It's 2064. Carla is ninety. Alfie died years ago. Sarah, retired, stays with her now, and the grandchildren visit twice a week. She goes walking, when she can, although the arthritis in her hips makes it difficult.

Carla is writing a birthday card to her great-granddaughter, who has just turned four. Sweetness fills the air from fresh-cut flowers in the vase. The room is warm. A pot bubbles gently on the stove.

“Dear darling girl,” she writes. “I hope you have a VERY special day today. Your Mummy, Daddy, aunties, uncles, cousins, grandma, grandpa, AND your great-grandma (that's me!) all love you very, very much. Today I picked you lilacs from the garden. That was your grandma's favour-”

This time it blooms in her brain. Her first thought is, I feel awfully tired. Then her right hand slips from the card and her right leg gives out from under her. She hits first the chair, then the floor. There is no pain. Watching the blood pool beneath her head, Carla is speechless with joy. She is right where she is supposed to be. She is at home.

The half finished card shows the date.

It's the first of May.