By George W. Sledge, Jr., MD
There's an old joke, a poor but telling one. The late novelist David Foster Wallace used it in a college graduation speech, but it's much older than that. Two young fish are swimming along and run into an old fish. "Good morning," says the old fish, "isn't the water fine today?" And then he swims on. One of the young fish turns to the other and asks "What's water?"
We swim in history yet are so caught up in the day-to-day that we rarely notice its swirls and eddies, unless strong currents buffet us: a war, some momentous election. Looking back, we suddenly recognize how far downstream we've come. I look at my life, a totally ordinary one lacking in historical impact and think, well, what times I have lived through. I was born in the middle of the Korean War, was in middle school and high school during the Civil Rights era, went to college in the midst of the Vietnam War, saw (on TV) the first landing on the moon, the impeachment of Richard Nixon, the fall of the Berlin Wall, the two wars in Iraq, 9/11, and a myriad of lesser events.
The last Civil War veteran died when I was four. When I was a grade-schooler, a World War I veteran with a loud hacky cough did house work for us. I remember someone saying his lungs were a mess ever since he had been caught in a poison gas attack in 1918. When I was in college, I met a woman who as a child had been placed in a lifeboat and rowed away from the sinking Titanic.
As a medical student, I was on the ward with an elderly man patient who had played jazz with Louis Armstrong in the French Quarter. As an intern, I helped take care of Bill Drake, an 82-year-old former pitcher in the Negro Baseball leagues. His baseball moniker was Plunk, for his habit of throwing beanballs at batters who crowded the plate. Another patient that year, a Spanish-American War veteran, died of bradycardia while I stood at his bedside administering an antiarrythmic. This has always left me feeling guilty given what we subsequently learned about antiarrythmic usage. A patient of mine had, as a teenager, sung at the White House at Christmas time for President Franklin Delano Roosevelt.
And that's just some politics and culture. But the science, oh the science, how amazing: my life has overlapped with Watson and Crick's description of DNA and the subsequent molecular biology revolution, the deciphering of the immune system, the creation of monoclonal antibodies, the Human Genome Project, The Cancer Genome Atlas, and the discovery of CRISPR/cas9. I have argued previously, and I still believe, that 500 years from now it is the science that will be remembered if there are still humans around to remember such things. And I haven't even touched on physics, chemistry, the computer revolution, and several others whose histories happen to coincide with my own, including most of what makes up modern oncology.
None of these things, at the time, seemed particularly extraordinary, and I certainly cannot claim any credit for even one of them. At most I thought "that's interesting" before moving on to another task. It is the cumulative weight of these things that makes me stop and wonder. We swim through history and rarely think about the fact that we are living it. I have not lived a particularly extraordinary life, but I have lived in extraordinary times.
I write this a few days after the Republican attempt at repealing Obamacare went down in (what appears to be) its final defeat. It has been a dramatic week, and an important one for the health care system and many of my patients. It has been one of those rare times where I actually felt, in the moment, that I was "living in history," if you will.
It got me thinking about the contingent nature of history, and its relation to cancer. The Affordable Care Act (ACA) as a political event is thoroughly entwined in one type of cancer. When winding its way through Congress in 2009, the Democrats had a large majority in the house and a filibuster-proof 60-member majority in the Senate. Then Senator Ted Kennedy, a passionate supporter of national health insurance, developed a glioma, setting off a complicated sequence of events that contributed to the poorly-written piece of legislation that eventually became the ACA, and no doubt contributing to its lasting unpopularity.
Seven years later, and largely as a result of the unpopularity of Obamacare, the Republicans hold a substantial, if gerrymandered, majority in the House of Representatives, a small majority in the Senate, and the Presidency. Having spent 7 years promising the immediate repeal and replacement of the ACA, and having passed a "repeal and replace" bill in the House, they fell one vote short in the Senate.
As in 2009, cancer proved to be an important part of the story. Senator John McCain, 80 years old, former war hero, and recently diagnosed glioblastoma multiforme patient, cast the deciding vote against repeal in a dramatic, made-for-TV late-night vote. Would he have done so without the diagnosis of glioma? Did his cancer diagnosis, fortuitously coming right before the vote, alter history?
Psychologizing from a distance is dangerous even for a psychologist, but even more so for an oncologist, so I'll try. Did the recognition of his own impending mortality allow McCain the freedom to break from party ranks, the freedom that comes when fate renders you no longer answerable to this year's dogma or the next election cycle? Did the diagnosis render him more sympathetic to poor people with cancer? Or, less charitably, was the proud naval veteran offering some payback to the President who had foolishly and inexplicably impugned his heroism and attacked his character? Or perhaps all three, for we need not have a single motive. A fourth possibility, raised by one of McCain's "friends" in the Senate, was that the tumor affected the senator's judgement, perhaps because he was tired when he voted.
We do know that Joe Biden, whose son Beau died of glioma, called McCain on the day of the vote. Why is glioma, of all cancers, such a huge part of this story? Biden did not compete for the 2016 Democratic nomination because of his son's diagnosis, with unknowable consequences for American history.
I suspect the cancer had something to do with McCain's vote. Certainly, the other member of the Senate with advanced cancer, Senator Mazie Hirono, brought a special passion to the health care debate derived from her life-threatening disease. McCain has been coy, saying only that he thought his vote was the right thing to do.
We see things through our own special lenses. A Marxist would point to history as a determinist juggernaut, events being largely independent of personalities. I've never believed that for a moment, though some things, in particular those involving technology, seem to have a life of their own, almost independent of any individual's desires or efforts. Such technologic imperialism aside, some historical decisions come down to one vote, and one voter wrestling with the consequences of that action.
Senator McCain's recent diagnosis, leaving aside its political impact, has interesting additional aspects. I for one am always happy that I am not the doctor facing the press after a prominent politico receives a horrible diagnosis. These doctor/spokesmen are in an awful position. Like all doctors, their primary responsibility is to their patient, and their patient's desires regarding transparency must be taken into account. I would add that, while physicians are well aware of the gloomy statistics for a particular population of cancer patients, many of us (myself included) suffer from an optimism bias for individual patients, and that bias is probably amplified by a reporter's microphone. Against these motivations, the public's right to know can take second place.
This can lead to some interesting sins of omission, and occasionally sins of commission. For instance, when Ted Kennedy's glioma was diagnosed, his doctors were very careful, and generally quite honest, about the diagnosis, but utterly quiet regarding prognosis. Their statement included, "He remains in good spirits and full of energy." As if that mattered.
More recently, McCain's doctors mentioned that "Scanning done since the procedure...shows that the tissue of concern was completely resected by imaging criteria." Think about what that sentence says, how it says it, and what it implies. First, that horrible, mealy-mouthed euphemism, "tissue of concern," when what they mean is "cancer" or "glioma." Second, the phrase "completely resected by imaging criteria," a relatively meaningless phrase implying a good outcome in a disease famous for local recurrence.
A physician saying "we got it all" in misleading medicalese changes nothing, and the press was not conned by this minor obfuscation. McCain's prognosis, the prognosis of patients with glioma, was made painstakingly clear in the many reports I read. McCain's political rival in the Arizona Republican primary, a physician, wished McCain well and told him to resign from office so that she could be appointed in his place. Presumably this is because, having been rejected for office by members of her own party, she therefore deserves to be a U.S. senator, and anyway McCain is toast. Classy.
The worst example of this sort of thing occurred with Massachusetts Senator Paul Tsongas, diagnosed with a non-Hodgkin lymphoma. Tsongas, viewed as a potential Democratic presidential candidate, underwent high-dose chemotherapy and bone marrow transplantation for his disease, the marrow being prepared with a selection method designed to eliminate cancer cells. After this procedure, in announcing his 1992 candidacy, Tsongas had his Harvard physician (and active political supporter) offer up the comforting claim that he was likely cured and therefore a viable candidate for completing a term of office. In fact, Tsongas had already suffered an axillary lymph node recurrence post-transplant. Not only was his candidacy nonviable, within 3 years he would die of recurrent disease. Dana-Farber's chief physician, in reviewing the case, would later say that the institution "made a bevy of mistakes."
History provides other examples of the intersection of cancer and politics. Perhaps the weightiest occurred in 1888. Kaiser Frederick III of Germany was, as German autocrats went, kind, intelligent, liberal, and pacific by nature. He also chain-smoked cigarettes and developed cancer of the larynx. Originally misdiagnosed (by Virchow, of all people), and subsequently under-treated—being the German Kaiser doesn't protect you from bad care if the pathology is wrong—he eventually died, miserably, after a reign of only 99 days.
His son, Wilhelm, was everything Frederick was not. He had a withered left arm—Erb's palsy due to a breech birth—that left him shy and insecure. And like some shy and insecure people, he over-compensated, getting into a naval race with Great Britain, antagonizing the French and Russians through his militarization of the German Reich, acting bellicose and paranoid, and eventually approving the attacks that started World War I.
His dislike of the Western democracies (particularly Britain) was partly ideological, and partly personal: in one angry outburst shortly after his father died, he said "an English doctor killed my father, and an English doctor crippled my arm—which is the fault of my [English] mother." Talk about mommy issues. How different the 20th century might have been had his father not been a chain-smoker, or had the physicians been a little bit better at their jobs. Historians cannot imagine the pacific anglophile Frederick getting into the same mess his son Willy created.
World War I was the 20th century's keystone event, leading to (in no particular order) the rise of the U.S. as a world economic and military power and the eventual collapse of the British empire, the collapse of the Romanov Dynasty and its replacement by the Bolsheviks, the kick-starting of multiple military technologies (such as the tank, the submarine, and the airplane), the collapse of the Austro-Hungarian Empire, the embitterment of a generation of Germans (including the young Austrian emigre Corporal Hitler, who drew his own conclusions regarding the war's lessons), and the collapse of the Ottoman Empire and the subsequent creation of the many Middle Eastern nation-states whose fractious histories continue to bedevil the 21st century. Before World War I, there was no country called Iraq, no country called Syria, no Palestine mandate leading to Israel, no Saudi Arabia.
After the Kaiser died, his doctors all stuck their scalpels into each other, and quite publically. The English surgeon wrote an inflammatory book blaming the Germans, and lost his medical license as a reward. There was, reading the accounts, plenty of blame to go around, with both pathologists and surgeons making a mess of things. This one cancer death may have been the most consequential in world history, and I certainly would not want to have been one of Frederick's physicians, taking credit for the whole bloody, tragic 20th century.
Not all cancer deaths are so consequential, of course. Most just affect the patient, the patient's family and acquaintances, and the patient's health care team. But that is more than enough. Our private histories need not rival Frederick's story to count as tragedies.