Until recently, the idea of making America's cancer wars anything less than all-out combat has been widely seen as the equivalent of appeasement. Now, that approach to cancer is being challenged in ways that mark a sharp break with the past.
The current challenge comes from three very different sources: "The Big C", a Showtime television series; Boston surgeon Atul Gawande's annals of medicine report "Letting Go", in the 2 August edition of the New Yorker; and critic Christopher Hitchens's "Topic of Cancer" account of his own cancer ordeal in the September Vanity Fair.
Uniting "The Big C" and Gawande's and Hitchens's essays is the argument they make for putting patients' lives, rather than a take-no-prisoners assault on their cancers, at the centre of treatment in cases for which no cure is possible. The result is a nuanced attack against the idea of a "war on cancer" – a phrase President Richard Nixon popularised on signing the National Cancer Act of 1971.
Nixon's militarisation of the struggle to treat cancer caught on quickly and has lasted into the present. Today, nobody embodies Nixon's thinking more fully than cyclist Lance Armstrong, the seven-time winner of the Tour de France, whose account of his own battle with testicular and brain cancer, It's Not About the Bike: My Journey Back to Life, became a number one bestseller soon after it was published in 2000. "Anything's possible. You can be told you have a 90% chance or a 50% chance or a 1% chance, but you have to believe and you have to fight," was Armstrong's advice to his readers.
Armstrong's advice is the kind that even the most sophisticated cancer patients and their doctors find hard to resist. In correspondent David Rieff's Swimming in a Sea of Death, his 2008 memoir of the losing battle with cancer that his mother, culture critic Susan Sontag, waged during the last years of her life, he recounts how Sontag, otherwise indifferent to sports, was inspired by Armstrong, seeing in his triumph over cancer reason to go on with her own debilitating treatments.
What makes "The Big C" and the Gawande and Hitchens essays so compelling is that in their opposition to a take-no-prisoners "war on cancer", they don't go to the opposite extreme and advise passivity, let alone the avoidance of sensible cancer treatments that can prolong life. The writers of "The Big C" and Gawande and Hitchens are not driven by hidden ideology. They have no mystical belief that suffering is good for the soul. They don't embrace the redemptive premise of films like The Last Holiday and The Bucket List, in which people who have led thwarted lives (Queen Latifah in Last Holiday, Jack Nicholson and Morgan Freeman in The Bucket List) start realising life's possibilities when they believe death is around the corner.
In "The Big C," much of which is played for laughs, Laura Linney is Cathy, a 42-year-old schoolteacher and cancer victim living in Minneapolis with her son and her husband, whom she has recently kicked out of the house. Cathy's decision to forgo treatment after she learns that she has incurable melanoma and 18 months to live, does embolden her to do silly things. At dinner in a restaurant, she announces she is only going to order desserts and liquour; and in her dermatologist's office, she opens her gown and asks him to evaluate her breasts. She refuses to cover up until she gets him to reveal that he thinks she has "an awesome rack".
But silliness is not at the core of "The Big C," despite its many jokes. Cathy's outward lightheartedness is her way of putting serious matters in perspective without succumbing to moralising or sentimentality. When Cathy tells her doctor that she is forgoing treatment because she likes her hair too much to lose it, it is her way of saying she doesn't trust him enough to confide in him.
Cathy's complaints about her husband Paul's objections to onions are similar in motive. Paul is an immature man, and Cathy is asking him to start looking more deeply into himself by carping about something he can change. The drama of "The Big C" hinges on those in Cathy's life seeing through her jokes, and in the case of an obese, surly teenager in her summer school class, we see the humour already paying dividends. Cathy and her student are drawn closer after Cathy – in a gesture of mocking extravagance – gets the girl to stop eating potato chips by paying her $10 to hand over the bag of chips she just bought.
In Atul Gawande's "Letting Go", jokes are not a worry. Gawande, whose previous books include Better: A Surgeon's Notes on Performance and The Checklist Manifesto, is a general surgeon as well as an endocrine surgeon at Brigham and Women's Hospital in Boston, and his essay, which comes with the subtitle "What should medicine do when it can't save your life?", consists of stories about people with catastrophic illness and the treatment they get.
At the centre of "Letting Go" is Sarah Thomas Monopoli, a 34-year-old woman, who never smoked in her life. Thirty-nine weeks into her pregnancy, Sarah learns that she has lung cancer, which has spread to the lining of her chest. She and her husband Rich decide that their first step ought to be to focus on their baby, and they do so successfully. Soon after they get Sarah's terrible diagnosis, their daughter Vivian, seven pounds nine ounces, is born without complications and with wavy brown hair like her mother. But that is the last good news the Monopolis get for the rest of "Letting Go".
Sarah is put on a relatively new drug, Tarceva, which targets a gene mutation commonly found in the lung cancers of women non-smokers. Unfortunately, Tarceva does not work for Sarah, and neither do two standard chemotherapy drugs that she is given. After four rounds of chemotherapy, Sarah is no better-off than when she was first diagnosed, but in the meantime, she has developed a blood clot, requiring her to take blood thinners, and a few months later, tests show she also has thyroid cancer.
Gawande, who is seeing Sarah every six weeks, notes her physical decline from one office visit to the next, but with encouragement from Sarah and her family, the aggressive cancer treatment of Sarah continues until her final return to the intensive care ward. None of her physicians says, "It's time to stop treatment. We have done as much as possible." Gawande confesses:
"In the previous three months, almost nothing we'd done to Sarah – none of our chemotherapy and scans and tests and radiation – had likely achieved anything except to make her worse. She may well have lived longer without any of it."
When exactly he and her other doctors should have said enough is enough, Gawande leaves open to question, but not in a way that lets anyone off lightly. The unambiguous conclusion of "Letting Go" is that Sarah and her doctors, including Gawande, were done in by the warrior culture that comes with modern oncology.
Christopher Hitchens, whose acerbic criticism of Mother Theresa and Bill Clinton and defence of atheism in God Is Not Great have made his reputation as one of the fiercest writers in Europe and America, fits exactly between Cathy and Sarah Molopoli when it comes to dealing with his cancer. Hitchens has willingly undergone chemotherapy for his esophageal cancer. He has young children, and he wants to be part of their lives as long as he can. At the same time, Hitchens rejects the rhetoric of being engaged in a war on cancer. He has acknowledged, as soldiers rarely do in the midst of battle, that he is engaged in a losing struggle. "I don't have a very long life to live," he observed on PBS's Charlie Rose Show.
There, Hitchens gave the public an extended view of the physical toll that his chemotherapy has taken on him, and in his Vanity Fair essay, he has gone out of his way to stress that, while prepared to fight for his life, he hardly feels like a combatant. Military analogies are misleading, he points out, when it comes to how he must deal with his cancer. During treatment itself, "the image of the ardent soldier or revolutionary is the very last one that will occur to you," he notes. "You feel swamped with passivity and impotence: dissolving in powerlessness like a sugar lump in water." Even your sex drives goes. Midway through "Topic of Cancer", Hitchens acknowledges one of the worst consequences of his treatment is, "If Penelope Cruz were one of my nurses, I wouldn't even notice."
What will Hitchens do next? At the end of "Topic of Cancer", he promises to tell us more, "if – as my father invariably said – I am spared." But what is already clear from both his and Gawande's writings, and from "The Big C", is the shared belief that it is not weakness to think that in place of a war to the death on cancer, we need to consider compromises that give us a better life rather than simply more life.
The hard part is knowing if, in America, we are up to such compromises. The serious and gentle challenge these compromises pose to the status quo leave little room for the triumphalism endemic to American culture; instead, they require our acknowledging, in the most fundamental of ways, the limits of our powers.
