The Emperor of All Maladies. Siddhartha Mukherjee
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Название: The Emperor of All Maladies
Автор: Siddhartha Mukherjee
Издательство: HarperCollins
Жанр: Прочая образовательная литература
isbn: 9780007435814
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Every evening, Farber came to the wards, forcefully driving his own sail-less boat through this rough and uncharted sea. He paused at each bed, taking notes and discussing the case, often barking out characteristically brusque instructions. A retinue followed him: medical residents, nurses, social workers, psychiatrists, nutritionists, and pharmacists. Cancer, he insisted, was a total disease—an illness that gripped patients not just physically, but psychically, socially, and emotionally. Only a multipronged, multidisciplinary attack would stand any chance of battling this disease. He called the concept “total care.”
But despite all efforts at providing “total care,” death stalked the wards relentlessly. In the winter of 1956, a few weeks after David’s visit, a volley of deaths hit Farber’s clinic. Betty, a child with leukemia, was the first to die. Then it was Jenny, the four-year-old with the aluminum teakettle. Teddy, with retinoblastoma, was next. A week later, Axel, another child with leukemia, bled to death, with hemorrhages in his mouth. Goldstein observed, “Death assumes shape, form, and routine. Parents emerge from their child’s room, as they have perhaps done periodically for days for short rests. A nurse takes them to the doctor’s small office; the doctor comes in and shuts the door behind him. Later, a nurse brings coffee. Still later, she hands the parents a large brown paper bag, containing odds and ends of belongings. A few minutes later, back at our promenade, we note another empty bed. Finish.”
In the winter of 1956, after a prolonged and bruising battle, Sonja’s son, three-year-old David Goldstein, died of metastatic Wilms’ tumor at the Jimmy Fund clinic, having spent the last few hours of his life delirious and whimpering under an oxygen mask. Sonja Goldstein left the hospital carrying her own brown paper bag containing the remains of her child.
But Farber was unfazed. The arsenal of cancer chemotherapy, having been empty for centuries, had filled up with new drugs. The possibilities thrown open by these discoveries were enormous: permutations and combinations of medicines, variations in doses and schedules, trials containing two-, three-, and four-drug regimens. There was, at least in principle, the capacity to re-treat cancer with one drug if another had failed, or to try one combination followed by another. This, Farber kept telling himself with hypnotic conviction, was not the “finish.” This was just the beginning of an all-out attack.
In her hospital bed on the fourteenth floor, Carla Reed was still in “isolation”—trapped in a cool, sterile room where even the molecules of air arrived filtered through dozens of sieves. The smell of antiseptic soap pervaded her clothes. A television occasionally flickered on and off. Food came on a tray labeled with brave, optimistic names—Chunky Potato Salad or Chicken Kiev—but everything tasted as if it had been boiled and seared almost to obliteration. (It had been; the food had to be sterilized before it could enter the room.) Carla’s husband, a computer engineer, came in every afternoon to sit by her bed. Ginny, her mother, spent the days rocking mechanically in a chair, exactly as I had found her the first morning. When Carla’s children stopped by, in masks and gloves, she wept quietly, turning her face toward the window.
For Carla, the physical isolation of those days became a barely concealed metaphor for a much deeper, fiercer loneliness, a psychological quarantine even more achingly painful than her actual confinement. “In those first two weeks, I withdrew into a different person,” she said. “What went into the room and what came out were two different people.
“I thought over and over again about my chances of surviving through all this. Thirty percent. I would repeat that number to myself at night. Not even a third. I would stay up at night looking up at the ceiling and think: What is thirty percent? What happens thirty percent of the time? I am thirty years old—about thirty percent of ninety. If someone gave me thirty percent odds in a game, would I take the odds?”
The morning after Carla had arrived at the hospital, I walked into her room with sheaves of paper. They were consent forms for chemotherapy that would allow us to instantly start pumping poisons into her body to kill cancer cells.
Chemotherapy would come in three phases. The first phase would last about a month. The drugs—given in rapid-fire succession—would hopefully send the leukemia into a sustained remission. They would certainly kill her normal white blood cells as well. Her white cell count would drop in free fall, all the way to zero. For a few critical days, she would inhabit one of the most vulnerable states that modern medicine can produce: a body with no immune system, defenseless against the environment around it.
If the leukemia did go into remission, then we would “consolidate” and intensify that remission over several months. That would mean more chemotherapy, but at lower doses, given over longer intervals. She would be able to leave the hospital and return home, coming back every week for more chemotherapy. Consolidation and intensification would last for eight additional weeks, perhaps longer.
The worst part, perhaps, I kept for last. Acute lymphoblastic leukemia has an ugly propensity for hiding in the brain. The intravenous chemotherapy that we would give Carla, no matter how potent, simply couldn’t break into the cisterns and ventricles that bathed her brain. The blood-brain barrier essentially made the brain into a “sanctuary” (an unfortunate word, implying that your own body could be abetting the cancer) for the leukemia cells. To send drugs directly into that sanctuary, the medicines would need to be injected directly into Carla’s spinal fluid, through a series of spinal taps. Whole-brain radiation treatment—highly penetrant X-rays dosed directly through her skull—would also be used prophylactically against leukemia growth in her brain. And there would be even more chemotherapy to follow, spanning over two years, to “maintain” the remission if we achieved it.
Induction. Intensification. Maintenance. Cure. An arrow in pencil connecting the four points on a blank piece of paper. Carla nodded.
When I went through the avalanche of chemotherapy drugs that would be used over the next two years to treat her, she repeated the names softly after me under her breath, like a child discovering a new tongue twister: “Cyclophosphamide, cytarabine, prednisone, asparaginase, Adriamycin, thioguanine, vincristine, 6-mercaptopurine, methotrexate.”
Randomised screening trials are bothersome310. It takes ages to come to an answer, and these need to be large-scale projects to be able to answer the questions. [But . . .] there is no second-best option.
—H. J. de Koning, Annals of Oncology, 2003
The best [doctors] seem to have a sixth sense311 about disease. They feel its presence, know it to be there, perceive its gravity before any intellectual process can define, catalog, and put it into words. Patients sense this about such a physician as well: that he is attentive, alert, ready; that he cares. No student of medicine should miss observing such an encounter. Of all the moments in medicine, this one is most filled with drama, with feeling, with history.
—Michael LaCombe, Annals of Internal Medicine, 1993
It was in Bethesda, at the very institute that had been likened to a suburban golfing club in the 1940s, that the new arsenal of oncology was deployed on living patients.
In April 1955, in the midst of a humid spring in Maryland, a freshly recruited researcher at the National Cancer Institute named Emil Freireich312 walked up to his new office in the redbrick Clinical Center Building and found, to his exasperation, that his name had been misspelled on the door, СКАЧАТЬ