Longevity is a game of compromises

“Cancer” is a dreaded word – and few of us would not have encountered it in our lives. Few would not have lost a dear one to the disease. I too have – father in 1992 and husband exactly 10 years later. However, it is not the most common cause of death, cardiovascular disease exceeding it by far in all parts of the world. Its only that as you live longer, the odds shift in favor of cancer. In this context I found the article “Why everyone seems to have cancer. ” in the New York Times fascinating reading

As I slowly but surely edge towards the 8th decade of life and care and support my mother in her 9th decade, I often wonder at the desperate striving for longevity that I see around me. While the life expectancy for women in this country was <50 years when I was a medical student in the late 60s,  I am now at the exact age when I should drop dead – in other words the life expectancy stands around 66 years today.  And so here onwards every year is a bonus – and I have no issues with that as I have led a pretty full and good life,  contributed my bit to the society and even more importantly not done too much harm!!

During my training years, conveying news of terminally fatal illness like heart disease  (pre-by-pass days) and cancer to anyone over 60 years was not considered too disastrous (overall life expectancy was <50 years) –  anyone ‘less than 50 years’ was considered young.  When my father had his myocardial infarction in 1971 (he had been a heavy smoker), it was diagnosed with only an ECG, and all that happened was that he was told to stop smoking and be moderate in his habits. I was doing internship at the time, and the association of coronary disease with lipid profiles and central obesity was yet to happen. Although he went on to have a by-pass surgery in 1986, we eventually lost to him to a lymphoma in 1992. He was short of his 73rd birthday – and we all felt that we had lost him too early, especially since his parents had both lived into their late 80s and longevity was in the family. But on the whole, 70s was not was not “Oh by Jove” early – the life expectancy for males at the time stood at 58 years. And,  cancer was considered a sentence without hope.

Much has changed since then. Coronary artery disease is detected earlier and earlier, and much is known about the pre-disposing factors. Blocked coronaries are opened up (angioplasty), not once but twice and thrice – and finally replaced (bypass surgery, which my father had). Tools to detect cancer earlier and earlier are being discovered and fairly good treatment is available for many of them (including the lymphoma that killed my father).

How do these diseases affect the nation as a whole. Authentic data on the cause of death is lacking in our country, since only a small fraction of the 9.5 million annual deaths in India occur in hospitals and only less than 0ne tenth of deaths are registered.   We have some indicators on the common causes of mortality from the  Special Survey of Deaths which was was carried out between 2001-03. It covered all deaths  in a sample of approximately 6.5 million and used Verbal Autopsy methodology. The general perception that cardiac disease was the leading cause of death was strongly substantiated, with it accounting for a quarter of the deaths.  This was followed by chronic pulmonary disease, tuberculosis  and cancer, placed at No 4  (approx 10% each).

So, as people strive to live longer, they have to be lucky not to have any major cardiac problem or diabetes or for the large numbers who have one or the other or both, be damn good in keeping these under control. The author ends the NYT article “Maybe someday some of us will live to be 200. But barring an elixir for immortality, a body will come to a point where it has outwitted every peril life has thrown at it. And for each added year, more mutations will have accumulated. If the heart holds out, then waiting at the end will be cancer.” But I guess each of us has to live out the time that has been issued out to us and longevity is a game of compromises.

Reflections on loss of dear ones (26/52)

Father, brother, husband, son, son-in-law and then grandsons –  these are the important men in our lives. One expects  that fathers will predecease you,  and whether bothers do is a matter of the order of sib-ship. Each of us hopes to predecease our spouse. But things don’t work the way we want them to!

My father, Vava, like all fathers, was a great influence in my life.  He was a heavy smoker and my early memories of him are with a cigarette in hand. He had a ‘heart attack’ in 1971, when he was just 52 yrs and spent many years after that struggling to quit the smoking, succeeding in his  post-retirement life.  He was otherwise healthy, without any diabetes or blood pressure problems. He adjusted to his compromised cardiac state and lived well. His problems recurred in 1985 and he decided to get his bypass surgery done in Mumbai in 1986, at a time when people who could afford got it done abroad and the procedure was still a rarity in this country. And 6 years later, in 1992,  he died of an unusual form of cancer, a T cell non-Hodgkin’s lymphoma, at the age of 72. It is a disease for which smoking is not even listed among the risk factors and for which the 5 year survival rate at that time was far lower than the 60 -70% currently quoted. He lived for only a few weeks after the diagnosis, but in that time talked to my mother more than he had probably ever had! And he prepared her in every way to face  life alone. This she has done with remarkable strength and fortitude, of course, with my younger brother providing the support every day.

Subhash was not just my husband, but also my best friend, scientific collaborator and the ‘constant’ in my life for close to 4 decades. He was disciplined in his habits, and maintained his trim figure with a measure of pride. He was a warm and loving son, husband, father, teacher and friend. But, after this essentially healthy person vomited his breakfast in his office one morning in May, 2001,  nothing was the same again. Surgery and chemotherapy did not really work against a cancer of the stomach, which even today has a poor 5 year survival rate.  He was a few weeks short of his 58th birthday at the time, and he had only 13 months to wind up an active and productive life. He did it with such composure and cheer, that those around him dared not show remorse or sorrow.

More recently, I am slowly losing the elder of my 2 brothers (both are younger than me), to a degenerative neurological disease. Most of  our lives, we lived on separate continents. But, we had a bonding that I suppose only brothers and sisters can have. He was a caring and sensitive person. However, over just the last 24 months, his memory bank has been wiped clean of  most of his life between his early years and a few moments ago! He is physically fit and is just past 60.

Tomorrow it  will be exactly  a decade since Subhash left us and later in the month two decades since we lost Vava; my brother is just about with us. These men in my life have been taken away by illness that is varied in their manifestations, but ill understood and untreatable even today.  Unexpected and untimely death is something most of us have faced.  The loss is irreplaceable, but as time passes, we make the slow adjustments, try to come to terms with the loss and  learn to live in the changed environment, especially when  the loss is of near ones. Most of the time, I think I have done a good job of this. But then, at unexpected moments and in a flash, the decade or two seem to disappear and all the events of that period, flash past as though it was yesterday.

Medics can write!

Over time there have been many doctors who have written and published successfully in the non-medical field. Some very successful writers have been doctors. In the 18th century there was Erasmus Darwin (poet and grandfather of Charles), Oliver Goldsmith (Vicar of Wakefield) and the poet John Keats and in the 19th century the great Russian writer Anton Chekov, and the all time favorite with so many, Sir Arthur Conan Doyle of Sherlock Holmes fame. Closer to our times, Richard Gordon wrote a series of humor filled ‘doctor’ novels which gently mocked at the medical profession. These were also made into movies in the 50’s with the handsome Dirk Borgade as the dashing Dr Simon Sparrow.   AJ Cronin wrote some lovely tales, all of which i read  avidly as a youngster. And in retrospect, his novel “The Citadel’ had some influence on my choice of medicine as a career.  Closer to the ‘best seller’ list are Robin Cook and Michael Crighton and from India there is Kaveri Nambisan, who is a practicing surgeon.  Another successful doctor-writer is Abraham Verghese, whose  earlier books, My own Country and Tennis Partner, were based on his own personal story as a physician. His novel of 2009, Cutting for Stone, topped the  NYT book chart for many weeks. All  three of these i would recommend  to all. Today, i am writing about another doctor author, who has stayed within his expertise domain but drawn on his personal experiences to give us a wonderful book.

The central character of the book  is neither man, woman, beast or object, but the universally dreaded “Cancer”.  The “Emperor of All Maladies”  by  Siddhartha Mukherjee  recounts the history and scientific developments in cancer, going back to the earliest mention of the disease. The author is a trained oncologist, who was inspired by the courage of those who he treated and transformed by the  triumphs and failures of the efforts to treat them.  He has delved into lives of the charismatic characters – doctors, scientists and lay crusaders – who have driven the research and led the campaign to place this disease onto the centre stage of our attention.

The paradigm till the end of the 19th century was that  ‘cancer is incurable’ and hence did not deserve attention of doctors. Although the American Association for Cancer Research was established in 1910 and there were efforts to set up a national laboratory, nothing really happened. It continued to be called  “The Great Darkness”  till the pre-was years. The National Cancer Institute (NCI) was passed in 1937 by President Roosevelt. The dedication of the pioneers like Sydney Farber who was the first use ant anti-cancer drug, anti-folate compound to treat childhood cancer, of Peyton Rous who described viral oncogenesis, of  Papanicolou who painstakingly scanned thousands of vaginal smears to describe the cellular changes of a pre-cancer state and many others led to changes in the understanding of the disease and approaches to its treatment. The subsequent few decades  saw the development of many anti-cancer drugs and multi-drug treatment regimes, the development of the controlled trial as a modality for  establishing efficacy of these regimes, and the realization that it was not going to be easy to make cancer “curable”.  These aand subsequent landmark events such as the establishment of screening programs, preventive oncology, the contributions of the era of molecular biology   are all dealt with with warmth and understanding.

He has also traced the parallel story of the ‘politics’ of cancer – for, what works without its own set of politics!! The increasing deaths due to cancer was, in the meanwhile pushing the demand for a “war on cancer”. The role of Mary Lasky in fighting the public battle and persuading the political class to assign the funds for this war make an equally interesting story. All these are interspersed with true life events and personal biographies.

The style is clear and the language is simple. The text is extremely readable and all the scientific aspects have been described in really simple fashion.   I don’t think a non-scientist should have any problems understanding any of it! Of course, i would like to have some feed back on this!

I have a personal point of contact with the events described in the book. Between 1978-80, I was a post-doctoral fellow in the iconic NIH campus at Bethesda. There were large number of other post-docs from India and my closest friend during that period had done her PhD at the Adyar Cancer Institute and moved to NIH to work at that “Mecca” for cancer research, the  NCI. The ups and downs of NCI fortunes are well brought out in the narrative of this book. The late 70’s was a down phase and my friend’s supervisor, a pioneer of the immunotherapy era of cancer,  had been a big shot in the NCI hierarchy. She spent many early months at NCI, injecting large batches of mice with various protocols containing BCG (what we give children for protection against tuberculosis). Then she injected them with tumor cells and measured the growth of the tumors by painstakingly using a vernier caliper on each mouse tumor. Since the batches were in hundreds, and space was at a premium on campus, all such work was out sourced.  So, she made these 6am to 7pm trips to a facility outside Philadelphia, i think, to make her measurements. But, soon thereafter, the boss was demoted, his lab reduced is size and strength and my friend had to change her supervisor. In the years that followed, this once ‘hot shot’ NCI scientist committed suicide – it happened a few years after i left NIH and i cannot say if his unfortunate end was in any directly linked to his NCI career!

So, for those of you who read non-fiction, this is a good book. Do let me now how you like it.