“I could not have written this book when I was 30 years old. It is not because of any great discoveries I have made or research papers I have published since. It is because of the experience the intervening decades have given me as I cared for thousands of cancer patients and accompanied many to their deaths.” So begins The First Cell and the Human Costs of Pursuing Cancer to the Last, a recent addition to the titles of books on cancer written by Azra Raza, MD, the Chan Soon-Shiong Professor of Medicine and Director of the MDS Center at Columbia University.
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Title: The First Cell and the Human Costs of Pursuing Cancer to the Last
Authors: Azra Raza, MD
Publisher: Basic Books
Publication Date: October 2019
Price: $28.95, hardcover, 368 pages
Seven Patients With Cancer
Organized in seven chapters plus an aftermath and epilogue, The First Cell is both a scientific and highly personal examination of cancer and its resulting human catastrophes. Each chapter is named for one of Dr. Raza’s friends or patients, all of whom died of cancer. She leads off with Omar, the 38-year-old son of a dear friend.
Omar had been diagnosed with a highly malignant osteogenic sarcoma of the left shoulder, and Dr. Raza becomes his confidant, medical advisor, and friend up until his death, described in a heart-rending scene as he dies in bed with his grieving mother. As soon as the reader meets Omar, we know he is a graduate of Oxford and Columbia. Over an elaborate meal, even though his mouth was “a battlefield of raw ulcers, abraded mucosa, and bleeding gums,” he entertained us with “his signature brilliant quips and observations. Such was his class, his chic.”
Dr. Raza travels in rarified circles, as her close friends include Pulitzer Prize–winning physician Siddhartha Mukherjee, MD, and renowned contrarian ethologist Richard Dawkins, plus a Who’s Who of luminaries in the oncology community. This is a good book that carefully weaves science, thoughtful critique, and humanity into a rich narrative.
Tough Love
Along with her doctor-patient narratives, Dr. Raza offers her opinion, often negative, of medicine: Once a “hostage of tradition,” but after undergoing a long, hard evolution to being evidence-based, it has morphed into a “monstrous business entity.” She supports this claim by asserting that in the 1990s, the oncology community was swept up into the pharmaceutical industry’s realization that developing cancer drugs offered an “untapped market of infinite monetary gain.” She becomes a bit overreaching in her blanket condemnation of an industry: “We have all [the oncology community] bought into…this grotesque enterprise, cornering ourselves into an untenable situation, carelessly squandering precious resources and unwittingly harming lives, damaging the overall well-being of the community.”
Despite her stridency, the author does make sound evaluation about the shortfalls of the drug development process, from soft clinical trial endpoints leading to U.S. Food and Drug Administration approval, the sometimes-questionable coziness of pharma and academia, and the very real problem of data manipulation, as pointed out by the famous meta-researcher George Ioannidis, PhD. However, one gripe about this book is her purple-prose attempt to turn science into literature, as when describing cancer: “deforming proteins, neutralizing death signals, forging ahead deliriously, driven by an unrelenting engine of malice, bursting its hot contents on unsuspecting organs…callously moving on. Cancer rules over the host with despotic autocracy.” Here, Dr. Raza did to cancer what Peter Benchley did to the great white shark in Jaws; she gave a disease intent.
Hopeful yet a Bit Short on Specifics
As per the book’s title, The First Cell, Dr. Raza’s exhortation to researchers in oncology is to move away from the existing discovery platforms of using artificial genetically engineered mouse models and reassess the preclinical approach. According to the author, the new strategy is to stop chasing the last cancer cell and focus on eliminating the first. She describes this approach as preventing the appearance of the first cancer cell by finding its earliest footprint. To that she adds another descriptor that doesn’t help clarify her scientific thesis: “To begin the ending, we must end the beginning. Prevention will be the only compassionate, universally applicable cure.”
“To begin the ending, we must end the beginning. Prevention will be the only compassionate, universally applicable cure."— Azra Raza, MD
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The prevention she speaks of is the “identification and eradication of transformed cancer cells at their inception, before they have a chance to organize into a bona fide malignant, incurable disease…. This may be a utopian dream, but it is achievable in reasonable time.” First, our knowledge of the etiology of hundreds of various cancers is just in its nascent stage. If this “first cell” hypothesis could pan out, then what? The author, although furious at the slow progress, remains evasive on the specifics of a plan forward.
Sharing a Personal Loss
The final chapter is on Harvey, Dr. Raza’s husband, also an oncologist, who dies of leukemia. She chronicles his battle with the disease from start to finish, in painstaking detail, offering some of the book’s best and honest descriptions of what cancer does to the human body and the emotional limits that are reached during the slow march to death. One morning, she went searching for her husband in their large apartment and found him staring out the glass windows that lined his study. She asked him if his parents were okay, and he said yes. She writes, “‘Then what’s wrong?’ In a hundred years I would not have suspected what he said next: ‘I have an enlarged lymph node in my neck.’ My heart skipped a beat.”
Simple hard nouns and verbs. The book would have been well served if it had all been written like that. However, that’s a minor complaint in the face of a wonderful, sad, hopeful tale of patients with cancer and the people who treat and love them. The First Cell is highly recommended for readers of The ASCO Post.
