I had previously thought of cancer as a straightforward enough, if unwanted, thing embedded in a well-oiled institution that closely monitored its flock in pursuit of the knowledge that would shortly result in a cure. The histories of cancer that I’d read generally told a story of progress, from the use of primitive treatments (ground puppy bones, sandalwood, turpentine) to more effective ones (x-rays and vaccines.)4 Even the bleakest of histories assume that a cancer (part cell division, part social history) can be described within the context of the history of medicine and the evolution of research strategies, treatments, and activism.5
In that moment of my postdiagnostic, post-first-surgery encounter with the doctor-resident / path report / mom-gown-bandages / possible micro-metastases / white coat / tiny room, I realized that no well-managed organization watches over cancer. Cancer, in all its nounishness, refers to everything . . . and nothing. Cancer pervaded the office, residing in each of these objects and people and the relations among them, but nowhere could it be specified as a thing. The main tumors were gone: cancer had only just begun.6 What on earth, then, do we mean when we refer to this concept, cancer?
Bitter debates, driven by jostling participants, rage around basic questions. Should premalignant lesions count as cancer when it comes to gathering statistics and deciding on treatment? Should insurance cover the costs of not exactly medically necessary reconstructive surgery? What about experimental treatments? Where and how should we even be looking for cancer? In each of these issues, the stakes are enormous, yet hardly anyone seems to challenge the terms and intersections of the debates. Anything but an objective thing, cancer can be better understood as a set of relationships—economic, sentimental, medical, personal, ethical, institutional, statistical.
Given the billions spent and made in developing treatments and the magnitude of the destruction of bodies and the social fabric, we desperately need new ways of understanding cancer—not as a disease awaiting a cure, but as a constitutive aspect of American social life, economics, and science. Malignant builds on this idea, presenting cancer as a process and as a social field, while also exploring its brutal effects at the level of individual experience.
I read personal, medical, economic, cultural, and epistemological together. These realms have—in often entirely obvious but complexly discounted ways—misleadingly separated the fact of cancer from its all-too-human interpretations. My mash-up includes the peculiar authority of the socio-sexual psychopathologies of body parts; the uneven effects of expertise and power; the possibly cancerous consequences of donating eggs to a girlfriend desperate to have a baby; the huge industrial investments that manifest themselves as bone-cold testing rooms; and the teeth-grittingly jovial efforts to smear makeup and wigs over the whole messy problem of bodies spiraling into pain and decay.
The quest to discern the interests behind how and when cancer is named can also diagnose the interests that produce and treat the disease. Malignant seeks the places at which these reciprocating diagnoses most paradoxically intersect, such as prognoses, research trials, legal battles, and screening debates. Unraveling the guiding logics of these institutions enables us to better understand who claims knowledge about cancer, and how—through methods as varied as statistics gathering or lay experience. While my argument will hopefully be useful in considering other diseases, a focus on our affair with this fundamentally unknown illness uniquely shines light on the institutions and perspectives that constitute illness in America.
PERFECT STORM
If you look up cancer in a medical dictionary, you will read that cancer begins when an injured cell speeds up the normal process of division. Eventually these quickly dividing cells may form a tumor, which then may build its own set of blood vessels in order to feed itself in a process called angiogenesis. (Blood cancers, or liquid tumors, don’t form static tumors in quite the same way.) Some cells may break off from a localized tumor and move to a different part of the body, colonizing a vital organ or bone. For most cancers, once this metastasis happens, you are probably sunk (a term one will not find in medical journals but that nonetheless feels accurate). These distinguishing features describe at least several hundred diseases that flutter under the cancer banner.
A more truthful account of cancer would require a full-blown epic movie series, for cancer has become a central, silent, ubiquitous player in twentieth- and twenty-first-century America. One would watch images of our greatness fading in and out to a heart-swelling orchestral score. Each of America’s iconic industries—agriculture, oil and gas, cosmetics, plastics, pesticides, tobacco, medicine, construction, military—has undoubtedly led to tens of millions of cancer deaths. The unique way in which cancer presents, decades after exposures, makes it central to the growth of both the industries and the illness, in short, to the existence of the United States as we know it.
If I were to direct such a movie, I would start by examining how cancer has become a potent metaphor for anything evil or scary. As a result, cancer—or at least the fight against it—provides a moral ground for anyone taking a stand against something bad, something that indeed might “metastasize” or spread, whether guns, fascism, or gay people. If the disease itself provides the archetype of malevolence such that “curing cancer” offers an equivalent to “saving the world” in all kinds of thought experiments, the stereotype of the diseased victim that one treats with kid gloves can be useful, too. Witness Tour de France winner (or ex-winner, since he has now been stripped of his seven victories) Lance Armstrong’s use of his year in treatment to at once explain his greatness and divert attention from his performance-enhancing drug use.
Tobacco’s relation to cancer has been well rehearsed. But for good measure my production crew would run footage from the 1970s, describing how the cigarette industry brains shifted the demographics of lung cancer with the jingle “You’ve come a long way, baby” for their special feminist cigarette, Virginia Slims. By sponsoring women’s tennis and advertising specifically to African Americans when no one else would, cancer incidentally joined progressive causes. The tobacco industry’s role in cancer does not end with the millions of lung cancer deaths. The industry inadvertently enabled the rise of the field that became epidemiology as a result of controversial attempts to link lung cancer to smoking. My blockbuster would describe how cancer also provided opportunities for major public health campaigns and philanthropic endeavors, shaping the form of both of those areas of the American Experience. In one ironic twist, the widow of the ad executive behind the 1930s advertising campaign “Reach for a Lucky Instead of a Sweet” became one of the main activists promoting the War on Cancer, launched in 1971. Cancer giveth fortunes and taketh them away.
Another thread of the documentary would focus on notable Americans prematurely lost to the disease: from Steve Jobs to James Baldwin, from Humphrey Bogart to Judi Bari. A full section would detail the life of Rachel Carson, the scientist who initiated the modern environmental movement with her book Silent Spring before her own name was added to the list of brilliant people—people we needed—dead of cancer. I’d include a section titled “The Celluloid Send-Off,” which would review a century of film and the star appearances of cancer as a sentimental storytelling trope.
I would wrap my producer’s blood pressure cuff around the military technologies that pumped the lifeblood of an American Century. The development of chemotherapy resulted from the autopsies of soldiers who had been killed by nitrogen mustard gas in World War I; it was found that the gas eradicated white blood cells from bone marrow and lymphatic tissue. Although the use of radiation as an experimental therapy for cancer patients began before World War II, the increased focus on its development coincided neatly with the government’s attempt to represent the “friendly” potential of nuclear technology. (Sure, radiation killed all those Japanese people, but it can do good things too!) Both of these cancer treatments led to the creation of a massive, powerful, and lucrative infrastructure even amid controversy about their efficacy. The military and cancer have enabled one another in ways that have yet to be understood.
Midcentury cancer experts
