Similarities of First-and Second-Hand Accounts of Cancer Diagnoses by Two Physicians in the Literature

— First-and second-hand accounts of cancer diagnosis in physicians are rare in the literature. In the books The First Cell: And the Human Costs of Pursuing Cancer to the Last, by Azra Raza, and When Breath Becomes Air, by Paul Kalanithi, similarities are seen. These similarities include devotion of the affected physician to his profession, and use of the literature, imagery, rhetorical questions, and repetition throughout the texts. These two works movingly show the devastating effects a cancer diagnosis has on the lives of these individuals, and how this diagnosis is uniquely devastating to a medical professional who is cognizant of their ultimate prognosis.


INTRODUCTION
Physicians are trained to know more about medical conditions than any of us.Therefore, when they succumb to a serious diagnosis like cancer, their impressions and insight are invaluable.In literature, there are rare first-or even second-hand accounts of the devastating effects of a terminal illness such as cancer on a medical doctor diagnosed with this devastating condition.In The First Cell: And the Human Costs of Pursuing Cancer to the Last, author Azra Raza, a medical doctor specializing in oncology, writes about her experience treating cancer patients and movingly, her experience with her husband's diagnosis of cancer.In When Breath Becomes Air, neurosurgery resident Paul Kalanithi details his experience with being diagnosed with lung cancer and his struggle to live the rest of his life, balancing his career with his love for his field.In both of these books, similar themes and styles arise.These include the overwhelming theme of overwhelming devotion to their work as physicians, deep relation to literature, use of imagery, use of rhetorical questions, and repetition.

II. DISCUSSION
Paul Kalanithi was a medical doctor who was diagnosed with lung cancer as a neurosurgical resident.He wrote an autobiography, When Breath Becomes Air, which became a National Bestseller.The book The First Cell: And the Costs of Pursuing Cancer to the Last (The First Cell), is a biography written by Azra Raza, whose husband Harvey is diagnosed with terminal lung cancer.Both Raza and her husband are medical oncologists, so they both have intimate knowledge of his diagnosis and dire prognosis.
In The First Cell as well as When Breath becomes Air, both authors relate deeply to literature.Kalanithi states, "I hadn't thought much more about a career but had nearly completed degrees in English literature and human biology.I was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful?I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain" (Kalanithi 28).In The First Cell, Raza similarly leans on poems and literature to convey the emotions that she and her husband are experiencing.For example, she quotes, "After great pain, a formal feeling comes-The Nerves sit ceremonious, like Tombs-The stiff Heart questions was it He, that bore, And Yesterday, or Centuries before?-EMILY DICKINSON" (Raza 257 The sky and all the planets could not comprehend your expanse Only my heart has the largeness to embrace the anguish" (Raza 35).Through their use of literature, the authors try to find the most appropriate words to relay their deepest emotions, leaning on the words of famed poets and authors to do so.
As a biology, literature, philosophy, and medical student and later as a neurosurgery resident, Kalanithi always struggled with the question of what makes life meaningful, and questions the relationship of meaning, life, and death.Once he is diagnosed with end stage lung cancer, he is forced to reexamine this relationship from his perspective both as a patient and physician.He realized that everyone "succumbs to finitude" (Kalanithi 198) and therefore fully embraces each day that he has left, doing his job as a neurosurgeon, while cherishing his loved ones, especially his wife and newborn child.He realizes that "money, status, all the vanities the preacher of Eclesiastes described" (Kalanithi 198) are unimportant and that what is most important are human relationships.Finally, Kalanithi continues to pursue his calling of neurosurgery and helping people, even as he is dying, because he reflects that even though he is dying, until he dies, he is "still living," (Kalanithi 150) and continues to pursue his passion of helping people through practicing neurosurgery until he is unable to do so.This book raises many important and difficult questions that people can relate to and causes the reader to reflect and ask themselves similar questions of how they would want to live their lives as they are actively dying.
Similarly, Raza relates that her husband Harvey is also devoted to his work, just as Kalanithi was.She writes, "W.B. Yeats was puzzled by the question: 'The intellect of man is forced to choose / Perfection of the life, or of work.' Fortunately for Harvey, it was never a question of either-or.For him, work was life and life was work.The two were inseparable.Once, toward the end, when I asked him to work less and maybe do other things that he did not have the time for before, his response was that such an act would make a mockery of everything he had stood for and had done until that point in his life.Work was his deepest passion outside of the family."(Raza 251-252).Kalanithi and Raza show that they strongly identify with their roles as medical caretakers and that these roles are only secondary to their top priorities as husbands and fathers.Their roles as physicians and caretakers for others strongly define them and their passions in life.
Kalanithi effectively uses imagery in the book to portray to the reader how he views his current situation, where he has almost reached the fruits of his many years of hard work."At age thirty-six, I had reached the mountaintop; I could see the Promised Land, from Gilead to Jericho to the Mediterranean Sea.I could see a nice catamaran on that sea that Lucy, our hypothetical children, and I would take out on the weekend.I could see the tension in my back unwinding as my work schedule eased and life became more manageable.I could see myself finally becoming the husband I'd promised to be (Kalanithi 7).
Here, the author describes how he has finally reached his goals and is on the verge of attaining his fullest dreams.These include being on a "mountaintop" where he could see the "Promised Land," as well as relaxing with his wife Lucy and their "hypothetical children."He can finally see his work demands relaxing, with the "tension" in his back unwinding."The use of this imagery is very effective, as one can envision Kalanithi reaching the end of his long journey up the mountain, which was his long and difficult medical training.He can see attaining all the goals he has set himself and which should be in his immediate future.Kalanithi also uses imagery to dramatically describe dissecting cadavers in anatomy class and how it results in a transformation of the students."Cadaver dissection is a medical rite of passage and a trespass on the sacrosanct, engendering a legion of feelings: from revulsion, exhilaration, nausea, frustration, and awe, to as time passes, the mere tedium of academic exercises.Everything teeters between pathos and bathos: here you are, violating society's most fundamental taboos, and yet formaldehyde is a powerful appetite stimulant, so you also crave a burrito.Eventually as you complete your assignments… Cadaver dissection epitomizes, for many, the transformation of the somber, respectful student into the callous, arrogant doctor" (Kalanithi 44).Here, Kalanithi outlines the stark contrast between what is appropriate and not.For example, while dissecting a cadaver should be revolting, the formaldehyde is a "powerful appetite stimulant," which makes you inappropriately hungry.In addition, though dissecting a cadaver should be a serious and positive experience, its effect is negative, transforming a "somber, respectful student" into a "callous, arrogant doctor."One can easily envision the hungry medical student who inappropriately changes from a naive and respectful medical student into a more cynical and uncaring doctor after thoroughly dissecting a cadaver.The author effectively uses imagery in these ways to describe his innermost thoughts, even when they are unpleasant, and allows the reader to empathize with all the author's experiences and revelations, causing them to be shocked by the author's admissions but also gaining insight into the author's experiences.Raza similarly uses imagery to describe what she sees happening to her husband, effectively using details to portray the dramatic effects of the cancer on him."After Harvey was diagnosed with cancer, we prepared ourselves for all sorts of eventualities, but even we were taken aback by the unexpected intensity and recurrent nature of the pain, appearing in wholly unpredictable places and forms.Masquerading as arthritis one day and a neuralgia the next, it showed up as venous thrombosis, assaulted nerves, skin and bones, digits and muscles, mucous membranes, glands, organs, and limbs in a series of reckless tsunamis.No tissue was spared.These were all manifestations of the collateral damage resulting from a twisted, misguided tug-of-war between the body's confused immune system and the lymphoma, and all were accompanied by intense pain."(Raza 256) Here, she uses metaphors to describe the utter devastation occurring to her husband's body, comparing the devastation to a "tsunami" which leaves in its path the devastation of "destroyed nerves, organs, and limbs," which are a result of a "tug of war" between the body's defenses and the lymphoma.This imagery used by Raza helps to bring to life the utter destruction left by one of the most devastating natural disasters-tsunamis-and this is similar to the destruction left by Harvey's lymphoma.

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In addition, Kalanthi uses rhetorical questions in the book to demonstrate the many difficult questions he has about what type of life is worth living.He asks, "Would you trade your ability -or your mother's -to talk for a few extra months of mute life?The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage?Your right hand's function to stop seizures?How much neurologic suffering would you let your child endure before saying that death is preferable?... What makes life meaningful enough to go on living?" (Kalanithi 71).These difficult rhetorical questions have no right or wrong answers.Kalanithi also asks himself a series of difficult rhetorical questions to demonstrate his own constant uncertainty of his situation.He asks, "While I could now walk without a cane, a paralytic uncertainty loomed: Who would I be, going forward, and for how long?Invalid, scientist, teacher?Bioethicist?Neurosurgeon once again, as Emma had implied?Stay-at-home dad? Writer?Who could, or should, I be? …Shouldn't terminal illness, then, be the perfect fit to that young man who had wanted to understand death?What better way to understand than to live it?"(Kalanithi 147).Through his questions, we can see that there are a series of different roles he sees himself in, and it is difficult for him to decide which are the correct ones for him.In addition, he asks whether his impending death will help him to further decipher the meaning of life and death, which is something he has always questioned.He refers to his terminal illness as being the "perfect fit" to understanding death, which is something that he has always wanted an answer to, and asks, "What better way to understand than to live it?"In this way, Kalanithi is almost acknowledging that his terminal cancer is providing him with insights and answers to questions he has always had about death and implies that it is something he should be grateful for, as a "perfect fit" for someone with these questions.Kalanithi's use of rhetorical questions reminds the reader that there are so many difficult questions that arise when caring for patients with serious and terminal diseases and force the reader to realize what these questions are, as well as to realize that there are no good answers to these questions.
Raza similarly asks a series of rhetorical questions throughout her writing.She states, "It is universally acknowledged that early detection is the key to the cancer problem.This is why screening procedures were set into motion decades ago and early detection has reduced mortality by at least 25 percent.Now we need to trace our way to even an earlier detection of cancer cells, prior to their appearance on scans.So why is it that only 5.7 percent of the total budget of the National Cancer Institute is allocated toward this critical area of research?Why is 70 percent of the budget funding research that concentrates on advanced malignancies conducted on animals and tissue culture cells that will lead to clinical trials with a failure rate of practically 90 percent?Why isn't it just the opposite, with the majority of support going to detect cancer at its inception?How many Omars, how many Andrews, will it take?What would it have taken to cure Harvey?" (Raza 262).Here, Raza questions why so little funding is allocated to cancer research and how many people will have to suffer from cancer until things are changed.Just as with Kalanithi, we can appreciate the author's sense of hopelessness and frustration at the situation, apparent in the series of questions she asks that have no good answer.Moreover, Kalanithi uses repetition to demonstrate his uncertainty and mixed feelings about his terminal illness.He states, "I woke up in pain, facing another day-no project beyond breakfast seemed tenable.I can't go on, I thought, and immediately, its antiphon responded, completing Samuel Beckett's seven words, words I had learned long ago as an undergraduate: I'll go on.I got out of bed and took a step forward, repeating the phrase over and over: 'I can't go on.I'll go on'" (Kalanithi 149).Here, we can see that Kalanithi is struggling with facing each difficult day and reflects that he feels he cannot go on but must persist.He counters his desire to give up with "I'll go on," quoting Samuel Beckett's words of "I can't go on.I'll go on."Through this repetition and back and forth, we can relate to Kalanithi's mental state, where he is conflicted and just wants to give up but does not allow himself to do so.Kalanithi similarly uses repetition to further demonstrate his decision to return to work."Here was the prognosticationno, not prognostication: justification.Justification of my decision to return to neurosurgery, to return to life.One part of me exulted at the prospect of ten years.Another part wished she'd said, "Going back to being a neurosurgeon is crazy for you-pick something easier…A couple of my professions actively discouraged the idea: "Shouldn't you be spending time with your family?" ("Shouldn't you?"I wondered….)"(Kalanithi 150-151).In these ways, the author shows that his prognosis and the decision to return to work are intertwined.He must defend his decision by questioning peers who are judging him for his decisions.Through repetition, Kalanithi shows the constant back and forth that he must endure not only in his own mind and daily life but in dealing with his peers who are questioning his decisions.

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Raza similarly uses repetition effectively to highlight her deepest concerns regarding cancer."I am not saying that all scientific research on animal models should be abandoned.What I am saying is that animal models are misleading and harmful for cancer drug development, because the disease cannot be reproduced in such simplistic, artificial systems.I am not saying that all cancer research should stop except that related to early detection.What I am saying is that more resources have to be dedicated to this area.I am not saying that technologies like CRISPR are all hype.What I am saying is that the discovery of CRISPR as a tool in molecular biology is truly revolutionary, but its application in fixing human cancer cells by cutting and pasting DNA needs years of careful study before commercializing it into billion-dollar companies" (Raza 336).In this way, with her repetition of "I am not saying" and "What I am saying," Raza seeks to clarify her deepest concerns regarding cancer research and treatment.In both situations, the authors use repetition to effectively remind the reader again and again of their most compelling beliefs.
Kalanithi's main purpose in writing the book was as a self-exploration journey and document; the author ponders the intersection of meaning, life, and death and attempts to answer these questions once he has been diagnosed with end-stage lung cancer.He uses his previous studies in biology, literature, philosophy, and medicine as well as neurosurgery to reflect upon his thoughts and observations.This book also serves as a means for him to share his experiences and struggles with the general reader as well as those in his situation as a dying patient; he is also sharing his thoughts with his loved ones, especially his wife and young child, who he specifically addresses at times.I believe Kalanithi was very successful in exploring the themes of the meaning, life, and death and relating these themes as not only a physician, but also as a dying patient.
Kalanithi's unique background as a scholar and neurosurgery resident makes his perspective a unique and very insightful one.His writing is persuasive and raises very interesting questions of how one should live one's life; should life be lived as though every day could be their last or should life be lived with delayed gratification in mind, as most of us do?It also raises the question of how dying patients should be treated by physicians and by society.
In contrast, Raza wrote this chronicle of her husband's experience with cancer as well as an overview of cancer to stimulate a call to action and a change in the status quo of how cancer is treated.She states, "Only the profound suffering of cancer patients has the power to ignite a brand of compassion necessary for demanding urgent and dramatic change.Only empathy can break the foolish consistency that is the hobgoblin of oncology and little minds.The future is in preventing cancer by identifying the earliest markers of the first cancer cell rather than chasing after the last.I have been saying this since 1984, and I will continue to say it until someone listens" (Raza 336).She is pleading for people to change how cancer research is performed as well as how cancer is treated.She knows firsthand the degree of suffering experienced by cancer patients under current practices and is desperate for change to alleviate this suffering.Through their writing, both Kalanithi and Raza draw attention to their experiences, in an attempt to process their own feelings and experiences as well as to highlight to the reader the stark reality of cancer patients living their final days as physicians and as human beings.

III. CONCLUSION
In both The First Cell and When Breath Becomes Air, there is much for the reader to learn from these unique books written by physicians, one who is diagnosed with cancer and one whose loved one is diagnosed with cancer.Both have a unique perspective as they are written by people most knowledgeable about the management and prognosis of their cancers.Both authors reflect that life is very precious and that a balance in life is most important.In both scenarios, the authors show the two physicians prioritizing their work as physicians and their roles as husbands and fathers.In addition, the authors' use of references to literature and poems, imagery, rhetorical questions, and repetition are effective in reaching the reader.First-and second-hand accounts of physicians diagnosed with cancer are relatively uncommon in the literature, but both The First Cell and When Breath Becomes Air share several similarities which underscore the deep trials that both patients, who are also physicians, endure.