The Magic Bullet

by Harry Stein

  “Which one’s she?” Logan had already gone over several dozen of the patient files Levitt had prepared.

  “Massive mediastinal Hodgkin’s disease? She’s one of Larsen’s.”

  “Oh, right”—as always, Logan had a better head for disease than for names—“she’s in the control group for the test of the new drug combination they’re trying against Hodgkin’s—they have her on ACE chemo.”

  The protocol in question was a Phase Three. ACE chemotherapy, an acronym for the three compounds involved in the treatment, had been pioneered almost twenty-five years before by Dr. Kenneth Markell, current head of the ACF. If it was less than completely effective, it significantly reduced tumor mass eighty percent of the time.

  “What’s the problem? Didn’t the report say she’s doing well?”

  “What does that have to do with it—this woman is the mother of ail pains.” He paused. “And there’s also a father.”

  The reference, as Logan soon learned, was to the patient’s husband, Roger, who seemed to spend almost as much time at the hospital as his wife, hovering over her, seeing it as his role to challenge the doctors’ every move.

  After a couple of minutes in their presence, Logan had a hard time deciding which of them he liked less: the endlessly self-pitying Rochelle, who seemed to see her illness as some vast plot to undermine her happiness; or the arrogant Roger, a take-charge guy without a clue. For the moment, he was content to stand back and watch Levitt handle these two.

  The problem today was that Rochelle was due to start a new round of chemotherapy in two days. For most every patient, of course, chemo is an ordeal approached with dread; but they swallow hard and take their medicine.

  Not Rochelle.

  “It will have to be postponed,” her husband put it to Levitt. “She’s not ready.”

  “I’m really sorry,” she said mournfully.

  “I’m afraid that’s not possible, Mrs. Boudin. We’ve been through this.”

  “You docs can do whatever you damn well please,” snapped Roger.

  “Actually,” came the measured reply, “you know very well we can’t. According to the terms of the protocol—”

  “Damn the protocol! Look at her—she’s looking great, she’s feeling fine! Why put her through this now?”

  “I feel like I’m losing control,” said Rochelle, her bottom lip trembling. “It’s not fair that you make me feel that way. Just thinking about it makes me nauseous.”

  “They just take advantage of your good nature. They make allowances for other patients on this protocol.”

  “That’s completely untrue.”

  “Easy to say—since you haven’t let us meet any!”

  “We’re bound to protect their anonymity just as we do yours.” Levitt exhaled deeply, trying to maintain his composure. “I understand, the treatment is extremely unpleasant. And, yes, thank God, the tumor does seem to be in remission. But we do this for a reason. We’ve been charting the lab values very closely and—”

  “So have we,” cut in Roger, “and we think it’s unnecessary. At the least, we insist on a reduction of the dosage.”

  “I’m sorry, we can’t do that.”

  Roger Boudin shook his head, as if scarcely able to believe the doctor’s unreasonableness. “I didn’t want to have to say this, but we’ve taken the numbers elsewhere for independent evaluation.”

  “You’ve what?” If he’d hoped to get Levitt’s attention, he’d succeeded beyond all expectations; for a moment Logan thought his colleague might lose it. But almost instantly he recovered his professionalism. “Mrs. Boudin,” he said blandly, turning toward the patient, “obviously it is your right to take that information to anyone you see fit. It is also your right to remove yourself from the protocol at any time.” He stared at the floor a moment, then cleared his throat. “If you choose to do so, kindly inform me as soon as possible so I can prepare the appropriate paperwork.”

  Levitt was playing with fire, and Dan Logan knew it. Would he really let her go—or was he simply convinced they were bluffing?

  Bingo! Almost instantly, Roger began backpedaling. “I don’t mean … no, it’s nothing like that. He’s a cousin of mine. We just got to talking about it.”

  Levitt stared at him coldly. “As I say, it is your choice. You have been informed of the rules.” He glanced at his watch. “I’ve got other patients to see.”

  He turned and began walking from the room. Logan followed.

  “Doctor?”

  They turned. It was Rochelle, her eyes moist. “Could you come back later?” she asked, a lost little girl. “Maybe tomorrow? Just to answer a few questions?”

  He nodded crisply. “Certainly.”

  As soon as they reached the hall, Levitt clapped his hands together. “Meaning,” he added, grinning broadly, “that you’ll be back later.”

  The malignant cells now number in the tens of millions. Having successfully migrated from the breast, they prosper in new environments; even when completely autonomous, free of all contact with their fellows. They have proven particularly adept at infiltrating bone.

  She tries hard to ignore the nagging pain. It is one more demand on her patience in a life full of such demands. For years she’s been saying she doesn’t believe in illness. Anyway, the Tylenol in her desk drawer still provides the temporary relief she needs.

  The progression is relentless. A malignant cell observes none of the constraints that inhibit normal ones. Each is now the equivalent of a professional killer, plundering nutrients that normal cells need to survive, showing contempt for physiological equilibrium and tissue architecture. The tumor replicates itself every three weeks. Each new generation of malignant cells is even more aggressive.

  Her husband knows her better than anyone. Before bed one evening he notices—not for the first time—that she is vigorously massaging the small of her back. Shrugging off her assurance, he insists she have it looked at.

  Logan got very little sleep that night—but he didn’t care. Propped up in bed, surrounded by piles of spiral-bound notebooks, sipping from a coffee cup—a gift from an old girlfriend, bearing a picture of Drs. Frankenstein, Kildare, and Mengele over the words Medicine, a straaaange businesss—he was so immersed in the notebooks, it was nearly dawn before he was even aware of the time.

  This was no mere assignment to be grudgingly endured. The descriptions of the trials being performed at the ACF were more than just fascinating; after his introduction to the place, they were invigorating. This was what mattered, not all the personality conflicts and petty bureaucratic maneuverings. Those came with every job everywhere. But only at the ACF was it possible to do this kind of remarkable work.

  The protocols were the heart and soul of the ACF, the very reason for its existence and wondrous reputation. For a young doctor, studying them was a chance to explore the thinking of the greatest minds in the field, to have the very future of cancer medicine laid out before him.

  Each of the thirty-six protocol proposals ran at least twenty-five pages and was loaded with the kind of obscure language and arcane detail that would quickly put off anyone outside the field. But to Dan, every one was like a chapter of an epic detective story. For it suggested a new approach to the age-old mystery of cancer; a plausible theory about why and how malignant cells grow and change as they do; a daring hypothesis about how this or that drug might have an impact where nothing had ever worked before.

  Logan was not surprised by the number of compounds that had demonstrated activity against malignancy—at least in a test tube or a rat. Too, he was prepared for the staggering variety of problems that remained in almost every instance, most involving the complex issue of toxicity: fully a third of the trials focused on mechanisms for targeting tumor cells while leaving surrounding healthy cells intact. But what did take him aback, what he had never before fully grasped, was how many of the most promising drugs had in some form been known to scientists for decades. It was just that, among the hundreds of thou
sands of compounds available, with more being developed every day, their potential uses had never before been fathomed, let alone tested; no one, until now, having made the essential leaps of logic and imagination.

  Logan found himself absorbed even by the specifics of patient eligibility, daily treatment plans, and statistical analyses of data. Able to see the desperate human beings beyond the cold numbers, he understood that a change of just a few percentage points in the survival rates represented the lives of thousands of individuals and the well-being of countless families.

  The next morning, Reston caught the bounce in Logan’s step as soon as he saw him approaching the administration building lobby.

  “Who’d you sleep with?”

  Logan laughed. “I have the feeling I’m not going to be sleeping with anyone for a long time—unless I find someone who gets turned on by randomized trials in Hodgkin’s disease.”

  “Ah, you’ve been going through the protocols.…”

  Logan nodded. “God, some of the stuff that’s being done around here!”

  “I know,” smiled Reston. “Amazing, isn’t it?”

  “I mean, I’m reading this stuff and thinking, What the hell do these people need me for?”

  “We went through that yesterday with Larsen—to do the scut work.” He snickered. “But don’t give me any of that false-modesty crap. You’re thinking the same thing I am: How soon before I get to run a protocol of my own?”

  Logan smiled. “Me? I’m a humble junior associate, I accept my station in life.”

  “Like hell.”

  “At least for public consumption.” He glanced around the busy lobby. “Look, seriously, that kind of talk’s not going to do either of us any good.”

  “Logan, they know we’re ambitious. Ambition is part of what they were after when they brought us here.”

  “Controlled ambition. Ambition in the service of the greater good.”

  Reston nodded. “You’re right. The first order of business”—his voice dropped slightly—“is figuring out which of the senior guys to try and get as a godfather.”

  “Reston, you’re really out of your mind, you know that?”

  “What are you, blind, deaf, and dumb or just pretending to be? You think you’ll get anywhere around here without one?”

  Logan shook his head. “Not me. I’m steering clear of that stuff. I want to stay on good terms with all of them.”

  “Not possible. Trust me, they’re sizing us up, same as we are them. Every one of them’s looking to put together the best team.”

  “Fine,” said Logan, exasperated. “Who do you want?”

  His friend grinned. “Me? Markell—why not shoot for the top?”

  They both laughed; they hadn’t so much as laid eyes on the august director of the ACF.

  “Good morning, gentlemen.”

  They wheeled. There, to their intense discomfort, his motorcycle helmet under his arm, stood Gregory Stillman. How much had he heard? His small, hard smile gave away nothing.

  “Hello, Dr. Stillman.”

  “Nice to see you again, sir.”

  “Logan and Reston, isn’t it—the Claremont twins?”

  “Actually, sir,” said Dan, “we hardly knew each other there.”

  “Don’t mind me, I play little tricks to remember names—something I picked up from a book on memory retention.” His eyes narrowed slightly. “I try to make an effort to know each of the junior associates personally. Tell me, do you have some time right now?”

  The two young doctors exchanged a quick glance. Logan knew full well that Shein would take it as a betrayal; he also suspected that this might be precisely what Stillman had in mind.

  Reston quickly made the decision for him. “Sure, we were just going to grab a bite in the cafeteria.”

  Ten minutes later they were in Stillman’s office, listening to the story of his own rapid rise within the ACF hierarchy. A mere fifteen years before, he blithely noted, he had been just a first-year fellow himself; today, “I’ve got eighteen people working for me.” He smiled. “Going on thirty. We’ve been fortunate lately in attracting quite a bit of funding to our work on breast cancer.”

  Stillman’s brilliant career, as the younger men well knew, was built on his pioneering work in the molecular origins of the horrific disease. While most earlier researchers had focused on surgical attacks on breast malignancy, or new versions of chemotherapy, Stillman aimed to attack it at its root. In his studies, he investigated possible derangement in DNA molecules; which proteins seemed to be overproduced in breast tumors and which were absent; the chemical agents within cancer cells that enabled them to replicate themselves with such deadly efficiency.

  “Would you like to hear what I’ll be working on next?” he asked. “This is going to be the next great breakthrough.”

  His visitors’ faces lit up: this was like being invited to the unveiling of a Da Vinci masterpiece.

  Stillman slowly rose to his feet. “Do you like opera?”

  “I do,” said Logan, confused.

  “Any particular favorite?”

  “Mozart. Especially The Marriage of Figaro.”

  Stillman chuckled with what seemed to be condescension. “Dr. Reston?”

  He hesitated, then smiled. “Especially Tommy. By the Who.”

  Stillman turned to Logan, unsmiling. “Evidently, Dr. Reston does not share our reverence for the past. Too bad. That’s where we’re going to find many of the answers to today’s problems.”

  Stillman had taken a CD from the corner of the bookshelf and placed it in a nearby machine. “This is Nerone, by Boito. It’s probably more … sophisticated than what you’re used to, but I hope you’ll enjoy it.”

  As the opening chords of the piece filled the room, he returned to his seat behind the desk. Opening a drawer, he withdrew a manila folder.

  “This began over a year ago,” he said. “A patient came in and asked me to examine her tits.”

  The word had been intended to shock, and he was pleased to note a reaction from Logan.

  “That’s my job,” he explained evenly. “I’m one of the top tit men around this place.” Catching Reston’s grin, he grinned back. “By the way, I’m no prude, like Larsen. I like ’em when they’re healthy too.”

  Caught off guard by Stillman’s aggressive tastelessness, Logan said nothing. What was going on here? If—as he’d allowed himself to believe—the point was to secure their allegiance, Stillman was going about it in a curious way.

  But suddenly the senior man was all business again. “She had an inflammatory carcinoma, a particularly bad disease—the tumor was diffuse, it didn’t form a lump. But the point is, there was something extremely unusual about this patient. I had given up hope on her, and then, to my surprise, some of her tumors—not all, but some—spontaneously disappeared.” He paused meaningfully. “A lesson for you here, gentlemen: Be alert for crazy exceptions to the rule, they’re the ones bearing secrets. It turned out this woman was taking a course of drugs and enhanced vitamins for a completely unrelated condition.”

  “May I ask what condition?” interjected Reston.

  Stillman shot him an annoyed glance. “Sure. After I’ve had our work patented.” He resumed his professorial tone—and changed the subject. “There are a number of interesting things we’ve been working on in this lab.”

  From the folder, he withdrew two eight-by-ten black-and-white photographs. “You’ll note this is a photomicrograph of malignant breast cells growing in a culture dish.”

  Sure enough, the cells were arrayed in the familiar chaotic pattern characteristic of breast malignancies. Many were joined together in irregular swirls, like stars in a Van Gogh night sky. Others were of grotesque size and shape. In some places they were heaped together in piles.

  “And this,” he said, displaying the second photograph, “is the same cell growth after a six-week exposure to one of the new chemotherapeutic agents we’ve been developing.” He paused. “I can tell you that
it involves a new mycotoxin—one of the ones a field researcher brought back last year from the Amazon.”

  The change was uncanny! More than half the cells were clearly dead or dying, their nuclei shriveled. In whole sections of the photograph, there remained no living cells at all.

  “That’s unbelievable!” exclaimed Reston.

  Stillman nodded crisply. “Yes. It is.” He stood up, signaling the session was over. “I’m glad you enjoyed it.”

  He ushered Reston into the hall first, then turned back to face Dan. “Of course, we know it can be a long way from a culture dish to successful clinical trials.”

  “Yessir.”

  “You can probably see I’m a difficult personality, Dr. Logan. I don’t give a good goddamn who I offend.”

  Logan, awkward, a silly grin plastered on his face, made no response. None was expected.

  “Just bear this in mind. I’ve got more protocols going at the ACF than anyone. Almost twice as many as Shein.”

  * * *

  Logan hardly had time to be anxious. He was obliged to spend the rest of this second day at the ACF in the computer room, trying to learn a system that beat anything he’d ever imagined for complexity, yet one that he couldn’t leave the room without having mastered: every procedure at the ACF—from ordering antibiotics to tracking patients’ progress—went through this machine.

  When he was finally done, it was after 8:00 P.M. Yet he dragged himself back up to the twelfth floor and made his way to Rochelle Boudin’s room.

  “Sorry I took so long,” he said apologetically. “I’m still pretty new here.”

  “Where’s Dr. Levitt?” replied Roger, clearly not a man big on pleasantries.

  “He’s off service.” Logan paused. “I’m sure you’ll see him from time to time, but you’ll be dealing primarily with me from now on.”

  The Boudins exchanged a glance. “What do you know about my wife’s case?” demanded Roger.

  “I’ll be working under the senior physicians, of course. But, please, I want you to feel comfortable discussing anything at all with me.”

  Rochelle looked him over for the first time. “I’m not sure any doctor can ever understand how we feel.”