death becomes him

Mournjenluc1Dying
Is an art, like everything else
I do it exceptionally well
I do it so it feels like hell
I do it so it feels real
I guess you could say I've a call
      – "Lady Lazarus," Sylvia Plath

The poet Sylvia Plath has always held a fascination for me, not because of her repeated suicide attempts (she succeeded on the third) and obviously troubled nature, but because of the stiletto-sharp clarity of her poetry, and how much raw emotion she managed to convey in such tightly minimalist phrasing.  "Lady Lazarus" is one of the most famous poems in her final collection, Ariel, brimming over with barely controlled white-hot rage. Scholars have analyzed it endlessly for autobiographical references to Plath's life (her daddy issues alone would fill tomes) and self-induced brushes with death, but what comes through for me in the poem is Plath's thinly-veiled contempt for those who were drawn to her precisely because she kept chasing after, and miraculously cheating, death.

The imagery presents the poem's persona as the featured act in a carnival sideshow, a person craving attention who is as addicted to the applause of the audience when she survives as they are fascinated by her death-defying (or seeking) feats. Plath tapped into a disturbing facet of our celebrity-obsessed culture: the glorification of nihilistic behavior, particularly of the "live fast, die young, and leave a good-looking corpse variety." There's something almost cannibalistic about our fascination with tragic figures in popular culture: we can't get enough news about their personal weaknesses and tragedies. Nowhere is this more evident than in the music industry, which is littered with the corpses of talented musicians who bought into this empty philosophy and paid dearly for it: Jimi Hendrix, Janis Joplin and Kurt Cobain spring immediately to mind, but they're in very good company.

The most recent train wreck in the music industry is pop singer Amy Winehouse, whose LP Back in Black showcases an extraordinary talent — and whose personal life is a shambles, to say the least. These days, she looks more like a strung-out homeless junkie than one of the biggest stars in the world. The drinking, the smoking (both cigarettes and crack), the ecstasy, the ketamine, have taken their toll: at age 24 Winehouse shows early signs of emphysema and an irregular heartbeat. On July 28, she was rushed to the hospital for an "adverse reaction to medication" — a claim that was greeted with more than a little skepticism, given her public touting of her drug use.

Sure, it's a waste of talent and human life, but it's her choice, so why even bring it up? You might be thinking. But I can't help feeling twinges of compassion for Winehouse, who has bought into that false philosophy, just as I have compassion for anyone who has despaired so completely that death seems a reasonable option to their current life. Clearly, a new role model is needed to show us how to live, and how to die — not with a nihilistic shaking of the fist in defiance of god-knows-what imagined enemy, but with grace, good humor and dignity. We have that role model in former Carnegie-Mellon University computer scientist Randy Pausch, who died of metastasized pancreatic cancer two days before Winehouse was rushed to the hospital for her "adverse reaction to medication." Randypausch20070919pprandypausch_50

Pausch needs no introduction, really: his famous "last lecture" at Carnegie Mellon has been downloaded and viewed by millions all over the world, and his passing was marked by every major media news outlet, and all throughout the blogosphere. If you are one of the three people who haven't seen the lecture yet, it's an hour or so well spent.

Pausch was breathtakingly candid and accepting of his fate,  joked about being able to do lots of pushups (which he ably demonstrated), and wisely refused to talk about his wife and children, who would be most affected by his death. Mostly, he talked about life: how to live well by pursuing your childhood dreams, not getting discouraged by the brick walls (they're there to test how much you want something), and how to leave some sort of personal legacy behind… even if it's just for your wife and kids. His is a memorable example of a life well-lived, and in choosing to share his lecture (and his fate) with the world, he also showed us how to die. As Wall Street Journal columnist Jeffrey Zaslow memorably observed, "His fate is ours, sped up."

I simply can't watch that lecture without getting all choked up, and I couldn't bring myself to blog about Pausch's passing until now. He gave us something very precious, you see, and we couldn't return the favor by saving his life. The cancer was inoperable; as it is, he lived five months longer than doctors expected. As Pausch knew better than anybody, there is no magical deus ex machina enabling us to cheat our common fate. But that doesn't mean scientists aren't trying. The day after he died, the American Association of Physicists in Medicine (AAPM) kicked off their annual meeting in Houston, Texas.

Just this past March, a very ill Pausch summoned the strength to testify before a House committee, requesting more funding for pancreatic cancer research. So the only way I can think to honor him is by highlighting some of the research presented at the AAPM meeting. Currently celebrating its 50th anniversary, the AAPM is dedicated to advancing the application of physics to the diagnosis and treatment of human disease — including cancer. As Pausch's family were making funeral arrangements, speakers at the AAPM meeting were describing the latest batch of innovative R&D that may one day make cancer a thing of the past.

One of the major obstacles to removing tumors via surgery is that not all of them have very well-defined borders, making it difficult to remove the tumors entirely without leaving a few errant cancerous cells behind — which continue to grow and multiply wildly until more tumors appear. There's also greater risk of complications, with long recovery periods. Researchers have been experimenting for years with various nanoparticle-based therapies. The basic concept is this: tailor the nanoparticles to gravitate towards cancerous tumors and lodge inside them, then deliver laser heat to that area; the nanoparticles will burn away the tumor and leave the healthy cells behind.

The latest twist on this sort of thermal ablation therapy comes from a group of researchers at the University of Texas' cancer center, who are also working on better ways to precisely guide and concentrate laser-generated heat in targeted tumors. It would help if we could see the process while it happens. In this case, they injected gold silica nanoshells  into brain cancer models. As expected, the nanoshells made a beeline for the target tumors and were handily taken in like long-lost friends. Then the UT scientists applied low-power laser light to selectively heat and burn away the tumor but not the surrounding healthy tissue. The twist: they added iron-oxide cores to the nanoshells, thereby making it possible to visualize them using magnetic resonance imaging (MRI). Their conclusion? "[T]he use of magnetic resonance temperature imaging and gold nanoshells hold the very real possibility of meeting the long-sought goal of improving the precision of thermal ablation, while sparing healthy tissue."

Since not all parts of a tumor will respond the same to conventional radiation therapy, which uses a uniform dose to the entire tumor. In the future, it might be more effective to target the more resistant parts of a tumor with stronger doses. It's known as "dose painting" in medical physics circles — or, more technically, as intensity modulated radiation therapy (IMRT). This means we'd need to be able to measure the degree of resistance in those different parts accurately — right down to the molecular level — and it turns out that this is no small feat, according to a new analysis by scientists at the Institut Jozef Stefan in Ljubljana, Slovenia, and the University of Wisconsin, Madison.

The conventional method relies on PET scans, which can be quite useful in measuring radio-resistance if the radio tracer fluoro-L-thymidine (FLT) is used. Cells grab onto FLT as they divide, and since cancer cells divide so rapidly, they pick up more of the FLT, and hence look brighter on a PET scan.(It's called a standardized uptake value.) If those cells in that region are still bright after a round of radiation therapy, it's pretty clear they're radio-resistant, and the therapy is ineffective on those cells.

IJS's Urban Simonic thinks there is another, more precise way to find the radio-resistant cancer cells by using a more dynamic approach: modeling how the radio-tracer travels through the body and is collected by cells over time. He and his Wisconsin colleagues compared the two techniques using the same set of PET scans, and found that the two approaches selected different regions as being resistant to radiation therapy. Oops. Whether or not one agrees that Simonic's approach is more precise or not, the discrepancy clearly needs to be addressed if dose painting is ever going to clinically effective.

Researchers haven't been idle on the dose painting (or IMRT) front either. Another paper at the AAPM meeting dealt with a new variant called volumetric modulated arc therapy (VMAT). Developed by researchers at the Memorial Sloan-Kettering Cancer Center, the method offers the same treatment as IMRT in roughly half the time. That's because, with IMRT, a computer-controlled linear accelerator sweeps a narrow slit of radiation across the tumor from various angles around the patient, one angle at a time. The VMAT technique — at least the variant described at the meeting — breaks that arc into 360 evenly divided beams. The researchers developed a computer program that adjusts the aperture shape and radiation does for each one of those 360 beams. And because the resulting aperture beams are much larger than in IMRT, treatment time is reduced significantly (up to 50%), along with the patient's exposure to any radiation leakage (down from 5 minutes to 2-1/2 minutes).

That's literally just the tiniest smattering of the fascinating research being done in this area, by PhD physicists, doctors, pharmacologists, oncologists, neurosurgeons, and so forth crossing disciplinary barriers to fight a common foe. None of this new cutting-edge technology came of age in time to save Pausch and the the millions of other people around the world who die from some form of cancer each year — all of whom have friends and family and colleagues devastated by their loss, even they don't warrant front-page obituaries in all the major newspapers. But we can honor them by continuing to fight the onslaught of disease, and we when we lose — as indeed, we must — by dying exceptionally well.

3 thoughts on “death becomes him”

  1. Very touching piece Jennifer, thanks. I do believe that more rather than less face their death courageously, quietly and in amazing and unanticipated ways.

  2. Blue Collar Scientist (http://bluecollarscientist.com/) was a blog I quite enjoyed. I was saddened to learn that Jeff passed away only a few weeks ago from complications due to liver cancer. His friend wrote a really wonderful tribute to a truly courageous man who not unlike Randy Pausch loved to teach and learn.

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