Authors: Harry Stein
“Never mind that,” snapped Larsen. “Let’s continue.”
“Dr. Larsen …” The words, the first his secretary had
spoken, were barely above a whisper, but Logan picked them up.
Larsen leaned toward her.
“That’s Mrs. Conrad.”
He hesitated an instant, frowned, then rose to his feet. “Dr. Kratsas,” he said, moving briskly toward the door, “take over, will you?”
“W
ho’s Mrs. Conrad?” ventured Logan, several hours later.
Rich Levitt, the senior associate whose patient roster Dan was about to inherit, stared at him across his tidy desk. “She’s an ovarian patient.”
“That’s it?”
“The wife of
Senator
Conrad …?” He raised an eyebrow, waiting for it to sink in. “… North Carolina? The Senate Appropriations Committee?”
“Ahhhh.”
“Why?”
Logan recounted the episode from the meeting.
“Don’t tell me that’s your first visit to the real world. How do you think this place gets most of its funding?”
Dan nodded. Of course, it made perfect sense. Every medical facility he knew of, no matter how supposedly democratic, provided treatment a bit
more
equal for the select few. What took him aback was the other’s straightforwardness. Entry into an ACF program was widely believed to be solely on the basis of suitability for a treatment protocol.
“I guess I kind of thought the ACF was above that kind of politics,” Dan admitted.
“Look, it’s not like she wasn’t a legitimate candidate. Let’s say she just got more consideration than
other
legitimate candidates. The important thing for you to know is that it’s not your problem: Mrs. Conrad’s not on our patient roster.” He smiled and shook his head. “Above politics? Some of these guys spend half their lives up on the Hill trying to shake money loose for their pet projects.”
“Any big shots on our patient roster?”
Levitt held out a hand and ticked them off. “Two congressmen. The administrative aide for the number-two man on the Senate Armed Services Committee. One Labor Department spouse, one Defense Department staff spouse.” He tapped his head and smiled. “It’s all right here in case of emergency. But none of them are as important as Mrs. Conrad. You saw it, she makes even Larsen jump.”
Logan didn’t know quite what to make of Levitt. Rarely had he encountered so improbable a mix of selflessness and utter cynicism; then again, increasingly that seemed simply a reflection of the ACF itself.
“So Mrs. Conrad’s the top VIP here now?”
“Absolutely.” He paused. “As far as I know.”
“What does that mean?”
Levitt exhaled deeply. Though he had no objection to answering the newcomer’s wide-eyed questions, his real concern was handing over his patients so he could move on to better things.
“Sometimes—rarely, but sometimes—there are people who get seen only by the top guys. They might even check in under phony names.”
“You’re kidding me.”
“Not that the rest of us don’t usually know there’s something going on.”
He glanced at his watch and sighed. “Look,” he said, rising to his feet, “I think it’s about time you met some of my—soon to be your—patients.”
“Well,” said Logan, following suit, “at least this part will be familiar.”
“Maybe. Although the patients you’ll be dealing with here may not be what you’re used to.”
Logan was baffled. “Actually, I had a lot of experience at Claremont dealing with terminal cancer pat—”
“No,” interrupted Levitt. “There are big differences. First, you were treating those patients individually, improvising as circumstances changed, right?”
“Of course.”
“Well—I can’t emphasize this strongly enough, Logan—here you have zero treatment options. None. Your job is to enforce the protocol. Period. Which means that sometimes you’ll actually have to go
against
your better judgment.”
Logan was silent as this hit home.
“It can be a huge psychological adjustment.”
“What happens if a patient starts questioning the terms of the protocol?”
“Happens all the time. Your problem is just making sure the patient doesn’t
leave
the protocol. Because then you’re messing with the entire study: there’ll be no way to know if that patient’s responding to therapy or for how long. When patients start dropping out, people start saying the work was sloppy or the treatment was too toxic.” He paused. “Trust me, if a protocol patient drops out on your watch, the senior guy running that study will have your ass. Some of those guys are killers.”
“I get that impression.”
Levitt nodded. “Yeah, I heard about that thing at Shein’s the other day. Welcome to the ACF.”
In fact, Logan had been thinking of Lukas’s gruesome face-off with Larsen, but no matter. “Some of these guys …” he ventured, “… you get the impression they’re liable to blow any minute.”
“You learn to take it in stride.”
“I mean, getting on the junior people is one thing. But they hate
each other
.”
“Absolutely.” He smiled. “When I first got here, another guy showed me a chart he’d done of the relationships between the big hitters. Each senior staffer was represented by a circle with lines representing normal interactions in black ink and lines representing
hate
interactions in red.” He paused for effect. “I’m telling you, the thing looked like a wiring diagram for the phone company.”
“But it doesn’t make sense. Even at Claremont, there were—”
“You have any idea how fierce the competition is for
funding? It’s a zero-sum game: every time someone wins, someone else loses.”
Levitt explained that in the case of Shein and Stillman, for instance, the animosity dated to Shein’s long-ago support of a young ACF researcher who had come up with a novel approach to breast cancer: using a syringe to shoot monoclonal antibodies directly into the bloodstream in a kind of biochemical search-and-destroy mission. Stillman vigorously resisted (and won) on the ground that the data on which the conclusions were based were incomplete—though soon afterward he wrote a protocol himself based on the same idea. Quite simply, Stillman regarded breast cancer as his turf; in mucking around with
his
cancer Shein had earned an enemy for life. More than one enemy, in fact—for Stillman numbered among his allies a half dozen key figures at the ACF.
“That’s par for the course. None of these guys can stand each other. Larsen—
he
probably hates Shein even more.”
“What’s the story there?”
He shrugged. “Nothing in particular. Just oil and water. To Larsen, Shein represents everything most loathsome not only about science but life. And vice versa.”
Logan had already sensed as much. “Do Larsen and Stillman get along?”
“Get
along
?” he asked, surprised. “You mean, like
friends
?” He stopped, began again. “Look, I’ll try and simplify things. The way it works is all the top guys have their own little fiefdoms and their own loyalists. The ultimate aim of each is to defeat all the others. But sometimes, for strategic reasons, they’ll forge alliances against a common enemy. Get it?”
“You make it sound medieval.”
He smiled. “Well, I’ve never actually heard of anyone using maces and boiling oil.”
Logan nodded soberly. “So what you’re saying is I’d better stay on
everyone’s
good side. Consider me warned.”
“And you’d better also be ready for some of what you’re going to be running into from patients—”
“That I’m familiar with. I’ve dealt with some pretty bad attitudes.”
“You think so? Because the ones at the ACF are a whole different breed. A lot of them have moved heaven and earth to get here; they’ve told their local doctors, ‘I no longer want this shit you’re giving me,’ and traveled thousands of miles to undergo a course of treatment that might end up doing nothing. The ACF is a roll of the dice and not many shrinking violets take it.”
“They’re fighters. Nothing wrong with that.”
Levitt nodded. “The truth is, if you’ve got cancer, there’s no better place to be treated. It’s just that full cooperation is
their
part of the bargain—and sometimes they make you pay for it.” He started from the room, Logan trailing after. “What I’m trying to tell you is that conflicts are inevitable because we and the patients basically have different agendas. We’re interested in finding ways to cure cancer. They want
their
cancer cured. No one ever uses the term
guinea pig
, but some patients eventually get the idea that’s what they’ve signed up for.”
“I see,” said Logan soberly.
“No, but you’re about to.” Rounding a corner, they came to a bank of gleaming elevators. “Let’s go see Rochelle Boudin.”
“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.”
T
he 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
.