When Breath Becomes Air by Paul Kalanithi
Read the moving prologue from number one bestseller and Wellcome Book Prize-shortlisted When Breath Becomes Air, about a young neurosurgeon and his diagnosis with inoperable lung cancer.
The annual Wellcome Book Prize celebrates the best new fiction and non-fiction books that engage with an aspect of medicine, health or illness, and each week until the announcement of the winner on 24 April at the Wellcome Collection we will be featuring an extract from the WBP2017 shortlist here on sciencefocus.com.
See the full shortlist at the bottom of this article, but first read the prologue from When Breath Becomes Air, the moving true story of Paul Kalanithi, who at 36 and on the verge of completing a decade’s training as a neurosurgeon, was diagnosed with inoperable lung cancer.
“Webster was much possessed by death
And saw the skull beneath the skin;
And breastless creatures under ground
Leaned backward with a lipless grin.”
— T. S. Eliot, “Whispers of Immortality”
I flipped through the CT scan images, the diagnosis obvious: the lungs were matted with innumerable tumors, the spine deformed, a full lobe of the liver obliterated. Cancer, widely disseminated. I was a neurosurgical resident entering my final year of training. Over the last six years, I’d examined scores of such scans, on the off chance that some procedure might benefit the patient. But this scan was different: it was my own.
I wasn’t in the radiology suite, wearing my scrubs and white coat. I was dressed in a patient’s gown, tethered to an IV pole, using the computer the nurse had left in my hospital room, with my wife, Lucy, an internist, at my side. I went through each sequence again: the lung window, the bone window, the liver window, scrolling from top to bottom, then left to right, then front to back, just as I had been trained to do, as if I might find something that would change the diagnosis.
We lay together on the hospital bed.
Lucy, quietly, as if reading from a script: “Do you think there’s any possibility that it’s something else?”
“No,” I said.
We held each other tightly, like young lovers. In the past year we’d both suspected, but refused to believe, or even discuss, that a cancer was growing inside me.
About six months before, I had started losing weight and having ferocious back pain. When I dressed in the morning, my belt cinched one, then two notches tighter. I went to see my primary care doctor, an old classmate from Stanford. Her sister had died suddenly as a neuro- surgery intern, after contracting a virulent infection, and so she’d taken a maternal watch on my health. When I arrived, however, I found a different doctor in her office - my classmate was on maternity leave.
Dressed in a thin blue gown on a cold examining table, I described the symptoms to her. “Of course,” I said, “if this were a boards exam question - thirty-five year-old with unexplained weight loss and new-onset back pain - the obvious answer would be (C) cancer. But maybe it’s just that I’m working too hard. I don’t know. I’d like to get an MRI to be sure.”
“I think we should get X- rays first,” she said. MRIs for back pain are expensive, and unnecessary imaging had lately become a major national point of cost- saving emphasis. But the value of a scan also depends on what you are looking for: X- rays are largely useless for cancer. Still, for many docs, ordering an MRI at this early stage is apostasy. She continued: “X- rays aren’t perfectly sensitive, but it makes sense to start there.”
“How about we get flexion-extension X- rays, then - maybe the more realistic diagnosis here is isthmic spondylolisthesis?”
From the reflection in the wall mirror, I could see her googling it.
“It’s a pars fracture affecting up to five percent of people and a frequent cause of back pain in the young.”
“Okay, I’ll order them, then.”
“Thanks,” I said.
Why was I so authoritative in a surgeon’s coat but so meek in a patient's gown? The truth was, I knew more about back pain than she did - half of my training as a neurosurgeon had involved disorders of the spine. But maybe a spondy was more likely. It did affect a significant percent of young adults - and cancer in the spine in your thirties? The odds of that couldn’t be more than one in ten thousand. Even if it were one hundred times more common than that, it’d still be less common than a spondy. Maybe I was just freaking myself out.
The X- rays looked fine. We chalked the symptoms up to hard work and an aging body, scheduled a follow- up appointment, and I went back to finish my last case of the day. The weight loss slowed, and the back pain became tolerable. A healthy dose of ibuprofen got me through the day, and after all, there weren’t that many of these grueling, fourteen-hour days left. My journey from medical student to professor of neurosurgery was almost complete: after ten years of relentless training, I was determined to persevere for the next fifteen months, until residency ended. I had earned the respect of my seniors, won prestigious national awards, and was fielding job offers from several major universities. My program director at Stanford had recently sat me down and said, “Paul, I think you’ll be the number one candidate for any job you apply for. Just as an FYI: we’ll be starting a faculty search for someone like you here. No promises, of course, but it’s something you should consider.”
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 weekends. 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.
Then, a few weeks later, I began having bouts of severe chest pain. Had I bumped into something at work? Cracked a rib somehow? Some nights, I’d wake up on soaked sheets, dripping sweat. My weight began dropping again, more rapidly now, from 175 to 145 pounds. I developed a persistent cough. Little doubt remained. One Saturday afternoon, Lucy and I were lying in the sun in Dolores Park in San Francisco, waiting to meet her sister. She glimpsed my phone screen, which displayed medical database search results: “frequency of cancers in thirty- to forty- year- olds.”
“What?” she said. “I didn’t realize you were actually worried about this.”
I didn’t respond. I didn’t know what to say.
“Do you want to tell me about it?” she asked.
She was upset because she had been worried about it, too. She was upset because I wasn’t talking to her about it. She was upset because I’d promised her one life, and given her another.
“Can you please tell me why you aren’t confiding in me?” she asked.
I turned off my phone. “Let’s get some ice cream,” I said.
The full 2017 Wellcome Book Prize shortlist - follow the links for extracts:
- How to Survive a Plague by David France (USA) Picador, Pan Macmillan
- When Breath Becomes Air by Paul Kalanithi (USA) The Bodley Head, Penguin Random House
- Mend the Living by Maylis de Kerangal (France) trans. Jessica Moore MacLehose Press
- The Tidal Zone by Sarah Moss (UK) Granta Books
- The Gene by Siddhartha Mukherjee (USA) The Bodley Head, Penguin Random House
- I Contain Multitudes by Ed Yong (UK) The Bodley Head, Penguin Random House