Storygram: George Johnson’s “Why Everyone Seems to Have Cancer”
The Storygram series, in which professional writers annotate award-winning stories to illuminate what makes a great science story great, is a joint project of The Open Notebook and the Council for the Advancement of Science Writing. It is supported by a grant from the Gordon and Betty Moore Foundation.
George Johnson, the author of nine books, is a former reporter and editor at The New York Times. He won a AAAS Kavli Science Journalism Award in 2014 for the following story. This annotation was done by Joanne Silberner and is co-published at The Open Notebook.
EVERY New Year when the government publishes its Report to the Nation on the Status of Cancer, it is followed by a familiar lament. We are losing the war against cancer.This lede grabs me for two reasons. From a structural standpoint, at this point I’m intrigued that Johnson hasn’t gone for the obvious anecdotal lede. And substantively, I’m concerned that we’re losing the war, or at least we think we are.
Half a century ago, the story goes, a person was far more likely to die from heart disease. Now cancer is on the verge of overtaking it as the No. 1 cause of death.OK, an enigma. I’ll happily stick with this story.
Troubling as this sounds, the comparison is unfair. Cancer is, by far, the harder problem — a condition deeply ingrained in the nature of evolution and multicellular life. Given that obstacle,This is going to seem like a small point here, but Johnson did something that makes a huge difference in clarity. He didn’t just say “that.” He said “that obstacle.” An English teacher at my high school would never ever let students use “that” or “this” as a pronoun without following the word with a noun. She even discouraged the use of a freestanding “it.” I tell my students today—there are times, especially in complicated stories, that you need to dictate to the reader exactly what you mean when you say “this” or “that.” This what? Here’s a challenge. Go through something you’ve written, and add nouns behind half the naked pronouns, or replace them with nouns. See if the story reads better. I bet it will. cancer researchers are fighting and even winning smaller battles: reducing the death toll from childhood cancers and preventing — and sometimes curing — cancers that strike people in their prime. But when it comes to diseases of the elderly, there can be no decisive victory. This is, in the end, a zero-sum game.It’s early in the story but already I’m struck by the variable pacing. Look at the sentence length, from the top of this paragraph. The first sentence is 8 words. Then 19, 31, 15, 8. This is how people talk. And it’s a great device for keeping a story lively. At the dawn of the computer age, I saw the great Jon Franklin do a presentation on story structure. He’d analyzed the sentence lengths in a book he’d written. In each chapter, the trend was shorter sentences early on, longer by the end, and chapter to chapter there was a slight increase. Sentence length is an often-forgotten but very effective tool! If you think something you’re writing is getting dull, but you need the information for the story, sometimes all it takes to get the reader through the section is mixing up the sentence length and adding a few sparkly words.
The rhetoric about the war on cancer implies that with enough money and determination, science might reduce cancer mortality as dramatically as it has reduced deaths caused by other leading killers — one more notch in medicine’s belt. But what, then, would we die from?A chance for me to rant about questions—when a story asks more than two questions in a row, I stop reading. Johnson keeps me reading and makes his question stand out by only using one. Heart disease and cancer are primarily diseases of aging. Fewer people succumbing to one means more people living long enough to die from the other.
The newest cancer report, which came out in mid-December, put the best possible face on things. If one accounts for the advancing age of the population — with the graying of the baby boomers, death itself is on the rise — cancer mortality has actually been decreasing bit by bit in recent decades. But the decline has been modest compared with other threats.
A graph from the Centers for Disease Control and Prevention tells the story. There are two lines representing the age-adjusted mortality rate from heart disease and from cancer. In 1958 when the diagram begins, the line for heart disease is decisively on top. But it plunges by 68 percent while cancer declines so slowly — by only about 10 percent — that the slope appears far less significant.A lovely explanation of a figure—lovely because he uses few words and no jargon. Everyone knows what a slope is. And again, look at his marvelous word choices. “Plunges” instead of “drops,” for example.
Measuring from 1990, when tobacco had finished the worst of its damage and cancer deaths were peaking, the difference is somewhat less pronounced: a decline of 44 percent for heart disease and 20 percent for cancer. But as the collision course continues, cancer seems insistent on becoming the one left standing — death’s final resort.He lets the irony speak for itself. And “death’s final resort” is my favorite sentence in the whole story, just because it is so, well, final. The wild card in the equation is death from complications of Alzheimer’s disease, which has been advancing year after year.
Though not exactly consoling,Throughout the piece, Johnson anticipates what the reader might be thinking and feeling. This practice is a dangerous one—if you’re wrong, you’ve lost the reader. Johnson makes it work (at least for me) by being dead-on. I will fight back with editors over some changes, but I never fight back about anticipating the reader’s feelings. If I’ve failed with the editor, then I’ve no doubt failed with many readers. the fact that we have reached this standoff is a kind of success. A century ago average life expectancy at birth was in the low to mid-50s. Now it is almost 79, and if you make it to 65 you’re likely to live into your mid-80s. The median age of cancer death is 72. We live long enough for it to get us.
The diseases that once killed earlier in life — bubonic plague, smallpox, influenza, tuberculosis — were easier obstacles. For each there was a single infectious agent, a precise cause that could be confronted. Even AIDS is being managed more and more as a chronic condition.
Progress against heart disease has been slower. But the toll has been steadily reduced, or pushed further into the future, with diet, exercise and medicines that help control blood pressure and cholesterol. When difficulties do arise they can often be treated as mechanical problems — clogged piping, worn-out valves — for which there may be a temporary fix.Note how Johnson uses familiar, everyday language to welcome the reader to continue with the story.
Because of these interventions, people between 55 and 84 are increasingly more likely to die from cancer than from heart disease. For those who live beyond that age, the tables reverse, with heart disease gaining the upper hand. But year by year, as more failing hearts can be repaired or replaced,The active voice might be the better option—it would be a chance to pit doctors against disease. cancer has been slowly closing the gap.
For the oldest among us, the two killers are fighting to a draw.As a survivor of breast cancer, which killed my mom, I’m sick to death of the fighting/battle/killing metaphor. It can imply that a person who dies is a loser who could have fought harder. But the metaphor works here, possibly because Johnson uses it sparingly, or possibly because I like the idea of the two diseases battling one another. But there are reasons to believe that cancer will remain the most resistant. It is not so much a disease as a phenomenon, the result of a basic evolutionary compromise. As a body lives and grows, its cells are constantly dividing, copying their DNA — this vast genetic library — and bequeathing it to the daughter cells. They in turn pass it to their own progeny: copies of copies of copies. Along the way, errors inevitably occur. Some are caused by carcinogens but most are random misprints.
Over the eons, cells have developed complex mechanisms that identify and correct many of the glitches. But the process is not perfect, nor can it ever be. Mutations are the engine of evolution. Without them we never would have evolved. The trade-off is that every so often a certain combination will give an individual cell too much power. It begins to evolve independently of the rest of the body. Like a new species thriving in an ecosystem, it grows into a cancerous tumor. For that there can be no easy fix.There’s music here. A lovely metaphor? Yes—“Mutations are the engines of evolution.” Simple clear sentences of varying length (16, 11, 6, 7, 18, 11, 14, 8—for those who are counting), and a related simile towards the end.
These microscopic rebellions have been happening for at least half a billion years, since the advent of complex multicellular life — collectives of cells that must work together, holding back, as best each can, the natural tendency to proliferate.I am guessing Johnson—rather than a scientist—created this poetic historical view. Writers can have these “pause and take a deep breath” moments only if they thoroughly understand their topic, and can work it in their heads and see what it looks like from all sides, not just from lining up the facts in a logical order. Being comfortable enough with a topic to manipulate and develop it is one of the things that can turn an everyday feature into an award winner. Those that do not — the cancer cells — are doing, in a Darwinian sense, what they are supposed to do: mutating, evolving and increasing in fitness compared with their neighbors, the better behaved cells of the body.There’s a lot of punctuation in this sentence. None of it is wrong, but I prefer not to see colons and dashes in the same sentence. And these are left at a competitive disadvantage, shackled by a compulsion to obey the rules.Johnson shows his great ear here. It’s tempting to overuse anthropomorphisms because they can do such a good job humanizing a story. Johnson keeps from crossing the overuse line by not resorting to a cliché (like the cancer-as-battle cliché), and by not carrying the anthropomorphism throughout the story. I encourage young writers with good editors behind them to try an anthropomorphism or two—but back off if the editor says you’re being heavy handed.
As people age their cells amass more potentially cancerous mutations. Given a long enough life, cancer will eventually kill you — unless you die first of something else. That would be true even in a world free from carcinogens and equipped with the most powerful medical technology.
Faced with this inevitability, there have been encouraging reductions in the death toll from childhood cancer, with mortality falling by more than half since 1975. For older people, some early-stage cancers — those that have not learned to colonize other parts of the body — can be cured with a combination of chemicals, radiation therapy and surgery. Others can be held in check for years, sometimes indefinitely. But the most virulent cancers have evolved such wily subterfuges (a survival instinct of their own) that they usually prevail.)) [[Another graf that sings—words like “colonizing” and “wily subterfuges” keep me, as a reader, with Johnson as he works through the idea behind the story. This careful wording appears throughout the story.[/annotation] Progress is often measured in a few extra months of life.
OVER all, the most encouraging gains are coming from prevention. Worldwide, some 15 to 20 percent of cancers are believed to be caused by infectious agents. [highlight]With improvements in refrigeration and public sanitation, stomach cancer, which is linked to Helicobacter pylori bacteria, has been significantly reduced,This may be an example of too few words—I’m not sure folks will understand what refrigeration and public sanitation have to do with H. pylori. especially in more developed parts of the world. Vaccines against human papilloma virus have the potential of nearly eliminating cervical cancer.
Where antismoking campaigns are successful, lung cancer, which has accounted for almost 30 percent of cancer deaths in the United States, is steadily diminishing. More progress can be made with improvements in screening and by reducing the incidence of obesity, a metabolic imbalance that, along with diabetes, gives cancer an edge.
Surprisingly, only a small percentage of cancers have been traced to the thousands of synthetic chemicals that industry has added to the environment. As regulations are further tightened, cancer rates are being reduced a little more.
Most of the progress has been in richer countries. With enough political will the effort can be taken to poorer parts of the world. In the United States, racial disparities in cancer rates must be addressed. But there is a long way to go. For most cancers the only identifiable cause is entropy, the random genetic mutations that are an inevitable part of multicellular life.This is a tough point for readers. We all want to think that something causes cancer, and if we can just avoid that something, we won’t die of cancer. Again, word choice keeps the story going. “(A)n inevitable part of multicellular life” says it clearly, but gently. But more than just word choice. Johnson has brought us to this point with step-by-step logic, clarity, and a viewpoint that expands from the immediacy of a scientist’s microscope to the grand sweep of evolutionary history.
Advances in the science will continue. For some cancers, new immune system therapies that bolster the body’s own defenses have shown glints of promise. Genomic scans determining a cancer’s precise genetic signature, nano robots that repair and reverse cellular damage — there are always new possibilities to explore.
Maybe someday some of us will live to be 200. But barring an elixir for immortality, a body will come to a point where it has outwitted every peril life has thrown at it. And for each added year, more mutations will have accumulated. If the heart holds out, then waiting at the end will be cancer.In my mind, endings are the second-hardest part to write, after ledes. I sometimes dredge up a point that didn’t fit in the rest of the piece, as a way of throwing the story forward. Johnson has chosen to echo previous thoughts, and it works because he says it so well—a few short, punchy sentences with simple and lively words, and an ominous and memorable final phrase.
Joanne Silberner is a freelance journalist who produces radio, web, and print stories for NPR, PRI, and other places. In the past few years she’s done series on cancer in developing countries, mental health and climate change, and noncommunicable diseases in Cambodia. Currently she is working on a series of stories about mental illnesses in developing countries. She’s been teaching journalism at the University of Washington for the past six years. Joanne is a graduate of Johns Hopkins University and the Columbia University Graduate School of Journalism, and she credits a class taught by John Wilkes at the University of California, Santa Cruz, for starting her on her writing career. She’s held jobs at Science News, U.S. News & World Report, and for 18 years she covered health, health policy, and medicine for NPR. She’s had one-year fellowships from the Harvard School of Public Health and the Kaiser Family Foundation, and many of her global-health stories have been funded by the Pulitzer Center on Crisis Reporting. Follow her on Twitter @jsilberner.