THE NEW YORKER:
ANNALS OF MEDICINE
What should medicine do when it can’t save your life?
by Atul Gawande
Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to
die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had
collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and
sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already
spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had
ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didn’t
get into the prognosis—she would bring in an oncologist for that—but Sara was stunned. Her mother,
who had lost her best friend to lung cancer, began crying.
The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For
the moment, though, Sara and her husband, Rich, sat by themselves on a quiet terrace off the labor floor.
It was a warm Monday in June, 2007. She took Rich’s hands, and they tried to absorb what they had
heard. Monopoli was thirty-four. She had never smoked, or lived with anyone who had. She exercised.
She ate well. The diagnosis was bewildering. “This is going to be O.K.,” Rich told her. “We’re going to
work through this. It’s going to be hard, yes. But we’ll figure it out. We can find the right treatment.” For
the moment, though, they had a baby to think about.
“So Sara and I looked at each other,” Rich recalled, “and we said, ‘We don’t have cancer on Tuesday. It’s
a cancer-free day. We’re having a baby. It’s exciting. And we’re going to enjoy our baby.’ ” On Tuesday,
at 8:55 P.M., Vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her
mom, and she was perfectly healthy.
The next day, Sara underwent blood tests and body scans. Dr. Paul Marcoux, an oncologist, met with her
and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had
started in her left lung. Nothing she had done had brought this on. More than fifteen per cent of lung
cancers—more than people realize—occur in non-smokers. Hers was advanced, having metastasized to
multiple lymph nodes in her chest and its lining. The cancer was inoperable. But there were
chemotherapy options, notably a relatively new drug called Tarceva, which targets a gene mutation
commonly found in lung cancers of female non-smokers. Eighty-five per cent respond to this drug, and,
Marcoux said, “some of these responses can be long-term.”
Words like “respond” and “long-term” provide a reassuring gloss on a dire reality. There is no cure for
lung cancer at this stage. Even with chemotherapy, the median survival is about a year. But it seemed
harsh and pointless to confront Sara and Rich with this now. Vivian was in a bassinet by the bed. They