Chapter One

Patient 101006 JDS

Scientific theories… begin as imaginative constructions. They begin, if you like, as stories, and the purpose of the critical or rectifying episode in scientific reasoning is precisely to find out whether or not these stories are stories about real life.

—PETER MEDAWAR, PLUTO’S REPUBLIC

Jeff Schwartz’s story begins in 2011, when researchers had discovered some of the secret handshakes cancer uses to trick our defender immune cells. Newly invented treatments blocked that handshake and unleashed the defenses in our blood. These drugs were available in trials, but not everybody knew about them.

Many cancer doctors were unaware of the new developments that might save their patients’ lives. Others refused to accept that such a breakthrough was possible. That refusal denied their patients the option to try it. It sometimes still does. It’s why Jeff Schwartz was willing to share his story.

Jeff Schwartz knows he was one of the lucky ones. His father died from lung cancer in the ’90s after increasingly ugly attempts to beat it—the usual protocols of cut, poison, and burn; surgery, chemo, and radiation. Just before the spring of 2011, Jeff was diagnosed with cancer too, kidney, stage 4.

So Jeff considers himself lucky, or blessed, or—he doesn’t really like to put too fine a point on it, you know? It wasn’t because he had some sort of influence or special knowledge or anything of the sort. What separated Jeff from the hundreds of thousands of people who died of the same disease during the same time was that he happened to live in California and happened to walk through the right door at the right time. That’s changed the way Jeff thinks about life and living. Now he hopes his story might reach someone else so they don’t have to be lucky.

I met with Jeff in his room on the forty-third floor of a hotel in midtown Manhattan. Jeff looks a little like a more biker version of Billy Joel post-booze and post–Christie Brinkley. He was dressed in jeans and a blue Izod shirt that hid the hard edges of the titanium cage that prevents his spine from collapsing. Surgeons had implanted it there, like he was Wolverine, after tumors had eaten away his spinal architecture. He told me about the cage. He pointed out the scars. These were facts, that was all, part of the story he was telling.

Jeff Schwartz had been a kid in Rockaway, Queens, who went through the public school system and drove a cab while he earned a degree in accounting and economics. His first job was at the mortgage desk of Lehman Brothers, his next at a Japanese bank run by Harvard MBAs. Neither was a good fit. Jeff was a music guy. He played guitar “pretty good,” he says; it was his secret identity, the other thing you tell people at parties when they ask what you do: “I’m an accountant, but really _______.” And maybe for good measure Jeff might talk about any of the hundred-plus Grateful Dead shows he’d seen, or how he’d been given Allman Brothers tickets for his bar mitzvah, or show you the first two measures of John Coltrane’s “A Love Supreme” tattooed around his left ankle like a musical mandala. Nights after the trading floor closed he’d head to the East Village to mix boards at CBGB and the Mudd Club for Talking Heads, Blondie, and Richard Hell and the Voidoids—he’s especially proud of assisting in the recording of Blank Generation. Maybe he wasn’t cool, he says, but he was on the scene.

His passion transitioned to his career because of baseball. He’d done a favor for a guy, and the guy thanked him with a pair of expensive tickets. Jeff had been a diehard Yankees fan his whole life. These were Mets tickets, great seats, really wrong team. So Jeff gave the tickets to a friend, who invited another friend and, long story short, that friend made him a job offer to be a junior guy with his company, a financial firm for clients in the music business. Jeff would come on as the young guy to help with the young talent. His first client was a new girl act, Joan Jett. That worked out for a few years, exciting times, and eventually he opened his own shop and moved out to Malibu.¹ His wife was a record company exec, they had a kid, they had a Lexus. He had an eye for talent and made 5 percent of what he made his clients,² and when one of his acts blew up, like Ke$ha or the Lumineers or Imagine Dragons, Jeff made good. But the real perk was his access. Stopping by their live shows was the coolest counterbalance to careful spreadsheets and checked math.

He admired the musicians, dug the music. But his value lay in the practical side. Music is a profession, though many musicians fail to realize it until it’s too late. “Most acts are one-hit wonders, guys smoking pot in their dorm room, they come up with a song that happens to be pretty good and then, that’s it,” Jeff says. “I tell my acts: If you don’t want to be serious then you’re wasting everyone’s time. Yeah, be a rock star, but this is how you’re going to buy your house. It’s going to be your retirement account. It’s how you’ll probably meet your wife or your husband. It’s more than lifestyle, it’s your life.” As far as he was concerned, the song you wish you wrote? If it isn’t “Yesterday,” It’s “Tie a Yellow Ribbon ’round the Ole Oak Tree.” They’re both about remembering, and they both made over a billion in Muzak covers alone.³

Jeff helped with the contracts, advised on royalty deals. There were writing fees and pennies from records or plays on streaming media, iTunes, Pandora, Spotify—the music world was changing fast in the early 2000s, and you had to watch every stream. The more digital the music got the more free it got, and the more it served as advertisement for the payoff of an international tour. Sending an act off was like christening a new trade ship after years of building. It could make or break, and Jeff wanted to be there.

And so in February 2011 he was in Portland, Oregon, watching the roadies set up for the first night of Ke$ha’s new tour and wondering if maybe he was pushing himself too hard. The 2011 “Get $leazy” tour—the dollar sign in place of the S being Ke$ha’s trademark—had packed shows scheduled across the Americas, Europe, Australia, and Japan. Jeff had taken Ke$ha on when she was a kid playing club dates. She’d blown up when Rihanna had signed her to open on her world tour, and now, at twenty-three years old, she was positioned to leave port and capitalize on the zeitgeist, with Jeff on deck to help steer the finances.

Jeff didn’t need to show up, but his presence there was a personal reminder to his talent. He was looking after their investment, and that investment was themselves. They should do the same. He really couldn’t avoid opening night, no matter how he felt. Which was too bad, because Jeff was feeling like crap.

He was always a little sick these days, a little weak, more than the usual morning stiffness—and the general ache now lasted all day. That came with hitting fifty, he knew that, the way his hair had gone white and thinned at the top. He’d adapted, wore it cut short with a white goatee. Late nights and discomfort were part of the rock-and-roll soul swap, same as the inevitable weight gain of late drive-through meals and no exercise. At least there was an upside—between the pain and the nausea, he was losing weight. He hurt, but he looked good. When he hit 180 pounds, he was happy to recognize his old silhouette in the hotel mirrors. But the weight kept dropping and he felt something else, a dread he couldn’t put his finger on.

Ke$ha, decked out in a rhinestone-studded leotard and laser-shooting sunglasses, ducked into the spotlight. Jeff felt cold. There was a pain in his side, or his belly, or his back—somewhere in the middle there. He wasn’t feeling any better as Ke$ha came back out in a star-spangled getup and fishnets to sing her hit, “Fuck Him He’s a DJ.” Jeff found a seat and watched the backup dancers and the band, professional musicians whose costumes were described as a cross between “Mad Max and prehistoric birds.” It was nearly midnight when Ke$ha finally performed a lap dance on an audience member duct-taped to a chair. An extra in a giant penis costume pogoed around the couple in a choreographed number.

Jeff checked his watch. The encore was thundering. Thank you, Portland, Oregon, and good night. Maybe, Jeff thought, he needed to just go lie down. But the pain he’d felt had been at a different level, and it didn’t go away. Ke$ha’s buses headed off to the next stop on the tour. Jeff stayed behind and quietly drove himself to the hospital.

A doctor looked him over. A phlebotomist took his blood. They ran the numbers, brought him back in, asked him to sit down. He remembers the doctor telling him that the first thing that stood out was his hemoglobin count. It was staggeringly low. With numbers like that, his blood didn’t have the means to transport oxygen to his muscles or his brain. That was probably what accounted for his exhaustion. But what accounted for the low hemoglobin? It might be cancer.

That suspicion led Jeff to the Angeles Clinic on LA’s Wilshire Boulevard—PET scans, the usual round of tests—and on President’s Day weekend Jeff was told: kidney cancer, stage 4. He didn’t know about stages, but he did know there wasn’t a stage 5.

He also didn’t know, and in the moment of shock wouldn’t have cared, that he was one of about sixty-three thousand people in the United States to get a diagnosis of kidney cancer that year. Of those, a far smaller percentage would get a diagnosis for the rare and specific cancer Jeff had. It was, in the language of cancer specialists, an especially “interesting” type of cancer, a particularly aggressive variety called sarcomatoid renal cell carcinoma.

“The doctors tell you, don’t go online when you get your diagnosis,” Jeff says. There’s no good that can come from trusting everything put up on the internet to interpret your fate. “But of course, that’s exactly what you do.”

He got as far as his car. He took out his phone and looked. The numbers, at first, looked—not bad, really. The five-year survival numbers, the standard numbers given for cancer at that point, were nearly 74 percent. That’s a passing grade, a majority, Jeff remembers thinking.

But then, reading further, he saw that the good number depended on other factors. The most important was how early you caught the disease.

The kidneys sit in the lower back, two filtering masses about the size of fists on either side of the spine, right about where you might hold someone to slow-dance at a junior high prom. They’re complex filters, composed of millions of tiny, capsule-shaped glomerular filters that sort out what the body needs from what it must discard. But like a demolition worker clearing out asbestos from a condemned building, those glomeruli are heavily exposed to all the concentrated toxins that come through the body. They are more likely to undergo DNA mutation as a result of that exposure, just as exposed skin catches more UV radiation and is more subject to the mutations that facilitate melanoma.

The survival rates Jeff was looking at were when you caught it early—when it was just in the kidney and the tumor was no larger than seven centimeters.

The United States doesn’t like metric measures, so it tends to translate them to nuts and fruits, and sometimes eggs and vegetables, to describe tumor size. For a five-centimeter, stage 1 tumor, the American Cancer Society site uses a lime. Stage 2 is a lemon, or a small orange, still localized as a mass within the kidney. Stage 3 means the tumor has started to spread within the kidney. The growing, spreading cancer—a peanut, a walnut, or an orange—if it’s stage 3, is still contained within the kidney area, so it can be more readily targeted by conventional cancer therapies—specifically surgery and radiation.

Since most of us have two kidneys, and can survive on one healthy functioning one, cutting out one whole kidney—what they call a radical surgery—is a common approach. But Jeff’s diagnosis was stage 4. That meant the tumors had entered the bloodstream and moved elsewhere, and possibly everywhere.

No matter where those mutated renal cells moved—they could fill the lung, lodge in and take over the liver—they would always be called “renal cancer.” (This naming system, as anachronistic as describing tumors in terms of fruits, changed because of cancer immunotherapy in 2017, itself a breakthrough.) And so when those mutated renal cells started colonizing his spine, Jeff’s cancer was “kidney cancer,” stage 4. And on the tiny screen of his flip phone, stage 4 kidney cancer looked really bad. The five-year survival rate hung at a guttering 5.2 percent, and it had been about 5.2 percent since the 1970s. The last new scientific advance for treating kidney cancer had been made thirty years ago. There isn’t any way to put a positive spin on that. You just close your phone, sit in your car, and wait until you’re calm enough to drive.

There really isn’t a good time to get a diagnosis like that, Jeff knew. Jeff was busy—but everyone is too busy for this sort of thing, and once he went through the usual reactions he realized that too. But hey, come on. He was really busy. His business was booming, his acts needed him, and he now had two little kids—one three years old, the other just a year. He wasn’t going to stop working, he wouldn’t make a big thing of it. He told only those clients who really needed to know, who’d need to make professional decisions. He told Ke$ha he was sick, didn’t say how sick. That seemed OK. Mostly, he decided to just keep moving forward.

Next, Jeff was referred to the larger affiliate hospital, the mothership, to see their kidney specialist. Maybe it was Jeff’s mood, but this doctor, he decided, was “a fucking prick.”

Let’s call him Dr. K. He had looked at the numbers. Stage 4 kidney cancer was pretty much a death sentence, especially in this rare agressive form, but there was always a chance. Dr. K started Jeff on a drug called Sutent. As the label promised, Sutent gave Jeff the usual symptoms of extreme nausea, lack of appetite, and daily dry heaves.

Meanwhile, his PET scans had come back. The cancer in his right kidney was now working its way up his spinal column, tumors leapfrogging each other like kids grabbing a bat handle for dibs. They scheduled surgery to look at that, and when the surgeons opened him up they found that the tumors had eaten into the bone. Fists of dense tissue fissured the central supporting column of his body and nervous system, and knuckled perilously into the wiring of his spinal cord. The structure was brittle and laced with a progressive disease; soon the tumors would either engulf and seize his spinal nerves, or his increasingly fragile vertebrae would fail under his weight like the collapsing World Trade Center towers, or maybe both.

It was moving fast, and either scenario would leave Jeff a quadriplegic at best. They needed to immediately secure the structure. The cancer was inscrutable, incurable, and complicated, but this was concrete physical work that a surgeon could do with a knife. Chunks of his spine needed to be cut out and titanium rods screwed in their place. It would give Jeff a Frankenstein posture, and he would have to live with a constant hum of background pain from the raw nerves—compressed by his collapsing vertebrae, permanently pinned to the titanium infrastructure like guitar strings hard against a fret board—but at least it kept him from being paralyzed. It was the deal to make. A month later they operated again, and finally took out the diseased kidney.

It was hard, the surgeries and the pain were extreme, but “I never stopped working,” Jeff said. “I tried to hide it from everyone.” He still got up in the morning, showered and shaved and dressed, cinched his belt tight to keep his pants from falling off his hip bones, got in his Lexus, and headed toward the freeway as he’d always done. Going to work.

“But I never went to the office.” Instead, he’d pull off somewhere south of Malibu, go through the McDonald’s drive-through to get an Egg McMuffin, and force it down before he even pulled back out to the road. Then he’d drive up and down the Pacific Highway taking calls on his car phone. “Every once in a while, I’d pull over, put the phone on mute, throw up out the window, and get back to the call,” he said. The McMuffins helped; they were soft, and much better than the dry heaves.

He had two doctors: Dr. K, his kidney specialist; and the surgeon, Dr. Z. Jeff saw Dr. K for the Sutent, and met with his surgeon a few weeks later for the follow-up. Both doctors had seen the same scans but gave him different messages. “The surgeon told me not to bother with the chemo anymore,” Jeff says. “He thought I should just give up trying to beat this thing and try and enjoy the little time I had left, without the side effects.” Dr. K was upset that the surgeon was telling his patient to ignore his prescribed treatment.

As far as Jeff was concerned, it wasn’t that Dr. K disagreed with the surgeon’s prognosis; he, too, thought Jeff was going to die. It was that the doctor was getting paid for every chemo treatment Jeff underwent, and Dr. K wanted to keep collecting the fee for the treatments, as long as Jeff was alive enough to take them.

Finally, in September, Dr. K gave him a final prognosis. “He told me that I was going to have six months, tops,” Jeff said. In retrospect, it’s surprising he was given that long. Jeff’s weight had dropped to 148 pounds, and increasingly more and more of that was tumor.

“The guy told me to go get my financial affairs in order,” Jeff says. “He was awful—no bedside manner, no compassion.” The way Jeff read it, “They were done with me. They’d given up.”

Jeff believes it was a matter of the doctors at the hospital having nothing left to bill for, that was how he saw it. Maybe that’s just how he thinks as a manager and accountant; maybe it’s more than that. Doctors are just people. While the best of them are very good at aspects of their jobs, and some of them are good at several aspects, it’s rare to find one who can act as both an expert physician for a patient’s physical body and a philosopher-priest for a human mind contemplating its own death. These are also the desperate thoughts of a desperately ill man raging against the tyranny of mortality, as presented by a series of guys in white coats. It’s a tough go, however you look at it. Bad news isn’t easy on anyone.

Either way, the medical professionals, the ones who knew more about what was laying waste to his body than Jeff himself could comprehend, had nothing more to offer. They saw no option but to give up. And so, the logical thing for Jeff to do was to follow the experts’ lead and give up too.⁴

His referring physician at the Angeles Clinic, Dr. Peter Boasberg, had another idea. There was a clinical study. Maybe, possibly, he could get Jeff on this study. “Maybe” sounded pretty good at that point. The drug being tested didn’t attack the tumors; rather, it attacked the tumors’ ability to shut down the natural immune response against them. It was called a checkpoint inhibitor. Already, there was a theory among researchers working with this drug that it was most effective in generating a strong immune response against tumors that had a high degree of mutation. That might include kidney cancer—cancer like Jeff’s.

All decisions about the study parameters fell to Dr. Dan Chen, MD, PhD, an oncologist immunologist who was also the cancer immunotherapy development team leader at Genentech, the company that made the experimental drug. Patients that might qualify for the study were presented to him in blind applications—each reduced to a code name of letters and numbers and the specifics of their medical history. Jeff Schwartz was now patient applicant 101006 JDS.

Originally the drug study had been designed to look at the drug’s effectiveness against solid tumors. It had been expanded to include melanoma, bladder, kidney, and several others. Did Jeff qualify for such a study? On paper, the answer wasn’t obvious.

If Chen was looking for reasons to exclude someone, he could definitely find justification to rule out patient 101006 JDS, but that didn’t make it the right decision. The study qualifications were advertised in terms of what types of cancers qualified. That description did not specifically mention the rare form of kidney cancer on patient 101006 JDS’s paperwork—but it was kidney cancer, and Chen strongly suspected that 101006 JDS’s rare cancer had many similarities to the cancers they believed would be responsive to their immunotherapy candidate, a new checkpoint inhibitor. On the negative side, this rare and aggressive cancer was now rooted deep in the bone, which the immune system has a difficult time infiltrating, but this patient fit the profile and, Chen suspected, might benefit from the experimental drug. If it was already approved and readily available, Dr. Chen would have put him right on it and hope it helped, as nothing else had. But in 2011 this immunotherapy was not yet an option in an oncologist’s toolbox. The only way for a cancer patient to access this drug was through the experimental trial.

Which made patient 101006 JDS an especially tough call. Chen knew the usual course of a stage 4 kidney cancer prognosis. As a physician and a compassionate human being, he wanted to say, look, if 101006 JDS’s disease qualified, he was in. But as a scientist and department leader in charge of a massive phase study, there was a problem. Based on the paperwork, patient 101006 JDS was probably too unhealthy for a physically rigorous trial; he might jeopardize the whole study. There was no computer algorithm, no chart or slide rule for making this decision. Chen had to balance out the factors and weigh them with his head and his gut.

Jeff didn’t know how to play the odds on this one, how hard he should hope or how he should proceed with the next phase of his life. On the one hand, there was no guarantee he would be able to start the new experimental drug trial for the immunotherapy, and he should prepare for that. But on the other, if he did beat the odds and get a green light, he’d need to be available to accept on the spot. To do that, he couldn’t be on any other cancer treatment. That meant he’d have to stop the chemotherapy and wait. The chemo had been making him feel terrible, and it hadn’t stopped his tumors from growing, but it was the only treatment offered. There was no telling how quickly his cancer would progress if he wasn’t actively poisoning it with the chemicals. It was possible that the chemo was slowing down his decline and buying him a few extra precious days or weeks with his family. Quitting that possibility on the slim chance that he might start something else, something experimental, that might work, and might not—that was a perilous trade-off. It felt like holding your breath to avoid breathing in poison.

Years later, Dan Chen still remembers everything about patient 101006 JDS—his profile as a potential study participant, his response, even his coded patient identity number, straight off the top of his head. As a scientist testing his first immunotherapy drug, Chen wouldn’t quickly forget his first responder. 101006 JDS turned out to be, as Chen says, “a special, special case.” Part of what made him special was the fact that, even knowing how it turned out, one could still make the case that from a data collection perspective, patient 101006 JDS shouldn’t have been allowed onto any kind of medical study at all.

“My initial reaction upon seeing him—it was all just on paper at that point, but it was, ‘Are you kidding me? Why are you sending me patients like this?’” The study Dan was running was a phase 1, meaning the first in humans, and his team had something of a fire under their ass to make this thing go. They’d started late in the immunotherapy game, despite the number of cancer immunologists who were then like secret sleeper cells within Genentech, and when they’d convinced the larger company to change the course of their research and allow them to head into this unproven direction for their drug development they were already years back, building a new drug program from scratch.

Before he’d joined Genentech, Chen had been working with cancer immunotherapy both in his lab at Stanford and with his patients at the Stanford University Cancer Center. Those early approaches hadn’t worked against cancer. But despite the failures of the various vaccines they had tried, and the uneven and sometimes disturbing effects of giving patients doses of strong immune stimulants like interleukin-2 and interferon, the researchers had seen glimmers of hope. Chen and other cancer immunology believers had seen them in their rare but real positive responders, and in those reported by a handful of other labs around the world. Most oncologists—most scientists—dismissed cancer immunology as a dead end, peopled by quacks and true believers who confused hope for good science. But Chen believed, as the handful of others who were still in the immunotherapy field believed, that there was something more to these positive responses than misinterpreted anecdotes.^* This drug study might help prove that.

Was patient 101006 JDS going to help the study? Chen wasn’t so sure. “He had a lot of disease. The disease was in bad places, including the bones, which is harder for cancer immunotherapies to treat,” Chen remembers. Worse, his “performance status” was horrible.

Performance status means: “What’s your day look like? Are you up and about? Or are you unable to get out of bed because you’re puking all day, and can’t eat?” Chen and other oncologists used performance status to predict how a patient was going to fare—whether in a clinical trial or with a traditional cancer therapy. It’s a more rigorous variation of: How you doing? And 101006 JDS wasn’t doing well.

“If you can’t get out of bed, if you can’t move, your outcomes are generally horrible,” Chen says. “Sometimes you have patients that are declining like this—” He puts his hand out, tilted like a graph nosediving. “You generally can’t reverse those patients. So putting people who are on a downward course on your trial is not a great way to figure out if your drug is safe.”

And that was the point of this phase 1 trial—to gauge the safety of a potential new drug by testing it in low doses. If it failed here, it failed. If that test was going to mean anything, it needed to be the truest possible reflection of the safety of the drug. From this perspective, patient 101006 JDS wasn’t exactly who you were dreaming of. Patients who were too weak and sick would fail the test no matter what you gave them—and that failure would be ascribed to the drug, not to the patient. It wasn’t just Jeff who would suffer, it was the entire study and, by extension, an entire generation of patients.

If the “How you doing?” test was somewhat subjective, the main criteria of entering the study were standardized and empirical. “We had a laboratory value that you had to meet,” Chen explains. These values had been provided to all the primary investigators who would be running the study; their patients needed to meet or exceed those values in order to even be considered.

101006 JDS’s lab values were bad. His albumen, his white blood cell count, was “not good.” Those values were a particularly negative indicator for a potential immunotherapy drug study candidate.

“First of all, you need to have the white blood cells,” Chen says. “You need to have the T cells. We didn’t know much about the drug at that point in time, but if you don’t have the T cells in the first place, then why would we be trying to give you a drug that’s going to react with the T cells?” That was the most important number in the trial, and Jeff was below that number value. “There was no way.”

Two months off the chemo, Jeff was sicker than ever—too sick to meet the eligibility requirements for the Angeles Clinic study.⁵ Thus began a back-and-forth, with Jeff’s doctors—Chen’s primary investigators on the study—in the middle.

“They had protocols,” Jeff says. “My hemoglobin had to be at a certain level. They drew my blood; I said, ‘Draw it again.’” Maybe Jeff’s levels were fluctuating, “so they’d try drawing it at different times of the day,” he says. “I was eating broccoli like crazy, every day, just trying to get the numbers up.”

“I know they were really trying anything they could,” Chen says. “There had also been an old observation that showed that rubbing the earlobes pushed out white cells—a real phenomenon, studied at Johns Hopkins, called something like ‘earlobe lymphocytosis.’” So they tried rubbing his earlobes. Jeff rubbed them at night or in the car, rubbed them right before they drew blood. That didn’t get his number up high enough, either.

In November Jeff’s oncologist at Angeles, Dr. Boasberg, had to break the news. He wasn’t going to qualify for the study. “And I knew that was a death sentence,” Jeff said. He wasn’t ready to give up, but he couldn’t simply will his immune system into health. “They offered to put me on a different drug trial,” he said. It wasn’t an immunotherapy, and Jeff had already gone the chemo route. It hadn’t worked, and it made him feel like shit, and he maybe only had a few months anyway. Was he really willing to feel like that again?

Absolutely, if there was a chance it would help him, that was his attitude. He hadn’t tried this particular drug, so at least he could try to think of this as plan B. But maybe, Jeff worried, it wasn’t really a plan at all—it was simply something to do, the medical equivalent of busywork for the doomed.

You try to put a good face on it, to go along, be a good patient, to not look at the couldas and wouldas. Cancer is full of those—lung cancer clinics filled with smokers who quit—and the important thing to Jeff was to keep moving forward. But it was tough not to see that two roads were diverging here, not to recognize that plan B was the wrong fork. The thing that his doctor wanted for him, the thing he thought might possibly help him—Jeff couldn’t get. This other study was clearly an afterthought—but maybe busywork was what he needed. Maybe it would help him. Definitely Jeff wasn’t seeing any other choice that didn’t amount to giving up and making peace with his fate.

The only problem was, Jeff wasn’t feeling peaceful. He kept glancing over his shoulder at the other path. Now, it was Jeff who had the tough decision: starting the study on offer meant giving up on some miraculous possibility of entering the checkpoint inhibitor study, but this bus was leaving, too. If he waited, he’d be left at the crossroads, stuck with nothing. And nothing, he’d already been told, meant entering hospice.

Meanwhile at Genentech’s San Francisco campus, Dan Chen had a problem. A number of them, really. One was a problem every oncologist had, the burden of the job. Cancer treatment is generally not a good-news field. To be a good doctor and researcher, you had to accept the fact of mortality and the terrible outcomes from the disease, even while working actively, often fruitlessly, against them, every day.

Part of what he had to accept regarded the fate of potential patient 101006 JDS. He looked bad on paper, but he’d been wavering near the line long enough that, even behind the coded identity, his case had become personal. Dan hoped for a good outcome for this guy—he knew it was a man at this point—but he also hoped for good outcomes for his drug, and for cancer patients in general.

“And now we’re coming up on the Christmas holiday, and everything is going to shut down,” Chen says. There would be a break at the company, short breaks maybe for some physicians, and the patients themselves might choose to go see far-flung friends and family, some of them for the last time. It’s what happens. That meant that the race to get this drug developed, tested, and to patients and the marketplace was about to suffer a major delay. “So I had to face the fact that if we don’t fill out this cohort before the holiday, we delay this whole trial,” Chen says. And that would have a ripple effect, and potentially serious consequences. The other patients couldn’t start until the cohort was filled. And no patients could get the drug, or have reason to believe it was worth getting, until the drug passed through clinical trials and, best case, expedited FDA approval. That one empty spot in his cohort had become a stop sign.

If patient 101006 JDS was ever going to be considered, it was now or never.

Jeff Schwartz was scheduled to begin the plan B clinical drug study on December 17. He remembers the morning, the car, the highway. The drive to the Wilshire Boulevard clinic was like a gallows march, dead man driving. The windows of his Lexus were shut tight against the Los Angeles air; his heater was cranked up to eighty degrees, just to keep him from shivering too hard to drive.

“I didn’t tell anybody, but—that was awful,” Jeff says. “I’d sorta resigned myself to it. I was going to keep fighting but…” Jeff stops. He hadn’t thought further that day either, at least not about himself, because, as far as he was concerned, he was done. The rest was about fiduciary responsibility. “Every penny I made, I made sure my kids had savings,” he says. “I paid my leases up front, not knowing if I’d be there to make the next payment. I didn’t get spiritual from it, it didn’t change that, but death, the prospect of it, knowing the end—” Jeff stops and considers the room for a moment. “Well, it changes the way you think about things.”

Jeff drove through the gate. He parked, pulled himself out of the car, checked in at the desk. There was the clipboard with the cheap pen. A nurse came out, called his name. She waited, smiled, turned. He followed through the doors and into a room, a comfortable chair. The overhead lighting was bright. His name had been transcribed to an ID, then matched with an IV. Studies have to be double-blind to avoid any bias or sentiment. For the sake of science, the patient is stripped of his identity. Good for science, but hard on us humans. The procedure would be: pull out the drip, check the numbers on the drip against the bracelet on the patient, enter the numbers on the form, hang the IV, unstop the stopcock. Patient 101006 JDS, formerly known as Jeff, was ready. His sleeve was rolled up, a catheter needle was inserted and taped. The drug would be useful, they’d discover later,⁶ for giving extra months of life to some kidney cancer patients, but almost certainly not of any use for patients like Jeff.

Five hundred miles north in San Francisco, Dan Chen was in his office as the sun came up. At 7:30 his phone rang. The sudden noise startled him. The call regarded patient 101006 JDS’s latest numbers. Maybe it was the ear rubbing, Dan doesn’t know; maybe there’s a value for sheer will. Whatever it was, the guy had popped over the line.

Maybe the numbers wouldn’t stay there, but they’d run the tests and he’d passed. It was a cold line and he’d crossed it. That part wasn’t a judgment call now, it was empirical. The next call, if Dan made it, would be to the clinic: Can they put this guy on the trial?

Dan remembers the light. It bounced off the cold gray chop of the San Francisco Bay and it did something to the room. He watched it, looked out the window.

“It wasn’t just about this one guy,” Chen says. “The trial would affect far more people. Was this guy just going to crash and burn?” Would he hurt the trial and hurt those people? If he let this one in, was Chen doing the right thing, or the wrong thing?

It all had to happen in a matter of minutes, the call with the numbers, his decision, but something about the light—maybe he’d watched too many movies but there was something of a Christmas miracle in it, that feeling you get that time of year, maybe a kindness, even when kindness could be misguided. Dan picked up the phone, called the clinic. The line was busy. He put the phone down, checked the number, tried again. Same thing. Maybe this was a sign? Maybe it was just a busy phone. He tried once more and got through. He gave the patient number, said, “Let’s put him on.” There was a pause and a noise, and a sort of panic. It sounded like somebody was running.

“So I’m sitting there,” Jeff said. “They had everything hooked up, that was it. The bag was hanging, they just needed to finish the job. And a nurse came running in and said, ‘Wait.’ Like there was something wrong with my blood or something.”

Then the doctor came in. “They called,” he said. Apparently, Jeff’s lymphocytes were up enough to fit into the protocol for the study.

“They said they were 1100 or something,” Jeff says. “I had the same cancer as before, it wasn’t getting better, but my numbers were better.” According to the blood work, his lymphocytes had finally showed up. “Maybe there was some miracle, what happened—I don’t know.” What he does know is they pulled the drip, unhooked the line from his vein. His doctor had one final message from Dr. Chen. “He said the message was, ‘Tell the patient Merry Christmas.’”

Three days later, on December 20, Jeff became patient twelve of the twelve-person study. He drove himself to the center. It was the first time the clinicians administering the study had met their trial patient in person. He was sicker than they had imagined. Sick enough that they called to make sure this guy was really supposed to be there.

Jeff went through the same setup as before: the clipboard and the forms, the stickers and the armband and the rolled-up sleeve and the needle. Except this time, he was infused with the experimental checkpoint inhibitor immunotherapy drug.

This was Jeff’s first experimental drug. They called it MPDL3280A. The mad scientist notion of that, an experimental drug, that was exciting, but also a bit frightening. MPDL3280A had worked in mouse models, but 90 percent of all cancer drugs that work in mice fail in human trials. “I asked them, ‘Hey, this stuff you’re giving me—is this going to blow my head off?’ And they say, ‘Fuck if we know.’ Because I’m the first one!”

It didn’t blow his head off. But it did do something. “Right away, I just came back to life,” Jeff says. “It was weird.” Was it really working? Or was that just in his head? He’d only gotten one dose, and a low dose—that was one of the goals of a phase 1 trial, to find the “lowest effective dose” of a new drug. That seemed like an unlikely scenario for an instant effect.

Jeff knew about the placebo effect, and he knew about the effect faith and hope can have on a person’s health and even on their outcome. He did plenty of that with his clients, talking them up; the power of belief was important and real, but it didn’t cure cancer. He also realized that he’d been off the chemo long enough that, no matter what, he was going to be less nauseous.

The next visit, two weeks later, they injected him again. And again, right away, he was pretty sure he was feeling better. He’d always been working, even while he was dying. Now he felt good enough to do things besides work. Good enough to take his five-year-old son to SeaWorld that month.

“I’m there, I felt a pop in my hip—it was my hip bone. The cancer had eaten right through it, it just popped right through the hip socket.” That did nothing to help his performance status, so that was a setback. He had another surgery, but it was just a surgery, rather than new cancer, one of his old problems coming home to roost. You didn’t worry about the old problems; you hoped to stop any new ones. His next appointment comes, Jeff gets another infusion of the experimental drug. And this time, he doesn’t just think, he’s sure he’s better now.

At home a few weeks later, his son asked him: “Dad, what happened?” Jeff didn’t know what he meant, but his son told him—he didn’t think that his father could lift him anymore. But here he was, throwing the boy up in the air, watching him squeal with delight. Jeff hadn’t really thought about that, but his son noticed. Something was improving. Then, the PET scans confirmed it.

On March 15, 2012, Dan got an email update from the physician at the trial clinic. The iffy patient they’d sent over, the one with significant fatigue, pain from a retroperitoneal node, the one unable to work or lift his young children—they wanted Chen to know. Patient 101006 JDS had been “recalled to life.”

Jeff understood how lucky he was, and he wanted to meet the people responsible for what he had received. He had known that the global lead on the study was a Dr. Chen, based somewhere in the biotech boxes in San Francisco. He’d hoped to call in, maybe a conference with the team, just to say thank you to the room.

“In July they told me there was a conference in LA, and that ‘Dr. Chen’ was going to be there. I’d always pictured this Dr. Chen, the mysterious Dr. Chen—you know, I’m picturing some geek in wire-rimmed glasses somewhere. I meet him and, here’s Mr. GQ.”

Jeff found Chen surprisingly charming and accommodating. Later, Chen brought Jeff into the San Francisco offices, then down to the labs. There was a sort of Willy Wonka feel to the whole thing. “This place, they’ve got a sign reading E. COLI on one side, CHO on the other,” Jeff says. “I ask him, ‘What’s “CHO”?’ He says it’s ‘Chinese Hamster Ovaries’! Then they bring me over there to a big steel vat. He asks me, ‘Know what this is?’ I tell him, ‘It looks like a brewery.’ Dan says, ‘Yeah, well, they’re brewing proteins.’”

Finally, Jeff was introduced to four researchers who had helped develop the drug and build the protein.⁷ “I meet them, they know who I am, and so they’re all crying,” Jeff says. “Because, these guys are geniuses, but they’re all like idiot savants, they never leave the lab.” After all the work that had gone into getting their immunotherapy drug ready, and after decades during which immunotherapy drugs had failed to save patients, the sight of a healthy man, returned from the brink of death by virtue of their efforts—it was a first.

“All these guys, I don’t know how they do it. They get rejected all day, everything they do fails, people die. Can you imagine being these guys? Chen is an oncologist, he does melanoma, all his patients, all these guys. Can you imagine?”

Dan Chen had done something for him, something big. So Jeff wanted to do something for Dan. “Chen doesn’t know me, not personally, he knows me by my initials from the study. So, he doesn’t know I’m in music.” Jeff asks Dan, who’s got a teenage daughter,⁸ “So, what’s her favorite band?” Chen tells him it’s a band called Imagine Dragons. Jeff smiles as he recalls: “So, next time the band is in San Francisco, I get her tickets, she goes backstage, then she’s on the stage throwing out balloons—it’s great! She’s having the time of her life. Dan says, ‘Thanks.’ I tell him, ‘Hey, thanks for keeping me alive!’”

Jeff was feeling well enough now that it was almost life as usual. That included going to his son’s weekend basketball games in the grade school gym. “My wife’s with me, she says, ‘Look, you know who that is, across the gym?’ I look and I can’t believe it—it’s K. Dr. Fucking K.

“So I march right over, I ask him, ‘You remember me?’ He says no. I tell him, ‘Well, you’re the fucking prick who gave me five months to live!’

“I saw him again six months later—our kids are the same age at the same school, he’s going to see me, and I went up to him again. I told him—I just had to say something. I had to tell him, ‘Look. A patient hangs on every word. Every word. You told me you had nothing left, told me I had five months to live, and my world was shattered.’”

Jeff also remembered what his other doctor had told him when he was getting sicker and hadn’t found a clinical trial. Dr. Boasberg had seen the new immunotherapy drug trials come through, he’d seen the transformative effects, things they never imagined. And he knew how quickly the new drugs were coming. “I might not get into the study now,” Jeff said. “But he told me, ‘Hang in there, because there are new drugs right around the corner.’”

In 2011, that was a rare and radical perspective. Not every oncologist was aware of what was happening in cancer immunotherapy. At the time, the vast majority still thought the immune-based approach to treating cancer was from the bad old days of false promises and ineffective vaccines. Jeff was lucky enough to have a physician connected to a place like the Angeles Clinic, staffed with oncologists open to the potential of cancer immunotherapy and geared toward clinical trials. Of course, he’d only gotten there because his cancer failed to respond to anything else. In that sense, he wasn’t so lucky.

When Jeff was in his twenties, cancer was an old man’s disease, and he didn’t much think of it. He was the kid filing out from some live show downtown with his ears ringing as snowflakes slanted through the streetlights. Not to get sentimental, but that trouble-free time really did seem like yesterday, like in the song. He can still picture the snow landing like lace on his black leather jacket, there and gone. He had all the time in the world.

“Just think of all the people who died, waiting,” Jeff said. “Just a little too early, or the ones who just gave up because a doctor told them they were done, that’s it.” That could have been him. It wasn’t. And why was that?

Jeff doesn’t know. But part of it has to do with luck, part with sheer will, part with faith, or something like it. And part of the answer took place more than one hundred years before, on the same downtown streets of Jeff’s youth, where a New York surgeon chased a medical mystery into the immigrant slums and returned with a recipe to cure cancer.