These doctors ... talking about surviving. One year, two years, like it’s the only thing that matters. But what good is it, to just survive if I am too sick to work, to enjoy a meal, to make love? For what time I have left, I want to live in my own house. I want to sleep in my own bed. I don’t wanna choke down 30 or 40 pills every single day, lose my hair, and lie around too tired to get up ... and so nauseated that I can’t even move my head.—Walter White, Season 1, Episode 5: “Gray Matter”
You knew this one was coming. As much as Walter White’s illegal meth operation plays into the plot of Breaking Bad, his terminal diagnosis with lung cancer provides the ultimate springboard into the criminal world, as well as an excuse behind Walt’s every decision. That’s a brilliant if simple stroke of storytelling: Cancer is an infamous disease that has touched seemingly every life on Earth, either directly or indirectly. It’s an instantly recognizable antagonist, just as villainous as high school bullies or goose-stepping Nazis. It’s an instant sympathy-earner in dramas because the character is given a badge of courage or the mark of a survivor, or both, with one simple word: cancer.
Walter White wrings every possible emotion out of that one word. Much like our earlier discussions of chemical reactions and the transformative power of chemistry in life itself, the cancer diagnosis acts as a sort of catalyst for Walt’s own transformation. Before it, he was simply existing; after coming to grips with it and making the insane decision to produce illegal methamphetamine in order to provide for his family, Walt truly starts living even as his body itself is rapidly shutting down. Cancer and the ever-present specter of death loom over Walt at every turn—a fact he uses to his advantage to gain sympathy quite often—even as he dodges more violent and instant causes of death with little more than his scientific acumen and the devil’s own luck.
A significant chunk of screen time is given to Walt in various stages of his battle with cancer, from the diagnosis very early on in the series, to the trying times of his chemotherapy and surgery, to his remission, and ultimately to his cancer’s return. In just about two years of TV time, we go from seeing Walt try (briefly) to handle the cancer diagnosis himself, to seeing him share the awful news with his family who instantly start arguing amongst themselves over the best course of action for him—treatment or no treatment—to various methods of treatment and hospital visits that exacerbate Walt’s symptoms; these story elements are adapted from the real-life experiences of millions of people afflicted with the disease.
Cancer is far too big a topic to tackle in a chapter, but essentially, it’s a group of diseases in which abnormal cell growth occurs, with the potential for this growth to spread throughout the body. I’ll be focusing this discussion on lung cancer—uncontrolled cell growth in the lung tissue—specifically since that’s the particular disease Walt deals with, though it goes without saying that cancer can affect any of the body’s cells, tissues, organs, and organ systems. Its ubiquity and variety helps to explain why this is a trillion-dollar-plus medical cost annually, worldwide.1
Walt’s cancer is an ever-present thread throughout Breaking Bad, even when it takes a bit of a back seat to the more thrilling and less realistic arc of becoming a meth-dealing kingpin, but to understand how well the show handled it, we’ll have to get a little more advanced.
Walt, a nonsmoker who just turned fifty the day before he’s diagnosed with inoperable lung cancer by Dr. Belknap, is given a couple of years to live (at most) even with chemotherapy. This is the inciting incident for Walt’s transformation into Heisenberg, but it’s also an enemy that Walt cannot outsmart, outgun, or bargain with, so cancer continues to rear its ugly head throughout the series. It’s not until Walt decides to pursue treatment, thanks in part to encouragement from his family, that we get a few more specifics on his diagnosis.
It’s the physician and “Top 10” American oncologist Dr. Delcavoli who oversees Walt’s treatment throughout the first two seasons—who’s also briefly flummoxed by Walt’s brush with a false fugue state—and eventually sees the cancer go into remission, which is a lessening of the disease’s seriousness or even a temporary recovery. It’s Delcavoli who delivers the diagnosis of “non-small-cell adenocarcinoma, Stage 3A” in Season 1, Episode 4: “Cancer Man.”
The “non-small-cell” part differentiates this type of cancer from, as you might have guessed, “small-cell” carcinoma, which accounts for 10–15 percent of lung cancers and is also known as oat-cell carcinoma due to the flattened shape of the cells when viewed under a microscope.2 Non-small-cell lung cancer includes three main subtypes—adenocarcinoma, squamous cell/epidermoid, and large cell/undifferentiated—depending on the type of lung cell affected, along with less common subtypes. “Stage 3A” refers to the cancer’s spread from the lung to nearby lymph nodes or other structures and organs, likely making surgical removal impossible.3
“Adenocarcinoma,” found in outer parts of the lung, occurs in the early stages of lung cells that will eventually secrete mucus (“adeno-” means “pertaining to the gland”); this subtype accounts for 40 percent of lung cancers. While adenocarcinomas are more common in women than in men and tend to occur in younger patients than most lung cancers, it’s the most common lung cancer to be seen in nonsmokers.4 That last trait specifically applies to Walter White who is described in the show as a nonsmoker, but it’s suggested that his exposure to chemicals earlier in his career might be the cause of his cancer. How accurate is this?
The first step in understanding what causes lung cancer is identifying risk factors. These include smoking tobacco (thought to account for 80 percent of lung cancer deaths), secondhand smoke, exposure to radon (the second-leading cause of lung cancer in the United States and the leading cause among nonsmokers), and exposure to asbestos.
Other carcinogens (i.e., cancer-causing agents) include diesel exhaust, radioactive ores like uranium, and inhaled chemicals like arsenic, beryllium, cadmium, silica, vinyl chloride, nickel compounds, chromium compounds, coal products, mustard gas, and chloromethyl ethers. High levels of arsenic in drinking water, air pollution in cities, and even the dietary supplement beta-carotene have been related to an increased risk of lung cancer.5
Most of these risk factors are preventable and can be minimized or removed completely since they’re either personal habits or hazards associated with the home or workplace. In Season 1, Episode 4: “Cancer Man,” Skyler seems to think that Walt’s shocking diagnosis stems from his work in what she calls the “application’s lab” twenty years earlier with “all those chemicals” around, on at least one occasion, without a proper ventilation hood. Walt shakes this idea off, saying, “We always took the proper precautions.”
However, there are risk factors that can’t be changed. These include personal and family history with lung cancer; having lung cancer increases the risk for developing lung cancer again in the future, and genetics plays a role in cancer risk. Radiation therapy to the chest as a treatment for other cancers also increases the risk for lung cancer, especially for smokers.
What exactly caused Walt’s cancer is left up to speculation. However, regardless of the specific factor, the mechanism of cancer remains the same: damage to a cell’s DNA, specifically the genes that regulate cell growth and differentiation. This abnormal cell growth can form either benign, noncancerous tumors or malignant tumors that can spread throughout the body—known as metastasis—wreaking havoc on its many systems.
In Breaking Bad, Bryan Cranston acts out both early and late-stage symptoms of his lung cancer in addition to the very real side effects to his treatment; more on those in a minute. In early stages of lung cancer, patients experience: coughing, including a persistent, chronic cough; coughing up blood or rust-colored spit and phlegm; difficulty breathing and wheezy breathing, known as “stridor”; loss of appetite leading to weight loss; fatigue; and recurring infections like bronchitis and pneumonia.6 Walt’s cancer has likely been affecting him for quite some time before the pilot of Breaking Bad since it’s his collapse that ultimately sends him to the doctor for a diagnosis. And when it comes to showing how Walt’s cancer is progressing or even returning, the show’s shorthand is to have Cranston coughing up blood on a number of occasions.
The late-stage symptoms of lung cancer are a little tougher to portray on camera, especially when the main focus of the story is less about the disease and more about the disintegration of Walter White’s morality. These symptoms, which occur as the cancer moves throughout the body, include: bone pain; swelling in the face, arms or neck; headaches, dizziness or weakness/numbness in the limbs; jaundice, a yellowish coloration of the skin; and lumps in the neck or collarbone region.7 Most of these symptoms are left up to the audience to infer, though they go a long way toward explaining Walt’s chronic agitation and persistent pain. If caught early enough, however, lung cancer can be treated.
The first step in treatment is a proper and exhaustive diagnosis, a process that can take three to five days. The custom diagnosis is necessary for a treatment plan that works for an individual since no two patients or cancers are identical. Diagnostic evaluations include: imaging tests like x-rays and CT scans of the lungs, sputum cytology (in other words, looking at coughed-up spit and mucus under a microscope for cancer cells), and a tissue sample, or biopsy. This biopsy can be performed through a bronchoscopy (examining the lungs through a lighted tube passed down the throat), mediastinoscopy (samples of lymph nodes taken from behind the breastbone through a surgical incision), or a needle biopsy, which uses x-ray or CT scan images to guide a needle into lung tissue for collection of abnormal cells. After all of that, a doctor will determine the staging (or progression) of cancer by another series of imaging tests, including CT scans, MRI, positron emission tomography (PET), and bone scans.8
Depending on the diagnosis, the treatment plan will differ on a patient-by-patient basis. Some patients will opt for no cancer treatment at all, preferring “comfort care” to treat the symptoms instead of the cause, rather than go through the taxing and grueling process of surgery and various therapies. Walt’s extended family has this very conversation with him in Season 1, Episode 5: “Gray Matter” in which everyone weighs in on whether or not Walt should undergo treatment. It’s a tough scene, especially when Walt Jr. takes his dad to task for presumably being too afraid to go through treatment even as Walt Jr. himself struggles to overcome his cerebral palsy, asking what would have happened if Walt would have given up on his own son as quickly as he is giving up now.
Surprisingly, it’s Skyler’s sister Marie, a radiologic technologist who knows quite a bit about the previously mentioned imaging diagnostics and radiation therapy treatments, who supports Walt’s initial decision to avoid treatment. It all comes down to Walt’s thought process: Does he choose to live out his few remaining days enjoying life to the fullest, or will he undertake the pain, extraordinary cost, and debilitating side effects of treatment for a bit more time on this Earth? Walt opts not to go through with therapy at first, but ultimately, he decides to undergo treatment, though on his own terms, a strong theme that pervades the rest of the series. For Walt, it’s either his way or the Heisenberg way.
But just because Walt decides to go through treatment, that doesn’t mean it’s going to be an easy road. According to Delcavoli, side effects of the various treatments “can be mild, to practically non-existent. Or they can be pretty darn awful.” These include hair loss, fatigue, lethargy, weight loss, loss of appetite, gastrointestinal issues, muscle aches and pains, sore and bleeding gums, nausea, kidney and bladder irritation, increased susceptibility to bruising and bleeding, sexual dysfunction, dry skin ... the list goes on.
Regardless of the side effects, Dr. Delcavoli, who prefers the term “treatable” to “curable,” has confidence in the proven track record of radiation and chemotherapy, which he explains in Season 1, Episode 4: “Cancer Man.” Additionally, optimism and support from loved ones certainly helps patients to get through the process. As Delcavoli says in Season 1, Episode 7: “A No-Rough-Stuff-Type Deal” in response to Skyler suggesting alternative medicine such as Eastern healing and holistic approaches, “Having a better outlook can make a tremendous difference.”
However, the proven, repeatable method of treatment usually includes a combination of the following procedures:
Walt’s diagnosis of an inoperable lung tumor requires him to go through chemotherapy and radiation therapy in order to attempt to shrink it down to a more manageable size. Progress of either the cancer itself or the treatment’s efficacy can be measured through a variety of tests and imaging scans like the PET scan Delcavoli mentions in Season 1, Episode 7: “A No-Rough-Stuff-Type Deal” as well as either diagnostic or exploratory MRIs. In this same episode, Delcavoli also believes they’ve got the “antiemetics tuned right” to keep Walt from feeling nauseous, but wants to look at another PET scan following the round of chemotherapy to reevaluate.
By Season 2, Episode 5: “Breakage,” Walt has completed his first round of treatment and there’s reason to be optimistic; by “4 Days Out,” the ninth episode of that season, Walt goes for a full PET/CT scan, and the results confirm that the tumor shrank by 80 percent. As long as the tumor hadn’t grown, Walt would technically have been in remission, but this was better than even Delcavoli had hoped for, initially aiming for a 25–35 percent reduction in mass.
This comes as great news for Walt and his family, but an anomaly on the scan temporarily terrifies Walt himself since it looks like a much larger tumor. However, this block is actually lung tissue inflammation known as radiation pneumonitis, a “fairly common” reaction to his radiotherapy, which explains his cough; Delcavoli prescribes the immunosuppressive, anti-inflammatory, corticosteroid drug prednisone to take care of it. Complicating matters a bit is the fact that Walt’s also coughing up blood, likely due to a tear in his esophagus from all that coughing, which Delcavoli wants to address immediately. Though Walt deserves to be chastised here—and more so considering that this was one of his rare opportunities to put a stop to his drug-dealing ways, but he chose not to take it—the good news is that the treatment has bought him more time.
In Season 2, Episode 11, “Mandala,” Walt meets with his thoracic surgeon Dr. Bravenac for the first time. Despite the initial diagnosis that the tumor was inoperable, after the first round of treatment, the doctors suggest a lobectomy as a “viable,” “pretty good” option. This matches up with Bravenac’s self-described “pretty good” track record for performing such surgeries following full-dosage radiation treatment. It’s a risky and aggressive path, but otherwise it’s just a matter of time until the cancer spreads. Walt undergoes the operation itself in the Season 2 finale, “ABQ,” allowing viewers to watch along with the surgeon thanks to a well-shot and beautifully edited medical montage inside the operating room. It’s all scrubbing in, lots of iodine, gleaming surgical instruments, and some clinical but gory shots of the sizable lobe of Walt’s afflicted lung being removed.
The beauty of montages is that audiences get to jump ahead in time and that characters get to move forward in their own story. Walt gets the results from his surgery during what appears to be the next day but is actually about six weeks later. The news is optimistic once more, though no hard figures are given. Walt continues his treatment at the oncology clinic in the eighth episode of Season 4, “Hermanos,” where a conversation with another cancer patient by the name of Gary reveals that Walt’s starting to blur the lines with his alter ego. Walt talks about the PET/CT scan paired with x-ray tomography as part of his radiation therapy, but also slips into Heisenberg mode for a moment when talking to the very fearful Gary:
Oh, to hell with your cancer. I’ve been living with cancer for the better part of a year. Right from the start, it’s a death sentence. It’s what they keep telling me. Well, guess what? Every life comes with a death sentence. So every few months, I come in here for my regular scan, knowing full well that one of these times—hell, maybe even today—I’m going to hear some bad news. But until then, who’s in charge? Me. That’s how I live my life.
For more than a year, Walt’s anxiety over his cancer takes a back seat to the concerns of his alter ego, Heisenberg, but by Season 5, Episode 8: “Gliding Over All,” Walt learns that his cancer is in fact back with a vengeance.
Fun Fact: In an interesting editing decision, Walt actually got a clean bill of health in this episode by way of a voiceover scene from Dr. Delcavoli, but this scene was cut and the test results were left ambiguous.9 This decision put the writers onto the path of Walt hiding the fact that his cancer had returned.10 By Season 5, Episode 9: “Blood Money,” it’s revealed that the results weren’t so great after all.
He’s back on chemo at this point, but, as he tells Hank—who has just figured out that Walt is Heisenberg before throwing his laundry list of sins in his face—he’s a dying man who runs a car wash, nothing more, and has less than six months to live. Despite resuming treatment in what’s likely a losing battle against the second onset of cancer, it’s Walt’s criminal life that ultimately does him in.
Inside Breaking Bad: The location used for the hospital scenes for Walt’s lobectomy were shot on location at Albuquerque’s Gibson Medical Center, formerly the Old Lovelace Hospital (also referenced in Better Call Saul), as discussed by Gilligan and producer Melissa Bernstein on Episode 412 of the Breaking Bad Insider Podcast. The defunct hospital was also used for scenes involving Walt’s fugue state, Skyler’s medical checkups and Holly’s birth, Hank’s recovery, and Brock’s treatment for poisoning.
Oh, and Marie Schrader’s career as a radiologic technologist? That was all actor Betsy Brandt’s idea. She wanted Marie to be a medical professional, but not a doctor or nurse.11 Radiologic technologists are medical personnel responsible for performing diagnostic imaging examinations and administering radiation therapy treatments, an occupation that crosses paths with Walter White quite a bit and gives Marie enough insider knowledge to lend weight to her advice in the show.12