Meet the Artistic Team behind 'Cancer: The Emperor of All Maladies'
Every president since Lyndon B. Johnson has made curing cancer a cornerstone of their health-care initiatives. With each passing administration, the claim that it can be conquered in a lifetime is made, only to evaporate as every advance in treatment is met by the ceaselessly morphing nature of the disease.
Cancer: The Emperor of All Maladies, the three-part, six-hour documentary, executive produced by Ken Burns, directed and produced by Barak Goodman, and based on the Pulitzer Prize-winning book by oncologist Siddhartha Mukherjee, is a deeply engaging, often riveting account of the world’s most terrifying and ubiquitous illness.
By turns illuminating, maddening, devastating and hopeful, the series weaves a compelling narrative that reaches as far back as an ancient Egyptian physician’s moving account of an untreatable breast cancer, through remarkable, diverse first-person stories in the present day. Everyone from doctors and researchers, to agitators, advocates, patients and families play an integral part in telling the tale.
Documentary sat down with Burns, Goodman and Mukherjee at the Winter 2015 PBS Press Tour in Pasadena, California to talk about the process of bringing such a monumental story to the screen.
As the writer of the original work, what was the process of book-to-documentary like for you?
Siddhartha Mukherjee: Film and writing are very different. As a writer, you can go backwards. Film, it seems, only goes forwards. So the change—and I'm talking on a meta level—is the intimacy you have with the subject. When you read a novel, you feel as if you can go back and understand that person twice or three or four times—and who hasn't gone back to read Anna Karenina to figure out who she is? But when she's on film, it only moves forward, so your level of intimacy with her is very different.
So that's one major area of difference, and I think it actually has consequences for the way this particular film was made. Your understanding of cancer and the way the film works is that it builds on prior pieces and continues to build, so in the end it takes on a dramatic cycle or helix of some sort, in which you keep adding. I didn't expect it to come out as nicely and as fully as it did.
Speaking of which, the book is so exceptionally rich in material. How did you decide what to use?
Ken Burns: The book is teeming with great stories, and it does offer a kind of outline of what you could do, or kind of a narrative through line. Then it became our struggle to figure out what could be left off and what we needed to focus on.
It’s so surprising: You have an oncologist who's written a book about cancer—which makes a lot of sense—but when you read it, you have something that is much more than that. As someone who's suffered from the early death of a parent through cancer—and it was a kind of animating event in my life—we found the right team to tell this story.
In every step of the film, you’re building on an understanding of cancer and the research behind it. This leads me to Episode Three, when you had to make up for the gap between the book’s publication and what’s happening in cancer research and treatment today.
Barak Goodman: Because of that, this is not one of those series where you can drop right in during Episode Three. You really have to have the primer of the science in Episodes One and Two to get what Three is about.
KB: One of the simple ways is to take the case studies that are a hugely important element of Sid's work and understand that they’re now history. They’re part of our portfolio but have to be replaced by these new discoveries of individual cases, where you can find the universe in a grain of sand. You can look at a specific case of Doug, who had melanoma, and extrapolate out from that.
We had the great challenge of mastering the history, and then there are so many moving parts in this: narrative, historical, exposition. It’s then coupled with very complex science that had to be rendered into digestible and understandable forms. Add to that meeting this cast of characters, who are not just the individual case studies but the extraordinary scientists and physicians who populate the film. Then there’s the intimacy of these stories, and all of that had to be woven together to figure out how much we could use.
BG: Some of our most compelling human stories weren't helping to build that final edifice. The pace of discovery right now is so accelerated, so enormous, that just between the time Sid's book came out and today, a whole new field of immunotherapy has flowered. Sid was very helpful, as were others, in helping us decide what was really important right now and what may be more of a flash in the pan.
KB: And as historians, we want to have the triangulation and perspective that comes with the passage of time and to be able to say, ‘Well, this didn’t work’ or ‘This is the serious thing.’ It's a really tough judgment call to make.
How much did you shoot and what was the process like?
BG: Honestly, it would eclipse by 50 times anything I've ever done before. These are three films in one. For the vérité alone it would be a project to winnow it all down to find the right moments and exclude other moments, but we had one team simply working on that aspect of it. We had another team doing the historical filmmaking. We had Chris Durance, who practically got a PhD in molecular biology during the course of this process. He was our science guy—the producer who had to understand, in great depth, what was going on. It took all these people.
The film is so carefully built that the editing process must have been architectural in scope. How did the team pull off integrating the dozens of different narratives that span centuries?
KB: When do you cut out of one thing to go back to another? These are huge, earth-shaking things. If you do it two minutes or 20 seconds too soon or too late, then all of a sudden you destabilize the story and you've got a gyrating top and not one that's spinning.
A real simple example of this is the whole [Sidney] Farber [a pediatric pathologist widely credited as the father of modern chemotherapy] narrative. The outcome of the Farber story is that childhood leukemia is more or less taken care of, but if you say that prematurely, in a talking head or in a line of narration before Olivia’s contemporary story is resolved, you have undercut the drama of Olivia. It seems obvious but it’s really very complex.
BG: I remember we had a moment when Ken came into a screening and said, "I think we should take out an entire character arc." At first this caused great reverberations. We had an investment in this young woman and she had a great story. But as soon as we pulled it, everything came together.
KB: Sometimes the very best—or something that in and of itself has a dynamic and is important—is ultimately destabilizing the more important thing. With its removal, there’s suddenly shape and contour and resolution for an episode and not some sense of attenuation.
BG: In editing, if these contemporary stories didn’t at all resonate with the past, they would seem completely out of the blue. Happily, they very much enhance each other. In the case of the Olivia story, we have a scene in which the parents are struggling to decide whether to enroll her in a clinical trial. The doctor says that the parents understand that they’re not experimenting on Olivia but that this is the way science advances, and we've illustrated that in the history. We've seen the examples of how these clinical trials have pushed knowledge.
KB: And later on as our narrative caught up to the present, we had another thing. As these contemporary stories became the central narrative progression, we then had to re-add historical antecedents, so that every time we talk about immunotherapy, we refer to a time a couple centuries ago, or a century ago, or ten years ago, in which physicians and scientists used earlier forms of immunotherapy. It helped anchor the contemporariness of that case study—the vérité with the historical narrative.
It’s a vigorous viewing experience. While I never felt like I was paying attention to the details, I was really paying attention to the details.
SM: This film requires the most active form of watching. The viewer has to make conceptual leaps by him- or herself, and in doing so becomes a participant. It’s much like the book. Sometimes I thought, ‘I'm not going to give you all that information.’ The reader, and now the viewer, has to figure out what the parallels are.
Life is complicated, and this is a complicated story. It’s driven by the drama and has a great deal of suspense. They want Olivia to survive but like physicians who want their patients to survive, that doesn't happen by not knowing. If you want someone to survive, you have to contend with the knowledge that's required.
The film’s subjects, like Olivia’s parents, all allowed you into their lives during their most vulnerable moments. How did you find these families?
BG: We decided to embed ourselves in two hospitals. They were very different from each other. One was a cutting-edge research hospital, Johns Hopkins, which had extensive experience with film crews and was extremely open to the idea, and also well-versed in how to handle the subject. The second location was a smaller regional hospital in Charleston, West Virginia, which was also very good. We figured that between these two hospitals, we'd see the extremes of care, as well as the panoply of care, in the United States.
We were able to become such a presence in them—kind of part of the furniture—and that became the best way to put patients at ease and get ourselves invited into their stories. We had the help of the doctors and nurses at these institutions in brokering the relationships too.
To a remarkable degree, these people were open to the idea of sharing their stories. I wouldn't say we had anybody who, having started the process, decided midway that they didn't want to do it anymore. They all allowed us to follow them all the way through.
KB: It wasn't about exploitation; it was about discovery. These people can help us all understand, in the positive outcomes and in the negative outcomes, what this disease is about and where we're going with it.
The outcome of many of the subjects’ trajectories wasn't happy. It may be fair to say that there were no real happy endings. As filmmakers, how do you contend with tragedy on such a personal scale?
BG: One of our children didn't survive. That was a difficult call. We didn't want to shy away from the reality of this disease. It's a brutal, horrible disease, but one in which the film will bring down to mere mortal size. It won't be as terrifying as perhaps it was when you began watching it, but we all know what cancer can do and we didn't want to sanitize it.
Elisabeth Greenbaum Kasson is a journalist and editor with an abiding interest in the intersection of art, culture, technology and business.