The following story diagram—or Storygram—annotates an award-winning story to shed light on what makes some of the best science writing so outstanding. The Storygram series is a joint project of The Open Notebook and the Council for the Advancement of Science Writing. It is supported in part by a grant from the Gordon and Betty Moore Foundation. This Storygram is co-published at the CASW Showcase.
Journalist and critic Christopher Hitchens supposedly said, “Everyone has a book in them and that, in most cases, is where it should stay.”
I’m going to ignore the abominable use of “them” in a singular sense and go straight to one of the exceptions to the statement. Sparked by his then wife’s encounter with cancer (she survived), journalist George Johnson broke away from his focus on physical sciences to write a book called The Cancer Chronicles. I’m glad the book didn’t stay inside him. The experience inspired Johnson’s interest in cancer, and a year later he produced a series of three essays for The New York Times that won the 2014 AAAS/Kavli Science Journalism Award in the Large Newspaper category.
I was thrilled when The Open Notebook asked me to take a look at one of those essays, “Why Everyone Seems to Have Cancer,” and surprised to find that it was an essay about a numerical trend—I teach journalism to college juniors and seniors and I don’t encourage them to focus on numbers. I was taught early on that people can’t hold more than a couple of numbers in their heads, and I agree. Johnson’s story uses numbers to illustrate the idea that the reason people think there’s a cancer epidemic is in large part that more folks are living longer lives, and thus to the age when cancer incidence is higher.
If indeed everyone has a book inside, that’s because everyone has, to one degree or another, lived in “interesting times” (which is evidently not a Chinese curse—but it’s still a good curse). My book would no doubt include my experience with cancer—my mother’s death from breast cancer 13 years ago, and my own diagnosis in 2010 (so far, so good). One result of being a cancer survivor is that I really don’t like reading stories about cancer. One result of George Johnson’s skill is that he had me from the beginning of the story and held me straight through, thanks to his careful story development and wonderful use of words.
What a delight it was to spend time with the essay and see how Johnson made it sing.
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. 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. 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.
A Conversation with George Johnson
Joanne Silberner: How did your story come to be?
George Johnson: My book The Cancer Chronicles had just been published, and I still had a bunch of ideas about cancer swirling around in my head. I happened to be in New York and stopped by The New York Times to see some old friends and editors. Just before I left, I was talking to Scott Veale, who has long been one of my favorite people to work with, and we brainstormed ideas for the Sunday Review. That’s when the idea began to crystallize.
The Sunday Review is one of my favorite places to write for. I worked for years on staff when the section was called The Week in Review. It was there with the support of great editors like Katy Roberts and Jon Landman that I developed a certain way of writing essays about ideas—mostly ideas about science. (Katy and Jon have since decamped to Bloomberg, and Scott is taking the recent buyout.) For me much of the effort of writing a piece like this involves concision and compression—distilling complex ideas and then establishing a rhythm that takes the reader through some fairly hard and sometimes abstract stuff.
JS: This is the fourth Storygram, and the third one focused on a story that does not have an anecdotal lede. You picked a lede that doesn’t even describe a scene—you went for numbers.
GJ: I’d say that I went for ideas. Numbers are just one way to illustrate them and drive them home. It never really occurred to me that this would be a story where I would focus on an individual—a patient or a scientist—because I was writing about something broader than any one medical case or discovery. Many people, very smart people, think that we’re in the midst of a cancer epidemic. I was surprised to learn, while I was writing the book, that the epidemiology really doesn’t bear that out.
And I wanted to show that, counterintuitively, in many ways we’re not losing the war on cancer.
JS: But anecdotal ledes are such an easy way to get people into a story.
GJ: Right, but sometimes too easy. I think that in this case it would have been a contorted approach. I suppose I could have found someone—a real person—to say why he or she thinks there is a cancer epidemic. It’s a natural thing to believe. As we all grow older, we see friends and relatives (and sometimes ourselves) getting cancer. Then I could have gone on and dispelled the illusion, which is caused by demographics—the aging of the population. Anecdotal ledes are something I do and like, but it’s not the first approach that comes to mind when I’m looking for a way into a story—and especially when I have only about 1,500 to 2,000 words.
More often I’m hoping to grab people with a powerful idea, and figuring out a way to capture it in a striking manner in maybe one to three short paragraphs. I think anecdotal ledes—and especially ones that feature patients—are overused. With the right subject and the right writer, they can work beautifully. (I’m thinking of an amazing piece that Amy Harmon did for The Times about cousins who both had melanoma and, through the luck of the draw, ended up in different arms of a clinical trial.) But I usually prefer to write about ideas directly.
JS: You used so many more numbers than I would ever allow any of my students to use, but you made it work. I want to know your secret.
GJ: I did? I didn’t notice that until you mentioned it in an email. But I guess you’re right. Thinking back, I suppose I could have made the points qualitatively, especially since we ended up having a really nice graphic that Bill Marsh at The Times did for the story. But the numbers can help the writing. They’re a kind of rhetorical device. I knew that a lot of people were going to read this piece and say “no way.” It contradicted their own experience. Having those numbers in there gives it a little more authority and can inoculate against doubt.
JS: But how did you make it work?
GJ: I don’t know.
JS: So I can’t steal your trick then.
GJ: I’m not sure there is much to steal. How about this? I didn’t just state the numbers. I tried to make them visual by describing the movement of two lines on a graph—cancer mortality versus cardiac mortality. That gets people to use their imagination—to see pictures in their heads. I also tried to use the numbers in sentences that were interesting because of their words. So you’re making the point verbally and with metaphors but then you’re punching it home with the numbers.
JS: Tell me about taking this through the editing process.
GJ: Last night I looked through an old email directory and it was interesting to see the story change from version to version. When I’m working with editors like Scott, whom I’ve known for years, I’ll write a lede or a quick summary—just something so they can see where I’m going. They may have some comments or some cautions. My first draft was messy and roughed out, and about halfway down it began to disintegrate altogether. I hardly ever know what I want to say until I start writing. At first I was planning to describe how, while I was writing my book, a conversation with a mathematician led to a realization about cancer statistics. And then go from there. Maybe Scott talked me out of that. Anyway, it became clear as I went along that the piece worked better without me in it.
Here are some notes from my editor after I filed the whole story: “I wonder if there’s a way to highlight the central paradox you explore in the bottom third higher up, perhaps even after the first graph, i.e. that contrary to the idea that we’re losing the war on cancer, which we’ve just been reminded of again last month, we’re actually winning in some key areas.” So I guess I had buried the lede. Scott pushed me to pull out that key counterintuitive idea and hit it earlier, because that might help pull readers into the argument quickly and give them an idea of how the conventional wisdom is underselling some very real progress.
So I did that. Then he had a few other suggestions here and there. They all made sense and made for a better piece.
JS: What about the headline, “Why Everyone Seems to Have Cancer”?
GJ: I remember when I saw it I just thought wow. That is such a brilliant headline. I think Trish Hall, the [Sunday] Review editor, wrote it. I never could have thought of anything like it. I think it had a lot to do with the story getting as much attention as it did, because it so perfectly captured what I was trying to say in a way that I hadn’t thought of. That is really great editing—so often these days, headlines steal from the text of the story. So when a reader gets to a nice line that you’re proud of, the impact has already been spent. The reader has seen the same words at the top of the story. (The horrors of “search engine optimization” have made this even worse—writing for Google’s computers instead of human brains.) A good headline is one that steps back and formulates the point of the story in an original and striking way. The writer can’t usually do that. It takes another mind. It was great to see that happening here. The editor really nailed it.
JS: Who were you writing this for?
GJ: When I’m writing for the Science Times section I keep in mind an audience of people who are really smart and motivated and not afraid to learn new things but who probably don’t know the specifics or the jargon. The Sunday Review, which is where this story appeared, has a somewhat broader audience—but just as smart and interested in ideas. I wasn’t necessarily thinking of people who are affected by cancer, but of course they are part of that audience too.
JS: You’ve written before about your ex-wife’s cancer. Did the experience of going through her cancer with her inform this piece?
GJ: That is what got me interested in the science of cancer. Before that most of what I’d written was about physical sciences—super strings, cosmology, artificial intelligence, quantum computers. It never would have occurred to me to write about cancer if it hadn’t been for Nancy’s diagnosis more than 12 years ago. She’s doing great now, by the way. Sadly though, my brother died of cancer while I was writing the book. I told his story in the epilogue.
JS: What do you think sets your three prize-winning essays apart?
GJ: Medical news stories are very important—and there are so many good ones—but I’m trying to write more about the deep theory of cancer and cancer as an evolutionary force. I think I wrote in that Sunday Review piece that cancer is not so much a disease as a phenomenon. This idea that a single cell in your body can start dividing and mutating and evolving just like some misshapen creature—it’s something that fascinates me and horrifies me at the same time. I’m more interested in writing about what we don’t know than what we do know. Cancer turns out to be the perfect arena for that, unfortunately.
George Johnson is the author of nine books, most recently The Cancer Chronicles. A former reporter and editor at The New York Times, he has written for National Geographic, Slate, Scientific American, Wired, The Atlantic, and other publications, and writes the monthly column Raw Data for The Times. He is co-founder of the Santa Fe Science Writing Workshop. His New York Times Sunday Review story “Why Everyone Seems to Have Cancer” was part of a package that won the 2014 AAAS/Kavli Science Journalism Award in the Large Newspaper category. Follow Johnson on Twitter @byGeorgeJohnson.
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.