OPENING THEORY

In chess, every move matters, but none more so than the first. Before the pieces are perturbed, before the knights’ steeds canter or the bishops set out on their diagonal pilgrimages, the match offers a near-infinity of potential outcomes. Ramifying mind-bogglingly from their initial set positions on the board, more possible arrangements of chesspieces can be laid out on the 8x8 grid than exist atoms in the universe, and those contingencies start to narrow down as soon as the first piece is advanced. Each parry and counterattack forms part of a cascade set in unstoppable motion by the opening maneuver. Only after a defeat can you work backwards, retracing the steps that tapered towards checkmate from the match’s opening. Then, during the post-mortem, fatally flawed schemes are laid bare in the harsh critical light of hindsight.

Oncology is no different. From the outset, your opponent immediately begins adapting to your tactics, sharpening its double daggers. Move boldly to the middle and it replies with the Sicilian Defense, angling to claim the center pawns, making it harder to shield your royalty. Venture a foolish gambit and arrive at the endgame in no time. You never get a second chance to make a first remission. On the other hand, you can’t overthink, can’t be vulnerable to paralysis by analysis.

Benjamin Franklin identified the principal morals of chess as foresight, circumspection, and caution. The oncologist would be well-served to aspire to the same prudent qualities in tackling the toughest adversary to occupy the checkered interior of the human body.

Beyond the mathematics and stratagems, there’s moralizing too. You begin to ask yourself if you’re white or black, where you fit in the Manichaean color scheme of the board. Being gray is not an option. You have to inflict damage, but also sustain it, and pawn sacrifice is a lot harder when you’re emotionally attached to the foot soldiers.

Even if you can manage to separate your heart from your head, the arrogance of the doctor gets erosively undermined in this exercise, worn down by the relentlessness and evasiveness of the grandmaster you’re facing. Your ego as a physician gets falsely girded by years of hierarchical training; in your rise through the pecking order you gather followers and sycophants who eventually default to you as the smartest guy in the room based on rank alone. But cancer doesn't care about your decades of graft, your titles, your publications, or your curriculum vitae. And it has more opportunity to explore permutations than you do, a million monkeys on a million typewriters; when they eventually chance to reproduce Shakespeare, they conjure Iago, pure evil. Meanwhile, you start to empathize with the vulnerable humanity of Kasparov jousting with Deep Blue, lacking in processing power and time while up against a monstrous, mercurial intelligence capable of sorting through endless iterations until it finds selective advantage.

It’s difficult, but not unheard of, to win the game by outpacing cancer’s ability to regroup between moves. Perhaps counterintuitively, the faster, more aggressive malignancies are the ones that tend to respond better to chemo, their warp-speed proliferative rates simultaneously presenting their greatest threat and their greatest weakness. Small cell lung cancer, Burkitt’s lymphoma, and acute promyelocytic leukemia can melt away as swiftly as they grew under the right set of circumstances, while slower cancers recede at a snail’s pace, if they change measurably at all.

Because complete remissions in cancer are too rare, we have convinced ourselves to be content with stability. A stalemate is not a loss, under the rules of chess or oncology. The important thing is to live to play another match, and to realize that not all cancers can be defeated by speed. The Accelerated Dragon doesn’t work every time. More commonly, when you try to go quicker you’ll make mistakes, short-sighted moves that force your pieces into needless positions of vulnerability. That said, not making a decision is still a decision, and you are on the clock. The longer you take, the more the enemy is learning, the corps of monkeys evolving from gibberish typos toward the First Folio. The key is to be both thoughtful and timely, and to learn from the successes and failures of your predecessors.

Here, the good news is that you don’t have to start scheming entirely from scratch. Tactics are refined and shared among players of chess and practitioners of oncology alike, each exchanging approaches in their own encoded shorthand. While the syntax may differ, the cryptic notation of the chessboard 1.e4 c5 2.Nf3 d6 does not look that dissimilar to the byzantine nomenclature of chemo: mFOLFOX6, 7+3, the arrestingly named proMACE-cytaBOM. Every abbreviation represents a line of attack crafted through past clinical trial & error. While these assaults open up lanes on the board, they also create susceptibilities and can only be repeated a finite number of cycles before the opponent, armed with an increasingly total recall, divines a means of escape.

What you want to avoid, at all costs, is clearing the way for a pawn to advance to the other side of board and become a queen, a previously minor character gaining the powers of a monarch. In cancer, this undesirable transformation happens through a hastened Darwinism, which winnows down the cells within a tumor until only the hardiest remain. Anything less than total annihilation and the last man standing can ascend to the throne, copy itself, and unleash a whole new army of steeled clones.

You may think this is all crazy talk, that we give cancer too much credit. And you’re right that it doesn’t have a conscious plan. But it can conjure the genius of the smart swarm, making so many variants of itself that one of them is eventually likely to acquire immortality, cranking out Hamlet through lucky keystrokes.

Trust me: play against it enough times, and you can almost convince yourself that it’s sentient, so cunning is the crab. It humbles the oncologist with its scuttling ability to outmaneuver, leaving us lost and bewildered in the garden of forking paths. Too often and too late we realize that, for all our lofty intellectualization, we’ve been playing checkers while the cancer’s been playing chess.

Then the patient loses, and that’s no game at all.