Saturday, May 17, 2014

Every Second Counts: Book Review


Every Second Counts, Lance Armstrong, and Sally Jenkins, Broadway Books, 2003.

Lance-o-phobes might consider Every Second Counts as a masterpiece of dissimulation.  This estimation would be too simplistic, however.  It is true, Lance Armstrong does a masterful job of denial of doping, he spins a mighty yarn.  Nevertheless, the book is not all about dope.  Lance Armstrong did suffer from a virulent form of invasive testicular cancer that metastasized into his lungs and brain.  Mr. Armstrong was subjected to traumatic chemotherapy, surgeries, and radiation treatments.  Against all odds, Mr. Armstrong fought and survived cancer.  I think Mr. Armstrong created the Lance Armstrong Foundation without mercenary motives: a place where cancer survivors could meet, share experiences, and be consoled by other cancer survivors.  The Lance Armstrong Foundation survives in spite of the personal backlash Mr. Armstrong experienced after the Reasoned Decision and the Oprah doping confession.  The foundation Lance Armstrong created still exists, but the foundation has been re-named Livestrong.  Mr. Armstrong resigned as the leader of the team.  Nevertheless, the Livestrong foundation continues to help people who suffer from the most insidious disease of all, cancer.

Cancer awareness and education is a good thing, after all, we all know someone who suffered from cancer.  My mother had breast cancer, she is a survivor.*  A friend of mine, Collin, was diagnosed with stage IV non-Hodgkin lymphoma.  I was his roommate.  He was a gifted college varsity athlete.  Collin needed a bone marrow transplant.  His stem cells were harvested, his immune system was killed, he was given radiation and chemotherapy treatments.  His stem cells were re-infused.  One fine day while at the University of Utah hospital, Collins' lungs began to cleave cells, he spent days expectorating blood.  Collins' condition deteriorated to the point that he was placed on a "death watch."  But Collin had the will to live and the man beat all odds: his lungs healed, and he was released from the hospital, his cancer in remission.  Then began after-effects.  Collin injected EPO to raise his red blood cell count.  There was little progress.  Collin had a damaged spleen that was cannibalizing his red blood cells, so his spleen was surgically removed.  Then shingles appeared.  Then the bone in his hips suffered severe atrophy; he received bilateral artificial hip replacements.  Then he began to experience cognitive problems with language and reasoning.  Then: unexpectedly, his cancer returned.  After the L'Alpe d'Huez stage during the 2001 Tour de France, the Salt Lake Tribune published a photograph of Lance Armstrong flexing his biceps, over the caption "King of the Hills."  I cut out the photograph and glued it to the wall in the garage where I used to work on my bikes.  Collin declared Lance Armstrong to be his favorite athlete.  Mr. Armstrong meant a great deal to both of us in those days.  Collin died one night in a convalescence home, from a ruptured artery.  Thus ended a valiant battle of a man whose life was terminated in such a sadistic fashion, by such a callous foe: cancer.  I have empathy with cancer patients and survivors; I have seen suffering first hand. I commend the intrepid research being done at the Huntsman Cancer Institute, and at other institutions who are committed to finally ending cancer as a disease once and for all.  I hope a cure is discovered soon, that extends to all cancer types.  In the meantime, never give up hope, ever.

Every Second Counts is a snapshot of happier days for Lance Armstrong, he was still married to Kristin Richard, he was focused on raising his son Luke, he was ecstatic about the birth of his twin daughters, Grace Elizabeth, and Isabelle Rose.  Mr. Armstrong was a loving husband and father, for the moment.  Later, Lance Armstrong divorced "Kik."  Kristin Armstrong lived in Austin, Texas with the children while Lance Armstrong lived in Girona, Spain, in his castle flat with his life in girlfriend Sheryl Crow.  A run amok playboy.  Not so family-focused then, of course.  Later there would be other women with whom Mr. Armstrong would sire children.  The later behavior of Lance Armstrong would tend to reinforce the opinion of the Lance-o-phobes.  Lance Armstrong is nothing more than a narcissistic selfish hedonistic psychopath.

A comment on the rough treatment Sally Jenkins received from the press after she attempted to support Lance Armstrong after the USADA allegations surfaced.  You paragons of virtues who live in glass houses should refrain from casting stones, for if you should stumble, the same fate awaits you.  Leave the poor woman alone.

Lance Armstrong Quotes
"It was not hard to feel that I'd been singled out because I was successful and American."
"Anyone who thought I would go through four cycles of chemo just to risk my life by taking EPO was crazy.  It was one thing to seek to maximize performance or explore a pharmacological grey zone.  It was another to court death."
"Luke's name is Armstrong and people know that name, and when he goes to school I don't want them to say, 'oh yeah, your dad's the big fake, the doper.'  That would just kill me."
The first quote by Lance Armstrong typifies his attitude towards his doping.  Indeed, Armstrong used the same logic when he stormed out of a meeting with Travis Tygart: everyone doped, but I am the only one being punished.  The second quote is a masterpiece of misinformation: what former cancer patient would take risks that might prompt a return of cancer?  Most sound-minded people would agree; the side effects of performance-enhancing drug use is not fully understood; drugs might trigger a genetic predisposition or genetic trait and terminate remission: so why take unnecessary risks?  The third quote, apparently, motivated Lance Armstrong to confess his crimes on Oprah.  Luke was being teased about his doper father, and Lance Armstrong wanted to set the record straight.  Ignoring the sincerity of his motives, these statements provide a window into the psychological makeup of Lance Armstrong as a man.

Tour de France 1999

Right from the start doping allegations plagued the miracle man.  Lance Armstrong was detected using a corticosteroid that was on the WADA prohibited list.  There were people who claimed Lance Armstrong, on his original therapeutic use exemption form filed with the UCI before the race, declared he was not using any forbidden prescribed medications by a doctor essential for his health.  Furthermore, under oath, Emma O' Reilly testified the corticosteroid prescription for saddle sores "that never existed" was backdated by Dr. Luis Garcia del Moral.  David Walsh alleges the UCI was fully cognizant of this prescription forgery.  However, Lance Armstrong would contest these versions of the story insisting he had followed proper protocol.
"I used an analgesic cream that contained corticosteroids to treat a case of saddle sores, so the press reported that I tested positive for a banned substance.  It was untrue.  I had received permission from race authorities to use the cream." P.76.
Nevertheless: during the 1999 Tour de France, the UCI decided to gather samples from selected riders that would be preserved until a suitable test could be developed to detect synthetic EPO: a drug that was being abused with particular virulence at the time.  When these samples were tested in 2004 by the French WADA accredited laboratory LNDD, several samples marked with Lance Armstrong's doping control number tested positive for synthetic EPO.  Lance Armstrong's 1999 Tour de France prologue, and 1999 L'Alpe d'Huez stage samples showed nearly perfect synthetic EPO isoforms.  After the mountain stages had stopped, the collected Lance Armstrong samples showed no sign of further synthetic EPO use, but, the samples did mimic physiological parameters that would be expected after an abrupt cessation of synthetic EPO use.  Of course, these tests generated an amazing amount of controversy, and the certainty of the test results remain debatable.  But, in 2004, the UCI, on the recommendation of Emile Vrijman, refused to suspend any of the riders who tested positive, including Lance Armstrong.  Emile Vrijman in a scathing report cited safety concerns with the WADA accredited Chatenay-Malabry laboratory that rendered the results suspect. Emile Vrijman also chided the behavior of WADA president Dick Pound, who openly opined on numerous occasions a philosophy that anyone suspected of using performance-enhancing drugs was guilty of committing crimes, and contesting the accusation in arbitration against infallible WADA was nothing more than a deceitful ruse on the part of the athlete.  Christiane Ayotte remarked that she found the LNDD results "surprising" due to the fact that stored EPO samples would degrade over time, thus the quantitative content of EPO in the samples could not produce the almost perfect isoform values measured at LNDD.  Christiane Ayotte also wondered if the prevailing attitude among the alphabet agencies was drifting toward acceptance of unverified "positive" samples.  The "A" samples of the 1999 Tour de France were not available in 2004 for testing.  Nevertheless, these "positive" results did fuel speculation that the miracle man might have been doping for his entire reign, and these rumors refused to die.

Tour de France 2000

After Lance Armstrong won an Olympic time trial bronze medal in Sydney, Australia, [since rescinded] he returned home to an announcement that the French government had opened a criminal doping probe against him and the U.S. Postal Service Professional Cycling Team.
"During the 2000 Tour, someone surreptitiously videotaped two of our medical staff as they threw away a couple of trash bags.  The tape was sent anonymously to a government prosecutor, as well as to the French 3 television station." P.72.

The medical waste supposedly contained traces of actovegin, a drug that may possibly aid recovery from acute injury.  However, actovegin was not on the prohibited list at the time.  Nevertheless, Sophie-Helene Chateau, the judge of instruction,
"Promptly subpoenaed all of my urine samples from the 2000 Tour as well as those of the rest of the U.S. Postal Service team.  She appointed an assistant prosecutor, Francois Franchi, to conduct an investigation.  We were charged with suspicion of using doping products, inciting the use of doping products, and using toxic substances." P.73.

The tests done on the U.S. Postal riders did not turn up any positives for EPO use.  I think the French launched the investigation for sensationalism.  Although the probe was of a long duration nothing was conclusively proven.  The rumors persisted about the miracle man using performance-enhancing drugs, unabated, however.  Why?

TDF 2000: Hautacam Climb

I remember this stage vividly even today.  Lance Armstrong never looked so smooth on the pedals.  In one kilometer of riding Armstrong was taking one minute out of "en Tete de la course" Javier Palacios Ochoa.  Lance Armstrong dropped Marco Pantani, who initiated an attack, like a hot rock.  The 2000 Tour was essentially over at this point, even though Marco Pantani remarked Lance Armstrong had peaked "too early."

TDF 2000: Mont Ventoux

The cold cruel mistral winds were in full force during this immortal stage.  Marco Pantani attacked and Lance Armstrong responded near the Tommy Simpson memorial.  Armstrong claims he told Marco Pantani to "ride with him," but Pantani claimed Armstrong told him to "get out of the way."  Marco Pantani also was very offended when Lance Armstrong claimed he had gifted Marco Pantani the stage win.  Lance Armstrong later insulted Marco Pantani by referring to him as "Elefantino" rather than the more respectful "Pirata."  This stage still rates as one of the greatest Tour duels of all time.

TDF 2000: Col de Joux-Plane

"Lance Armstrong will not win the 2000 Tour de France."
Marco Pantani
Still smoldering with fury Marco Pantani solo attacked the peloton and built up a lead of over ten minutes.  Lance Armstrong and the U.S. Postal Service team had to respond to this attack up-tempo.  Lance Armstrong was so intent on catching Marco Pantani, Lance Armstrong failed to take a musette bag at the feed zone.  The result of this blunder was a spectacular bonk on the Col de Joux-Plane. Marco Pantani's ploy seemed to be working in masterful fashion.  First, Lance Armstrong was passed by arch-rival Jan Ullrich, then by Richard Virenque, both of whom looked at the stricken Lance Armstrong with amazement.  There is no way of knowing how much time Lance Armstrong would have lost, or even if he would have finished the stage, if not two good Samaritans, Roberto Conti and Guido Trentin, in an act of supreme sportsmanship, had not paced Lance Armstrong to the summit of the climb, and sheltered him from the wind.  Marco Pantani later claimed he suffered "stomach cramps from drinking ice-cold sugar water on a hot summer day," and after being caught by Lance Armstrong, Marco Pantani faded quickly and retired to the back of the peloton.  Marco Pantani withdrew from the Tour the next day, and he would never ride again in a Tour de France, because, he had been granted the notorious title of persona non grata: a title imposed on him because he was suspected of several violations of performance-enhancing drug use during the 2001 Giro d' Italia.  ASO had had enough of Marco Pantani, in the same way, ASO ostracized Richard Virenque; post-Festina.

Tour de France 2001

The doping allegations against Lance Armstrong entered a new phase, but this time the allegations were substantive and long-reaching.  From The Tour Is Won on the Alpe, Jean-Paul Vespini, (David V. Herlihy, Translator), Velo Press, 2008.

"The 2001 Tour was barely underway when the journalist David Walsh of London's Sunday Times published explosive new charges fingering the champion himself, Lance Armstrong, who was seeking his third straight Tour victory.  In a highly detailed article, Walsh presented a number of troubling allegations linking Armstrong to drugs, focusing on the racers' association with the controversial Italian doctor Michele Ferrari, whom the American himself had praised for his integrity.  Walsh asserted that Lance Armstrong had visited the doctor on numerous occasions over the years, and even listed the dates and locations of their encounters.  Walsh also quoted a former Motorola racer who asserted that EPO had been widely used by the team when Lance Armstrong had been a member.  The source also cited a few other troubling affairs, including the case of Lance's former teammate Kevin Livingston, who had experienced strange variations in his red-blood-cell count." PP. 143-144.

TDF 2001: The Team Time Trial

Christian Vande Velde and Roberto Heras collided in the U.S. Postal Service train during the team time trial.  Vande Velde broke his arm and had to withdraw from the Tour.  Since the team time trial clock stops when the fifth rider crosses the line, (thus the picturesque spreading out of the riders at the line), Lance Armstrong could have ordered the team to abandon Vande Velde and Heras.*  Instead, Lance Armstrong ordered the team to wait for Heras and Vande Velde to recover from their accident.  Incredibly, even with the wait, the U.S. Postal Service Team finished the team time trial forth on the course, @ 1 minute 26 seconds behind Credit Agricole, who rode an inspired team time trial in support of maillot jaune Stuart O' Grady.
*Note: the train consists of nine riders if none have abandoned the race previous to the team time trial.  If a rider is separated from the train and falls behind he or she is awarded a separate time.

TDF 2001: Outside of the Time Limit

Then there was an escape by Francois Simon and Russian rider Andrei Kivilev during a rain-soaked stage of the 2001 Tour.  Francois Simon finished the stage with a lead of 35 minutes.  Of course, in the end, this escape did not figure into the final general classification, however, the peloton, including Lance Armstrong and Jan Ullrich, did finish outside of the time limit.  According to race rules, Lance Armstrong and Jan Ullrich could have been disqualified from the race.  In spite of the insistence from some disgruntled fans that everyone outside of the time limit be disqualified, Tour officials found a loophole in the rules: if a certain percentage of the peloton fell outside of the time limit, then the disqualification could be waived if a reasonable cause could be found for the delay.  Torrential rain might be an acceptable excuse, or possibly a blizzard.  But stupidity?  After all, nobody wanted to expend the energy to reel in the breakaway, did they?

TDF 2001: "The Look" L'Alpe d'Huez

Lance Armstrong put on a masterful performance of suffering during this stage.  Feigning fatigue and illness Lance Armstrong fell to the back of the leading group, a place where many riders "go out the back."  Scenting blood Jan Ullrich and his Team Telekom lieutenants drove a hard tempo, trying to drop Lance Armstrong.  But at the base of L'Alpe d'Huez, an amazing transformation occurred.  Lance Armstrong experienced an amazing recovery, the recently exhausted man suddenly showed amazing resilience.  Lance Armstrong launched an attack, looking over his shoulder through his Oakley sunglasses at Jan Ullrich, while Phil Liggett commented, "Well, are you coming or not?  The answer is not!" as Lance Armstrong pulled away.  This brazen audacity by Lance Armstrong became immortalized in the annals of cycling as "The Look"

The reaction to Lance Armstrong at the summit of L'Alpe d'Huez was mixed.  From: The Tour Is Won on the Alpe, Jean-Paul Vespini, (David V. Herlihy, Translator), Velo Press, 2008.

Both applause and disapproving whistles greeted Lance Armstrong at the finish line.  The crowd at L'Alpe d'Huez, as skeptical as it was admiring, was focused on a fundamental question: was Lance Armstrong really the great champion of the new century, or did he simply have access to a yet unknown pharmacopeia?  It was rather unjust to be suspicious of him at that point.  The American, after all, had always claimed to be clean, and no firm evidence had indicated otherwise.  Jan Ullrich finished second 1:59 behind.  He had lost over 8 seconds per kilometer behind Lance Armstrong, "the motorcycle." P.144.

TDF 2001: Pla d'Adet

The course of Pla d'Adet passed the spot where Lance Armstrong's former Motorola teammate Fabio Casartelli died during a Tour descent in 1995.  Jan Ullrich almost duplicated Fabio Casartelli's feat when failing to negotiate a turn, he plunged off a precipice into the trees.  Incredibly, in spite of all indications, Jan Ullrich emerged unscathed.  In a gesture of supreme sportsmanship, Lance Armstrong stopped pedaling and waited for Jan Ullrich to catch up.  On the last climb Pla d'Adet, Lance Armstrong attacked Jan Ullrich who did not respond:
"I crossed the finish line alone and toppled off the bike, spent, the new leader of the Tour de France.  We had done what Johan [Bruyneel] asked, and attacked at every opportunity, and the result was that we had won three of the last four stages, and made up 35 minutes and 24 places in the standings.  In two days alone, we'd made up 22 minutes.  It set a record for the biggest deficit ever overcome." P.118

Remarkable what obsessive training and performance-enhancing drugs can accomplish.  If there was a concern about Lance Armstrong using performance-enhancing drugs during the 2001 Tour de France, the suspicions should have focused straight on the results of these stages.  There was simply too much uniformity of performance, that indicated artificiality.

2004 Tour de France: Lance Armstrong Goes Postal!

During the 2001 Tour de France, the invariable questions from the press and public ensued; all focused on Michele Ferrari, who was under investigation for allegedly supplying riders with doped blood.  A link had been established between Michele Ferrari and Filippo Simeoni; a proven doper.  In the investigation of Michele Ferrari, the name Lance Armstrong surfaced.  Lance Armstrong stated that Michele Ferrari had advised him merely on mundane matters: altitude testing, power meter training, watts per kilogram; legal topics that all top riders discuss to improve performance.  Lance Armstrong also claimed that he was working with Michele Ferrari in preparation for an attempt on the world record one hour ride.  But Michele Ferrari had a bad reputation: he brazenly declared in an interview that EPO was no more dangerous than drinking ten liters of orange juice.  Michele Ferrari was also a star student of Francesco Conconi, a notorious doping doctor who was accused of providing human growth hormones and doped blood to the 1980 Italian Olympic Team.  Francesco Conconi had also designed a medical regimen for Francesco Moser: to prepare him for his world record one hour ride in Mexico City in 1984, a ride that dwarfed the old one hour Mexico City world record ride set by Eddy Merckx in 1972.  Francesco Moser would later admit he had injected "doctored" blood prepared by Francesco Conconi and Michele Ferrari.  During the 2004 Tour de France, a curious incident occurred between Filippo Simeoni and Lance Armstrong that directly related to Michele Ferrari.  After Filippo Simeoni publicly accused Lance Armstrong of using illegal substances provided by Michele Ferrari, Filippo Simeoni attempted to join a breakaway on flat stage 18 near the end of the 2004 Tour.  There was no need to reel Filippo Simeoni in, as he was no threat to the general classification.  But unexpectedly, and contrary to cycling etiquette: (a maillot jaune never leaves the peloton to ride down a breakaway), Lance Armstrong went after Filippo Simeoni with a vengeance.  Lance Armstrong reportedly told the breakaway group, if Filippo Simeoni did not return to the peloton immediately, Lance Armstrong would order his team to attack and reel in the breakaway.  The riders in the breakaway group, seeing the maillot jaune in the breakaway were furious with Filippo Simeoni, because he was jeopardizing their chances for a stage win.  Filippo Simeoni had to submit to the pressure, he capitulated, returning to the back of the peloton where he faced further rider insults.  Later, Filippo Simeoni declared he had been threatened by Lance Armstrong: and he filed a lawsuit demanding compensation.  The case was settled in Filippo Simeoni's favor.  This incident was later cited as evidence of bullying and tactics of intimidation Lance Armstrong used throughout his professional cycling career: tactics which included forcing his hapless teammates to use performance-enhancing drugs against their wills: all to satisfy Lance Armstrong's monomania to be the greatest Tour champion ever.

Spinning a Myth: It's All About the Weight

Lance Armstrong does spend some time discussing his weight: prior to and post-cancer.  This discussion cannot be ignored because during the Motorola period Lance Armstrong rode an average Tour, and most years he withdrew long before Paris.  Since Armstrong maintained an aura of innocence as to his drug use there had to be another explanation for his tremendous improvement on the bike; a magic bullet, if you will.  A University of Texas physiologist Edward F. Coyle performed a series of experiments on Lance Armstrong and concluded that the increase in performance from prior to post-cancer was the result of increased pedaling efficiency, and loss of weight.  Edward F. Coyle's conclusions generated a furious debate among other sports physiologists, however: some called his research bunk, others questioned his methodology, and some even accused him of miscalibration of his instrumentation.  In Every Second Counts, Lance Armstrong does a masterful spin job of misleading dissimulation to support Edward F. Coyle's conclusions.

"Every once in a while, I'd deliver a big ride: when I was 21, I had come out of nowhere to win the Worlds, and then a stage of the Tour de France.  But mostly I cruised for months at a time, performing decently but not exceptionally, just meeting the definition of "professional."  After cancer, I realized I'd been operating at about half of my abilities.  For one thing, I carried 15 to 20 pounds more weight than I should have, some of it in puppy fat and some of it in margaritas and tortilla chips.  After cancer, I was twenty pounds lighter." PP.155-156.

"Under Johan [Bruyneel], I began training seriously, and kept the weight off, and discovered what a huge difference it made in the mountains, where your own body was your biggest adversary.  The lost weight, I discovered, made me 10 to 12 minutes faster over a mountain stage; I figured it saved me about three minutes on every mountain pass I rode.  As a young rider, I would start off at the gun and just go.  I didn't really know how to race: I mashed big gears and thrashed around on the bike.  My position is all wrong. Now with Johan [Bruyneel] and Chris Carmichael, I studied proper aerodynamic positioning and effective cadence." P.156; italics added.

Indeed!  It was obvious.  It was better training, altitude tents, better coaching, better diet, higher drive and motivation, improved technology, power meters, improvements in skin suits, space-age bicycle design, wind tunnels, computer analysis of power outputs.  But dope?  Forget about it!

Conclusion:

As Lance Armstrong told Floyd Landis: "There was no mystery and no miracle drug that helped me win the Tour de France in 1999!"  This statement is disingenuous, of course, but it does reinforce the notion that winning Grand Tours requires hard work, and nobody worked harder than Lance Armstrong.

Lance Armstrong also misleads us when he claims after his former teammates departed U.S. Postal Service they maintained good relations.  Tyler Hamilton lived in Girona, Spain; and when he joined CSC, Tyler Hamilton claims he actively avoided Lance Armstrong like the plague.  There were rumors Lance Armstrong fired Kevin Livingston, who joined Team Telekom (T-Mobile) to bring in the Spanish rider Roberto Heras, and further interactions between Armstrong and Livingston were terse, at best.  In Every Second Counts, even though Lance Armstrong speaks very favorably of Floyd Landis, who had just received a new two-year contract with the U.S. Postal Service Professional Cycling Team, by the end of the contract Floyd Landis was so fed up he would have retired from cycling rather than continue with the U.S. Postal Service Professional Cycling Team.  As Lance Armstrong says in his book, "some people regarded him as a tyrant," and from accounts of his conduct, there appears, today, very few who would disagree with this statement.

Update 2020

* A lady friend of mine, her name is Gail, has a particularly difficult time dealing with cancer.  All four of Gail's sisters are dead.  Three of Gail's sister's died of cancer at a very young age.  Gail's fourth sister died young of unknown "natural causes".  When Gail's sister Janice lost all of her hair as a side-effect of chemotherapy, Gail and her family members shaved their hair in support of Janice, and vowed to remain bald until Janice recovered.  Gail and her family shaved their heads to raise cancer awareness among the community, and Gail and her friends launched a cancer awareness Internet campaign stylized, #Janice's Army, or #Janice's Army Strong, on Facebook.  Janice died in 2017 from cancer.  In May 2019, Gail's last remaining living sister, Debi, died of cancer.  Debi's obituary states, "No funeral is planned.  In lieu of flowers, donations may be made toward fighting cancer."  An appropriately blunt message.  When I got confirmation that Debi had died, I wrote this message to Gail.  "I am heartbroken for you.  My mom died in September 2019, from bone marrow cancer.  My mom had a virulently pernicious breast cancer that metastasized throughout her whole body.  My mom suffered for years with chronic pain, she dealt with chemotherapy treatments, baldness, radiation treatments, and expensive hospitalizations.  So, I understand your pain".  Gail greatly suffers emotionally from the loss of her sisters.  Gail said her sisters were; "my best friends".  My mother is no longer a survivor, she is a statistic.  Gail's sisters who died of cancer, Janice, Valerie, and Debi are no longer survivors, they are statistics.  Cancer leaves behind a wake of family tears, shed by mothers, fathers, sons, and daughters.  "In lieu of flowers, donations may be made toward fighting cancer".