Powell talked to eating disorder specialists and psychiatrists, but her husband tended to shun them. He refused to take any medications, or be treated in any way, for his depression. “When you have feelings,” he said, “like sadness or anger about your cancer or your plight, to mask them is to lead an artificial life.” In fact he swung to the other extreme. He became morose, tearful, and dramatic as he lamented to all around him that he was about to die. The depression became part of the vicious cycle by making him even less likely to eat.
Pictures and videos of Jobs looking emaciated began to appear online, and soon rumors were swirling about how sick he was. The problem, Powell realized, was that the rumors were true, and they were not going to go away. Jobs had agreed only reluctantly to go on medical leave two years earlier, when his liver was failing, and this time he also resisted the idea. It would be like leaving his homeland, unsure that he would ever return. When he finally bowed to the inevitable, in January 2011, the board members were expecting it; the telephone meeting in which he told them that he wanted another leave took only three minutes. He had often discussed with the board, in executive session, his thoughts about who could take over if anything happened to him, presenting both short-term and longer-term combinations of options. But there was no doubt that, in this current situation, Tim Cook would again take charge of day-to-day operations.
The following Saturday afternoon, Jobs allowed his wife to convene a meeting of his doctors. He realized that he was facing the type of problem that he never permitted at Apple. His treatment was fragmented rather than integrated. Each of his myriad maladies was being treated by different specialists—oncologists, pain specialists, nutritionists, hepatologists, and hematologists—but they were not being co-ordinated in a cohesive approach, the way James Eason had done in Memphis. “One of the big issues in the health care industry is the lack of caseworkers or advocates that are the quarterback of each team,” Powell said. This was particularly true at Stanford, where nobody seemed in charge of figuring out how nutrition was related to pain care and to oncology. So Powell asked the various Stanford specialists to come to their house for a meeting that also included some outside doctors with a more aggressive and integrated approach, such as David Agus of USC. They agreed on a new regimen for dealing with the pain and for coordinating the other treatments.
Thanks to some pioneering science, the team of doctors had been able to keep Jobs one step ahead of the cancer. He had become one of the first twenty people in the world to have all of the genes of his cancer tumor as well as of his normal DNA sequenced. It was a process that, at the time, cost more than $100,000.
The gene sequencing and analysis were done collaboratively by teams at Stanford, Johns Hopkins, and the Broad Institute of MIT and Harvard. By knowing the unique genetic and molecular signature of Jobs’s tumors, his doctors had been able to pick specific drugs that directly targeted the defective molecular pathways that caused his cancer cells to grow in an abnormal manner. This approach, known as molecular targeted therapy, was more effective than traditional chemotherapy, which attacks the process of division of all the body’s cells, cancerous or not. This targeted therapy was not a silver bullet, but at times it seemed close to one: It allowed his doctors to look at a large number of drugs—common and uncommon, already available or only in development—to see which three or four might work best. Whenever his cancer mutated and repaved around one of these drugs, the doctors had another drug lined up to go next.
Although Powell was diligent in overseeing her husband’s care, he was the one who made the final decision on each new treatment regimen. A typical example occurred in May 2011, when he held a meeting with George Fisher and other doctors from Stanford, the gene-sequencing analysts from the Broad Institute, and his outside consultant David Agus. They all gathered around a table at a suite in the Four Seasons hotel in Palo Alto. Powell did not come, but their son, Reed, did. For three hours there were presentations from the Stanford and Broad researchers on the new information they had learned about the genetic signatures of his cancer. Jobs was his usual feisty self. At one point he stopped a Broad Institute analyst who had made the mistake of using PowerPoint slides. Jobs chided him and explained why Apple’s Keynote presentation software was better; he even offered to teach him how to use it. By the end of the meeting, Jobs and his team had gone through all of the molecular data, assessed the rationales for each of the potential therapies, and come up with a list of tests to help them better prioritize these.
One of his doctors told him that there was hope that his cancer, and others like it, would soon be considered a manageable chronic disease, which could be kept at bay until the patient died of something else. “I’m either going to be one of the first to be able to outrun a cancer like this, or I’m going to be one of the last to die from it,” Jobs told me right after one of the meetings with his doctors. “Either among the first to make it to shore, or the last to get dumped.”
Visitors
When his 2011 medical leave was announced, the situation seemed so dire that Lisa Brennan-Jobs got back in touch after more than a year and arranged to fly from New York the following week. Her relationship with her father had been built on layers of resentment. She was understandably scarred by having been pretty much abandoned by him for her first ten years. Making matters worse, she had inherited some of his prickliness and, he felt, some of her mother’s sense of grievance. “I told her many times that I wished I’d been a better dad when she was five, but now she should let things go rather than be angry the rest of her life,” he recalled just before Lisa arrived.
The visit went well. Jobs was beginning to feel a little better, and he was in a mood to mend fences and express his affection for those around him. At age thirty-two, Lisa was in a serious relationship for one of the first times in her life. Her boyfriend was a struggling young filmmaker from California, and Jobs went so far as to suggest she move back to Palo Alto if they got married. “Look, I don’t know how long I am for this world,” he told her. “The doctors can’t really tell me. If you want to see more of me, you’re going to have to move out here. Why don’t you consider it?” Even though Lisa did not move west, Jobs was pleased at how the reconciliation had worked out. “I hadn’t been sure I wanted her to visit, because I was sick and didn’t want other complications. But I’m very glad she came. It helped settle a lot of things in me.”