Checkpoint
A story about Immunotherapy, hope and the extraordinary power within us. PATIENT & CAREGIVER EDUCATIONAL FICTION
MANHATTAN, NEW YORK | Wednesday, October 1, 7:20 A.M.
The blood was brighter than Pandit Narayan Joshi expected.
He stared at the white handkerchief in his palm.
For a moment, neither he nor his daughter spoke.
Outside the apartment windows, Manhattan was beginning its morning. Delivery trucks groaned along Lexington Avenue. A siren passed somewhere below. The October sun had only begun to touch the upper floors of the buildings across the street.
Five minutes earlier, Narayan had been sitting before the small brass figures his daughter had arranged for him on a table facing east. He had finished his morning prayers, complained that American milk never made proper tea, and asked whether Central Park really needed to be quite so large.
Then he had coughed.
Once.
Twice.
The third time, blood came into his mouth.
“Papa, sit down.”
Naina was already reaching for her phone.
“I’m calling an ambulance.”
Narayan folded the handkerchief carefully, hiding the red stain inside.
“Cancer,” he said.
“Papa, don’t do that.”
“I am seventy-four years old. I know what coughing blood can mean.”
“It can mean twenty things.”
He looked at his daughter.
Naina Joshi had spent twelve years in law enforcement. She could enter a room full of armed strangers without changing her expression.
This morning her hands were trembling.
Narayan noticed.
“So,” he said gently, “perhaps you should sit down too.”
MSK EMERGENCY DEPARTMENT, MANHATTAN | Wednesday, October 1, 3:00 P.M.
By afternoon, neither of them was joking.
The emergency CT showed a mass in the upper lobe of Narayan’s right lung.
There were more scans. Blood tests. A bronchoscopy. A biopsy.
MEMORIAL SLOAN KETTERING, NEW YORK | Saturday, October 4, 3:00 P.M.
Three days later, Narayan and Naina sat across from Dr. Sapna at Memorial Sloan Kettering.
Dr. Biswas stood beside the computer monitor.
Narayan had decided that hospital consultation rooms were designed by people who disliked uncertainty. Everything was square. The table. The screen. The tissue box. Even the window seemed to frame Manhattan with unnecessary precision.
Only the words were uncertain.
Dr. Sapna folded her hands.
“The imaging raised three possibilities — a serious lung infection, tuberculosis, or cancer. The follow-up biopsy confirms lung cancer.”
Naina inhaled sharply.
Narayan did not move.
After several seconds he asked, “Am I dying?”
“Papa — ”
But Sapna answered him.
“You have a serious illness, Mr. Joshi. But dying is not today’s diagnosis.”
Narayan studied her.
“You chose those words very precisely.”
“Yes.”
“I am a priest. We also learn to choose words precisely.”
For the first time that afternoon, Sapna smiled.
She turned the monitor toward them.
“The important thing is that the PET-CT does not show cancer in distant organs. Dr. Biswas believes the tumor can be removed surgically.”
Naina almost sagged with relief.
“Then operate.”
Dr. Biswas shook his head gently.
“Not yet.”
Her relief disappeared.
“Why not?”
“We want to treat the cancer before surgery.”
“But if you can remove it, why leave it there?”
Narayan raised one hand.
“Let the doctor finish.”
Sapna pulled her chair slightly closer.
“There is a term you may hear us use — neoadjuvant therapy. It simply means treatment we give before the main treatment, which in your father’s case is surgery.”
“Why?”
“For several reasons. We may be able to shrink the disease. We may begin treating cancer cells too small for a scan to show us. And sometimes, by reducing the amount of disease beforehand, we give the surgeon a better starting point.”
“So you’re not postponing the surgery?”
“No. We are preparing for it.”
Naina nodded slowly.
“And perioperative?”
Sapna smiled.
“You’ve been reading.”
“Too much.”
“Perioperative is the broader idea. Treatment around the time of surgery — sometimes before it, sometimes afterward, sometimes both.”
Narayan looked from one doctor to the other.
“What treatment before?”
“Chemotherapy,” Sapna said. “And in your case, most likely immunotherapy as well.”
Narayan frowned.
“Chemotherapy I have heard of.”
He paused.
“Immunotherapy I have not.”
MSK HOSPITAL, NEW YORK | Saturday, October 4, 5:37 P.M.
That evening, after Narayan and Naina had left, Dr. Sapna found Dr. Biswas still looking at the scans.
“He’s fit for seventy-four.”
“Very.”
“Node positive, but resectable.”
Biswas nodded.
“Right upper lobe. No distant disease. Performance status good.”
“Molecular panel?”
“No actionable driver. EGFR negative. ALK negative.”
“And PD-L1?”
“Moderate expression.”
Sapna enlarged the image.
“So no molecular address for targeted therapy.”
“Not one we can use here.”
“Platinum-doublet chemotherapy plus checkpoint inhibitor?”
“That would be my preference. Neoadjuvant treatment, restage, then surgery if everything behaves.”
“And afterward?”
“We decide from the pathology, recovery and overall perioperative plan.”
Sapna looked at the gray-white mass on the screen.
“If he tolerates treatment.”
“He probably will.”
Biswas glanced at her.
“You always say that before immunotherapy.”
“No. I always say probably.”
“That word does a great deal of work in oncology.”
“In our profession, it has to.”
For several moments they looked silently at the scan.
On the screen, the tumor appeared indifferent to statistics, fear, technology, prayer and hope.
MSK HOSPITAL, NEW YORK | Monday, October 6, 10:00 A.M.
At the next appointment, Narayan arrived carrying a notebook.
Naina carried three pages of questions.
Sapna looked at them.
“Which one of you is the dangerous one today?”
“My daughter,” Narayan said immediately.
“Papa.”
“She interrogates professionally.”
Naina ignored him.
“I have a basic question.”
“Good.”
“You’ve mentioned chemotherapy, targeted therapy and immunotherapy. Are they basically three different medicines trying to do the same thing?”
Sapna considered the question.
“Same broad objective. Different strategies.”
Narayan opened his notebook.
Naina leaned forward.
“Start with chemotherapy.”
“Chemotherapy uses drugs that are particularly effective against rapidly growing and dividing cells. Cancer cells often do that very aggressively.”
“But healthy cells divide too.”
“Exactly. Some healthy tissues can also be affected. That’s why chemotherapy can cause side effects involving things like blood cells, hair, the digestive tract and other rapidly renewing tissues.”
Naina thought for a moment.
Then she looked at her father.
“Okay. Let me try something from my world.”
Narayan sighed theatrically.
“Now the police have arrived.”
She continued.
“Suppose a terrorist is hiding inside a crowded public place.”
Sapna listened.
“I can stop him by dropping a bomb on that area. I’ll probably get the terrorist — but I may injure innocent people nearby.”
Sapna nodded cautiously.
“As a rough analogy, yes. Chemotherapy is much more controlled than dropping a bomb, obviously, but your point about collateral damage is useful. It attacks cancer effectively, but some healthy cells can be affected too. That is why we choose the drug, dose and timing carefully.”
Narayan wrote something down.
“And targeted therapy?”
Naina answered before Sapna could.
“Smart missile?”
Dr. Biswas, who had just entered the room, smiled.
“Your daughter is getting ahead of us.”
Sapna continued.
“Targeted therapy begins differently. We study the tumor for particular proteins or molecular changes that may be helping the cancer grow.”
“A fingerprint?” Narayan asked.
“Closer to an address.”
He looked interested.
“If the cancer has that particular address, we may have a drug designed to interfere with it.”
Naina nodded.
“So my smart missile finds the address first.”
“Yes. That’s a useful analogy.”
“And it does not damage healthy cells?”
“Not quite.” Sapna shook her head. “Targeted treatments can still have side effects. ‘Targeted’ does not mean harmless. It means the treatment is aimed at a particular molecular feature of the cancer rather than broadly at dividing cells.”
Narayan raised his finger.
“And my cancer?”
“We tested it.”
“You found the address?”
“No.”
He looked disappointed.
Sapna smiled.
“That does not mean we have no treatment. It means that particular strategy is not the right one for your tumor.”
Naina looked down at her notes.
“So chemotherapy is the broad attack. Targeted therapy needs a molecular address.”
“Yes.”
“And immunotherapy?”
Sapna paused.
“That one is different.”
She drew two circles on Narayan’s notepad.
“Your immune system already has cells called T cells. Part of their job is to recognize things that should not be there and attack them.”
“Like policemen,” Naina said.
“Or soldiers,” Narayan added.
“Either will do.”
Sapna drew another circle.
“Cancer creates a special problem because it develops from our own cells. And some cancers become very clever at exploiting the normal safety mechanisms of the immune system.”
“What safety mechanisms?”
“Your immune system has brakes. It needs them. Otherwise it could become so aggressive that it damages your own body.”
Narayan nodded.
“Sensible.”
“One of those braking systems involves proteins we call immune checkpoints. PD-1 on T cells and PD-L1 on some tumor cells are examples,” Dr. Sapna explained.
Naina frowned.
“Now you’ve lost him. I’ve lost you too.”
“Possibly.”
Sapna smiled.
“Then ignore the medical names for a moment. Some cancer cells can send what amounts to a ‘Do Not Attack Me’ signal to the immune system.”
Narayan leaned forward.
“So the soldier sees the enemy but does nothing? Because it cannot attack this foe, carrying a valid ID and pretending to be a friend?”
“In simplified terms, yes.”
“And immunotherapy kills the cancer?”
“Not necessarily by attacking it directly. A checkpoint inhibitor can block that stop signal.”
Narayan became very still.
“The strength to fight and stop the intruder was already there?”
“Yes.”
“The medicine simply allows it to act?”
“That is one way to think about it.”
A smile appeared slowly on Narayan’s face.
“I know this story.”
Naina closed her eyes.
“Here we go.”
“Hanuman.”
Sapna laughed softly.
Narayan turned toward her.
“When Lord Hanuman was young, he possessed extraordinary powers. But later he no longer remembered the full extent of his own strength. When the time came to cross the ocean to Lanka, Jambavan reminded him.”
Narayan recited softly:
“का चुप साधि रहेहु बलवाना?”
Then translated:
“Why do you remain silent, O mighty one?”
He tapped Sapna’s drawing.
“Jambavan did not give Hanuman his strength.”
“No.”
“He reminded him of what was already within him.”
Sapna nodded.
“As an analogy, that works nicely. Immunotherapy does not invent your immune system. In this kind of treatment, we are trying to remove signals that are restraining immune cells that may already have the ability to fight back and attack the intruders.”
Naina was staring at the drawing now.
“Wait.”
She took the pen.
“Checkpoint. That I understand.”
She drew a little box between the circles.
“Imagine one of my officers at a security checkpoint. A dangerous man approaches, but he is carrying a credential that tells the officer, ‘This person is cleared. Do not stop him.’”
Sapna nodded.
“The officer isn’t weak,” Naina continued. “And he isn’t absent. He has simply received the wrong clearance signal.”
“And if you invalidate that signal?”
“The officer can act.”
Sapna smiled.
“That is not perfect immunology.”
“Nothing involving my father and Hanuman is perfect immunology.”
Narayan looked offended.
“But between your police checkpoint and his Hanuman story, you’ve both captured something important,” Sapna observed.
Narayan closed his notebook.
“So I have Hanuman.”
Naina said, “I have law enforcement.”
Sapna pointed toward herself.
“And I have T cells.”
Narayan smiled.
“Excellent. Between the three of us, perhaps the cancer has chosen the wrong family.”
MSK HOSPITAL, NEW YORK | Late October — Early November
The first treatment was uneventful.
The second was not pleasant, but manageable.
Narayan lost his appetite for several days and announced that hospital food had finally accomplished what seventy-four years of spiritual discipline had failed to achieve:
Detachment from earthly pleasures.
Naina laughed for the first time in weeks.
After the third treatment, the scan was encouraging.
The mass was smaller.
Dr. Biswas did not use the word dramatic.
Naina did.
Narayan used Hanuman.
Sapna used neither.
“We’re moving in the right direction,” she said.
That evening, father and daughter walked slowly beside the East River.
The city lights trembled on black water.
Narayan stopped at the railing.
“You were afraid I was going to die.”
Naina looked straight ahead.
“I still am.”
“Good.”
She turned.
“Good?”
“Fear is useful in proper quantities.”
“And in improper quantities?”
“It becomes the disease.”
She slipped her arm through his.
For several minutes they walked without speaking.
Hope had returned so quietly that neither trusted it enough to name it.
MANHATTAN, NEW YORK | Mid-November
Nine days later, Narayan began coughing again.
Get Ashutosh Bhatnagar’s stories in your inbox
Join Medium for free to get updates from this writer.
Not blood this time.
A dry, stubborn cough.
By evening he was short of breath walking from the bedroom to the kitchen.
Naina called Sapna.
Within hours he was back at the hospital.
MSK HOSPITAL, NEW YORK | Mid-November — Later that evening
The CT showed new hazy changes in both lungs.
Naina stood outside the room while Dr. Sapna and Dr. Biswas studied the images.
“Infection?” Biswas asked.
“We have to exclude it.”
“Progression?”
“The pattern doesn’t fit.”
Biswas looked at her.
“Checkpoint pneumonitis?”
“That’s my concern.”
He exhaled slowly.
“Just as we were getting him toward surgery.”
“If it’s immune-related, surgery waits.”
“And immunotherapy?”
“Stops.”
Naina had approached behind them.
“Stops?”
Sapna turned.
“What happened?”
“We think your father may have developed inflammation in his lungs caused by the immunotherapy.”
“Pneumonia?”
“No. Pneumonitis. They sound similar, but they aren’t the same thing. Pneumonia usually refers to an infection. Pneumonitis means inflammation of the lung tissue. In his case, we’re concerned the activated immune system may be causing it.”
For several seconds Naina said nothing.
Then anger replaced fear.
“You told us his immune system would fight the cancer.”
“Yes.”
“And now you’re telling me it may be fighting his lungs?”
“Yes.”
“That makes no sense.”
“It makes more sense than I wish it did.”
Naina stared at her.
Sapna lowered her voice.
“Remember the brakes we talked about?”
Naina nodded.
“They exist for a reason. We release some of those restraints so the immune system can fight cancer. Occasionally the immune response becomes too active and inflames normal organs.”
“Only the lungs?”
“No. Depending on the patient and the drug, immune-related inflammation can affect other organs too — the bowel, liver, kidneys, hormone glands, skin, and more.”
Naina looked frightened.
“So this could have happened anywhere?”
“It can happen in different places. That is why patients receiving these treatments are monitored closely and why we tell families to report new symptoms early.”
“And you can treat it?”
“Often, yes. The first step is recognizing it. We hold the immunotherapy. We rule out infection and other causes. If the inflammation is significant, we use medicines such as steroids to calm the immune response.”
“You turn the immune system back down.”
“In a manner of speaking.”
“And the cancer?”
“We deal with one danger at a time.”
From inside the room, Narayan called weakly.
“Naina?”
She turned away before Sapna could see her cry.
MSK HOSPITAL, NEW YORK | Late November
That night his oxygen requirement increased.
The next morning was worse.
Narayan, who had entered treatment talking about Hanuman, now spoke very little.
By Saturday evening, he looked at Sapna and asked the question he had asked once before.
“Am I dying?”
This time she pulled a chair to his bedside.
“You are very sick.”
“That is not what I asked.”
“No.”
He waited.
“I don’t think you are dying tonight.”
Narayan smiled faintly.
“Again, very precise.”
“Still necessary.”
After Sapna left, his nurse came in carrying a small envelope.
Her name was Maria.
She had cared for him for three days and had already learned that he liked his tea almost offensively hot.
She placed the envelope beside his water.
“What is this?” he asked.
“A prescription.”
Narayan opened it.
On the front, in large blue letters, were two words:
KEEP STRONG
He laughed.
Then coughed.
“You have terrible handwriting inside.”
“That’s why I’m a nurse and not a calligrapher.”
He read her note.
One day at a time. We are all rooting for you.
Maria adjusted his oxygen tubing.
“I’m off tomorrow. Sunday.”
“Lucky woman.”
“I go to church on Sundays.”
Narayan nodded.
She hesitated.
“If it is okay with you, I’ll light a candle for you.”
He looked at her for a long moment.
Then he touched the card.
“Maria, I have spent most of my life lighting lamps for other people.”
“I know.”
“So yes. Tomorrow, you light your candle.”
She smiled.
“And I too will light my Diya (lamp).”
“For yourself?”
He shook his head.
“For you.”
Maria’s eyes filled before she could stop them.
“Well,” she said, clearing her throat, “then I suppose we’re both covered.”
MSK HOSPITAL, NEW YORK | Late November — Early December
Sunday passed.
Then Monday.
The steroids began to work.
Narayan needed less oxygen.
By Wednesday, he could walk to the door and back.
By Friday, he completed an entire circuit of the corridor with Naina on one side and Maria on the other.
“Do not become sentimental,” he warned them. “I am only walking.”
“You’re impossible,” Naina said.
“No. Apparently I am resectable.”
Maria burst out laughing.
Even Sapna, standing at the nurses’ station, had to turn away.
MSK HOSPITAL, NEW YORK | December
Surgery was postponed until Narayan’s lungs had recovered.
Three weeks later, Dr. Biswas reviewed the new scans.
The inflammatory changes were receding.
The tumor remained substantially smaller.
He pointed at the monitor.
“I think we go.”
Sapna nodded.
“How much surgery?”
“Right upper lobectomy should do it. Nodes as planned.”
“No pneumonectomy?”
“I don’t think so.”
Sapna studied the scan.
“So the neoadjuvant therapy did what we hoped.”
“It certainly seems to have helped.”
Biswas leaned back.
“You know what the family will call this if pathology is clean.”
“Don’t say it.”
“Miracle.”
“We don’t use that word.”
“You don’t.”
“And neither do you in my clinic.”
He grinned.
“Then let’s wait for pathology.”
The operation lasted several hours.
Naina spent every one of them walking between the waiting room and a window overlooking Manhattan.
Narayan’s prayer beads were wrapped around her wrist.
When Dr. Biswas finally appeared in surgical scrubs, she stood so quickly that her chair tipped backward.
“He’s okay,” he said first.
She closed her eyes.
“The operation went as planned. We removed the upper lobe and the lymph nodes we needed.”
“And the cancer?”
“We send everything to pathology.”
“So you don’t know?”
“I know what I saw.”
He smiled gently.
“Now I want to know what the microscope sees.”
Naina nodded.
She had become extremely tired of microscopes.
MSK HOSPITAL, NEW YORK | Wednesday, December 24 — Christmas Eve
Six days later, Narayan was sitting upright in bed when Dr. Sapna and Dr. Biswas entered together.
Naina noticed immediately.
Doctors arriving together could mean very good news or very bad news.
She stood.
Biswas looked at Narayan.
“The pathology is back.”
Narayan straightened.
“We found no viable cancer cells in the tissue we removed.”
Silence.
Naina blinked.
“What?”
“The area where the tumor had been is still visible. We know where the cancer was. But under the microscope, the specimen and sampled lymph nodes contain no viable tumor.”
Narayan looked from one doctor to the other.
“So the surgery found no living cancer?”
“In the tissue we removed, yes.”
“And that means I am cured?”
Dr. Biswas shook his head.
“It means you had what we call a pathologic complete response. That is an excellent result.”
“But?”
“In oncology there is usually a ‘but.’”
Narayan smiled.
“We still follow you carefully. Scans. Appointments. Surveillance. A remarkable response does not give us permission to promise the future.”
Naina was crying now.
“But this is the best result we could have hoped for?”
Dr. Sapna smiled.
“Yes.”
“A miracle.”
Sapna opened her mouth.
Narayan raised one finger.
“Doctor.”
She stopped.
“Let my daughter have her miracle for one minute.”
Biswas looked at his watch.
“Sixty seconds.”
Naina laughed through her tears and kissed her father’s forehead.
After a moment she whispered:
“So was it Hanuman?”
Narayan looked offended.
“Obviously.”
Sapna folded her arms.
“What about my T cells?”
“Also Hanuman.”
Naina wiped her eyes.
“And my checkpoint?”
Narayan considered this carefully.
“Perhaps Jambavan was working security.”
Even Dr. Biswas laughed.
“Jaaki rahi bhavana jaisi, Prabhu murat dekhi tin taisi.”
We often perceive the same reality through the lens of our own convictions, experiences, and understanding.
MANHATTAN, NEW YORK | Early February
Several weeks later, Manhattan lay under fresh winter snow.
Narayan stood again beside the small prayer table in his daughter’s apartment.
The brass lamp burned quietly.
Beside it stood Maria’s card.
KEEP STRONG.
Naina entered carrying two cups of tea.
“You kept the card.”
“Of course.”
“You also kept your hospital wristband.”
“That is evidence.”
“Of what?”
“That your doctors are extremely expensive.”
She handed him his tea.
For a while they watched the city wake.
Then Naina asked:
“Papa, if someone back home asks you what happened, how will you explain all these treatments?”
Narayan thought.
“Surgery is easy.”
“Go on.”
“You remove what should not be there.”
“Chemotherapy?”
He looked towards her.
“Your bomb.”
Naina laughed.
“A controlled bomb.”
“Very controlled, apparently. It attacks cancer strongly, but innocent neighbors may suffer.”
“Targeted therapy?”
“The smart missile — but only if the enemy has an address you know how to find.”
She nodded.
“And immunotherapy?”
Narayan looked at the little flame.
“That is different.”
“How?”
“Sometimes the body already has warriors capable of fighting.”
Naina waited.
“But the cancer learns how to show them a stop sign.”
“A checkpoint.”
“Yes.”
“And the medicine?”
“It does not always fight the enemy itself.”
Narayan picked up Maria’s card and placed it beside the lamp.
“Sometimes it removes the false stop sign.”
He paused.
“And lets our own defenders do what they already know how to do.”
Outside, traffic had begun filling the avenues.
Inside, a candle had been lit in one faith, a lamp in another, and somewhere between a priest’s Hanuman, a police checkpoint, a smart missile, a surgeon’s plan and a T cell’s molecular signal, several frightening medical words had become a little easier to understand.
Chemotherapy.
Targeted therapy.
Immunotherapy.
And finally —
hope.
READER NOTE
Checkpoint is a fictional story created for patient and caregiver education. Cancer treatment is individualized according to cancer type, stage, molecular testing, overall health, and many other factors. This story is not a substitute for advice from one’s treating medical team.
ACKNOWLEDGEMENTS
With gratitude to Surgeon Commodore and Oncologist Dr. Subhash Ranjan for the clinical inspiration, analogies, and medical review that helped shape this story. Dr. Sapna and Dr. Biswas are fictional characters; Dr. Subhash Ranjan’s likeness is used for Dr. Biswas on the cover with permission. Developed in collaboration with ChatGPT.
Checkpoint • Educational fiction for patients and caregivers
Graphic Summary
