DURING THE SUMMER OF 1947, in a Dorchester three-decker so close to the Franklin Park Zoo that the wind sometimes carried the trumpet of an elephant, a small boy fell ill. His body grew warmer and his skin paled. He refused food, and still he threw up, and – most alarming in a 2-year-old – he became lethargic.
Robert Sandler’s illness was even more evident because his identical twin, Elliot, remained as robust as ever. In late August, Robert was admitted to Children’s Hospital, where doctors examined his body, X-rayed his bones, and drew his blood. They found that his lymph nodes, spleen, and liver were swollen. His blood, teeming with immature white blood cells, confirmed a dreaded diagnosis: acute leukemia.
Then, children with leukemia always died, usually after only a few weeks or months. Doctors could ease some of the symptoms, boost their patients’ low red blood cell counts with transfusions, and fight infections with the new wonder drug, penicillin. But even the most accomplished doctors were powerless to fight these armies of rogue white blood cells. There was no medicine to cure leukemia.
Rather than getting sent home to die, as many patients were at the time, Robert was seen by Dr. Sidney Farber, a 44-year-old researcher at Children’s and the son of an immigrant from Buffalo. Farber’s earlier work had suggested that folic acid hastened the progress of leukemia. Now the doctor was eager to test a revolutionary idea that didn’t yet have a name: using drugs to fight cancer itself. Farber asked Robert’s parents to bring him to the hospital’s Tumor Therapy Clinic so he could receive injections of a new treatment, a synthetic chemical that worked against folic acid.
For two months, on every day but Sunday, Robert’s mother, Helen, took him from their apartment above a pharmacy to the hospital for treatment. If no one could look after Elliot, she took him, too. Elliot, now 66, remembers his mother pushing him and his brother in a double baby carriage to the trolley that went past their building at the busy corner of Blue Hill Avenue and Seaver Street. They would transfer to the subway, where Helen always tried to maneuver the boys into the front seat so they could be distracted by the dark tunnel before them.
Elliot still has sharp memories of the hospital ward. He remembers the stomach-curdling smells – vomit, blood, ether – and the squeak of gurneys and the giant wheels on the wooden wheelchairs. “I remember one time when Robert was admitted, I went up with him because he didn’t want to be alone,” Elliot says. “He was in a lot of pain.”
Still, despite Farber’s injections, Robert’s leukemia grew worse. He began to limp, and he lost weight. By late December, his small body bruised and his gums bleeding, Robert could no longer walk. He seemed near death.
But Farber, who later founded the research center that became Dana-Farber Cancer Institute, had a new antifolate to test. On December 28, he began injecting Robert with a drug called aminopterin. This time, the boy’s improvement seemed miraculous. By mid-January 1948, Robert was walking for the first time in two months. His bleeding had stopped, and his appetite turned ravenous. In another few months, Farber would write in The New England Journal of Medicine, Robert’s “activity, alertness and nutrition are equal to or better than those of the well twin.”
Robert’s family thought he was cured. Pictures of Robert and Elliot, both looking healthy, appeared in local newspapers as proof of victory against leukemia. But the celebration was short-lived. Robert had only been in remission, and after a few months, he grew sick again. One night in 1949, the Sandlers called an ambulance for their ill boy, as they had done many times before. Elliot remembers watching the crew help his brother from their apartment. He never saw Robert again.
Elliot can still see the black coat his mother was wearing in his grandmother’s living room when she and his father, Solomon, returned from the hospital. Helen Sandler stood by the window, crying. “He’s gone,” she said over and over. “He’s gone.”
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WHEN ROBERT died in April 1949, Elliot became, in the language of psychologists, a “twinless twin.” Researchers believe that losing a twin, even as early as at birth, has a profound influence on the survivor. And Elliot, like many survivors, wondered again and again through the years: Why did Robert die and he did not? If their DNA was nearly identical, how could the arc of their lives have been so dramatically uneven? For more than six decades, survivor’s guilt plagued Elliot.
“I’ve often said to my wife, and my kids as well: ‘I don’t understand. Why him and not me?’ ” Elliot said last month, sitting at his kitchen table in Readfield, Maine, his voice wavering and his eyes filling.
His answer finally came last year, after Dr. Siddhartha Mukherjee, an oncologist, became fascinated with Robert’s story. Mukherjee knew what the Sandlers did not: Robert’s place in medical history was monumental. He was one of the first children with acute leukemia to go into remission. Those successes, although temporary, persuaded Farber to continue his work developing the treatment that would later be called chemotherapy.
Mukherjee, a former postdoctoral fellow at Dana-Farber Cancer Institute and staff member at Massachusetts General Hospital, had an emotional connection with the boy described in Farber’s journal article only as R.S. At the time he read about him, while researching a book he was writing about cancer, one of Mukherjee’s children was the same age.
“So I had a very visceral reaction to this child,” Mukherjee, now at Columbia University Medical Center, said just after his book, The Emperor of All Maladies: A Biography of Cancer, was published last year. “I became obsessed with trying to find the name of the child and trying to find out any detail of his life.”
First he needed the boy’s full name, but the records he scoured used only initials. He discovered the key to Robert’s identity 8,000 miles from Boston, on a visit to India. On a whim, Mukherjee decided to track down a biographer of Dr. Yellapragada SubbaRow, the biochemist at Lederle Laboratories in New York who had collaborated with Farber. SubbaRow, born in India, had discovered how to synthesize aminopterin and had shipped it to Farber for his trials. SubbaRow’s biographer, S.P.K. Gupta, had not only a roster with the full names of Farber’s patients in the trial, Mukherjee said, but also a 1948 newspaper photo of Robert, Elliot, and their mother.
When Mukherjee returned to the United States, he used a city directory to track down the Sandlers’ address from the 1940s. But no one in the Dorchester neighborhood knew anything about the Sandlers.
The Emperor of All Maladies won the Pulitzer Prize for general nonfiction in April. Mukherjee dedicated his book “To Robert Sandler . . . and to those who came before and after him.”
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Elliot Sandler was pushing a cart around Sam’s Club in Augusta, Maine, last November when his cellphone rang. It was Mukherjee. A day or two earlier, Elliot had gotten a phone call from a cousin who had seen a Globe Magazine interview with Mukherjee that mentioned Robert. Elliot called his family. One of his daughters – he has four grown children – got in touch with Mukherjee’s publisher, Simon & Schuster.
Mukherjee told Elliot he had been looking for him for years. (The Sandlers had moved to Stoughton shortly after Robert died. Robert and Elliot’s father died in 1978. ) A few months after they spoke on the phone, Mukherjee and Elliot, both full of questions, met in New York for a joint appearance on CNN and went to dinner at an Italian restaurant.
Elliot, who runs a video production business, told Mukherjee how little his family knew about Robert’s role in the development of chemotherapy. They knew only that he had received a new treatment. In their minds, the medicine was a failure because it didn’t keep him alive. “My mother and I had no idea of the part that Robert had played in any of this,” Elliot says. “We simply didn’t know.”
His death weighed heavily on all of them. Elliot’s mother, Helen, wondered whether Farber had helped Robert. Doctors had not requested her consent for the study, since it took place before the Nuremberg Code of medical ethics – prompted by barbaric Nazi experiments on concentration camp prisoners – began to guide human trials.
About eight years ago, in an oral history project recorded by her granddaughter, Helen paused as she flipped through a photo album and came to a young Robert. “That’s my bad memories of losing my son after having him declared cured because they used him as a guinea pig,” she said.
Helen, who will turn 90 this week, had agonized about her decision to allow the hospital to perform an autopsy on her son, then a violation of her Jewish faith’s prohibition against desecrating dead bodies. But the doctors at Children’s had told her that the autopsy would greatly help their research, and she relented.
Elliot, too, held close the pain of his brother’s death. In early black-and-white pictures of Robert and Elliot, the boys look like duplicates, eyes gazing in the same direction, expressions almost identical. Their mother dressed them alike, in trousers with suspenders, bow ties, and black-and-white oxfords or in dark winter coats. In each photo, Helen scrawled the boys’ names in ink, so no one would forget who was who.
“Very rarely would he talk about” Robert, says Susan Sandler, Elliot’s wife. “I think it was just too painful.”
Elliot mourned what might have been if Robert had lived. “I had a pretty decent musical career, and I often wondered, would he have been as talented as I turned out to be?” Sandler asks. “Or more so? Would we have been a team? Would we have played the same thing, liked the same things? What about gals? Who knows? All question marks that will never be answered, but you can’t help thinking about it.”
Talking to Mukherjee, whom Elliot calls “Dr. Sid,” eased his own internal struggle. Mukherjee explained to him how one twin could get leukemia and the other not. “It was a cell in his system that went crazy, and mine didn’t,” Elliot says. “Go figure.”
The simple explanation was enough to assuage decades of guilt. “It’s just been an amazing journey,” Elliot says. “It really has. The meeting with Dr. Sid and the conversation about why [Robert] and not me lifted 62 years of weight.”
Judith Inman, Elliot’s younger sister, was born after Robert died, but she was well acquainted with the aura of sadness surrounding his death. Her family rarely spoke of him, she says, partly emblematic of a time when people didn’t openly discuss their problems.
Although Helen Sandler has declined to speak publicly about Robert and the book, she, too, has been comforted by the knowledge of Robert’s role in medical history, her daughter says. “It was so fulfilling for her to hear that there was some good that came from that, that it was the right thing to do,” Inman says.
The pain of losing a son has never left. Helen is haunted by the way Robert once gazed at her, silently following her around the hospital room with his eyes, Inman says. “And that was the last time she saw him.”
Nearly a year after he first learned about his brother’s place in history, Elliot still can’t help thinking, “What if?” As he read Mukherjee’s book and learned about the promise of Robert’s chemotherapy, he wondered whether his twin might have lived longer if the doctors had extended his treatment.
“But they didn’t know,” he says. “It was the beginning of the beginning.”