Medicine begins with storytelling. Patients tell stories to describe illness; doctors tell stories to understand it. Science tells its own stories to explain diseases. The story of one cancer's genesis – of carcinogens causing mutations in internal genes, unleashing cascading pathways in cells that then cycle through mutation, selection, and survival – represents the most cogent outline we have of cancer's birth.The Emperor of All Maladies is a book of stories: author and cancer physician/researcher Siddhartha Mukherjee states that his intention with this book was to write the “biography” of cancer, and to achieve this, he looks back to the earliest account of the disease (found on a forty-five-hundred-year-old Egyptian papyrus), traces the standards of care for the afflicted through the millenia, and along the way, provides biographies for the cancer physicians/researchers who sought “the” cure, and intermittently, shares the details of his own patients' battles. This is a lot of information, and while I appreciate the ambition of Mukherjee's project, it didn't quite synthesise into a cohesive whole for me. Sometimes dull and frequently overwritten, I also found much fascinating in this book and am happy to have picked it up.
Normal cells are identically normal; malignant cells become unhappily malignant in unique ways.As I noted recently when I reviewed Mukherjee's The Gene, I was interested in reading Emperor in order to have information to combat those conspiracy theorists who blithely aver that “they” have found the cure for cancer and are suppressing it “for profit”. If nothing else, this book makes it clear that cancer is no one thing (other than out-of-control cell growth, various cancers present in wildly different ways), with no one cause (we learn of the HP virus that causes cervical cancer, the environmental origin of mesothelioma, the dizzying variety of genetic and environmental factors that can trigger breast cancers), and no one cure applies to every case. It was interesting to learn of the evolution of cancer cures – from surgery to radiation to chemotherapy to today's gene-targeting medicines – and that a combination of these techniques still makes for best practises. Learning the stories of the people who dedicated their professional lives to the development of these techniques – researchers who often succumbed to cancer themselves – it's impossible to imagine that any of them, rushing to make advances and being the first to publish results, would be capable of suppressing “the” cure under orders from some mysterious “they”; research builds upon previous research in such a way that even if one lab is somehow gagged, another will eventually make the same links.
As for the researchers, these were some of my favourites: Andreas Vesalius – the sixteenth century anatomist who made the first thorough study of the human body and failed to find the “black bile” that Galen had imagined as the cause for cancer in ancient Rome, and which physicians had accepted as fact for centuries; Sidney Farber – the researcher turned clinician who essentially invented chemotherapy to battle childhood leukemia (and I know that Mukherjee wanted me to be equally interested in Mary Lasker – the socialite who partnered with Farber to push for national funding for the “War on Cancer” – but her story felt peripheral to me); Barry Marshall – so convinced that stomach cancer is caused by an infection that he created a broth of the bacteria from a patient's stomach, drank it, and gave himself a precancerous ulcer (which was then cured with antibiotics; which is today's standard of care in early stage stomach cancer); Cecily Saunders – the British physician who created the field of palliative medicine in response to the terminal patients who weren't of much interest to those oncologists who were fighting only for victories in the war on cancer; George Crile – who fought back against the idea of the radical mastectomy as the only cure for breast cancer (and the related stories of generations of surgeons removing ever more muscle and bone during mastectomies to prevent relapse, those same generations of women who helplessly submitted themselves to the scalpels and advice of their well-intentioned doctors, and the link between the rise in political feminism and the birth of medical feminism, The fact that one of the most common and most disfiguring operations performed on women's bodies had never been formally tested in a trial stood out as even more starkly disturbing to a new generation of women).
I was fascinated by how so many specific cures were invented through the back door, as it were – “Hey, I've incidentally created an antifolate in the lab, anybody need that?” “Over here!” – and as we have only recently been mapping the human genome, the future of gene-targeting cures sounds exciting (and especially as there are apparently all of these synthesised molecules awaiting a purpose). For example: In 1993, researcher Brian Druker (with others) isolated a transgenic molecule – a chemical kinase inhibitor derived from sea bacteria, of all things – that would turn off the cancer causing mutation in CML (a rare form of leukemia), but when the astonishing results were presented to the executives of the drug company where he worked, they weren't excited to spend 100-200 million dollars on years of clinical trials for the benefit of the few thousand Americans afflicted with CML each year. Eventually, the company allowed Druker to do a very small scale trial, and as patient after patient went quickly into complete remission – and as the dawn of the internet chatroom alerted other sufferers to the existence of this miracle treatment – “Gleevec” rapidly made the jump to market, where it is today considered the cure. (And perhaps not incidentally, people with CML need to be on Gleevec for the rest of their lives to remain cancer-free, so in this case, “the cure for cancer” is certainly in a drug company's best long-term interest.)
So, much was interesting, but in a long book, I grew to resent those parts that weren't so interesting (for me anyway): there could have been less about the missteps and deadends in cancer research; the battle with tobacco companies to acknowledge their contribution to lung cancer is well known and unnecessary (and covered at length here); the drawn out history of funding for (American) cancer research didn't pique my interest; and while I understand the connection between the AIDS activists of the 1980's and later terminal cancer patients – people on the brink of death shouldn't be forced to wait for a decade of safety trials before being offered a new medicine; they are more than willing to be the trial if it offers any hope at all – the foray into AIDS felt off-topic. Mukherjee certainly has a talent for explaining science to the layperson, but with his jumps forward and backwards in time, I'd say he has less skill with putting it all in historical perspective (I had to keep doing this for myself, “Ah, he's talking about the Fifties again, when this research was going on over there and this political pressure was affecting things here”.) And he frequently overwrites the prosey bits: when I'm concentrating to follow the science, I don't want to be slowed down by trying to parse out, “Women wrote to their surgeons in admiration and awe, begging them not to spare their surgical extirpations, as if surgery were an anagogical ritual that would simultaneously rid them of cancer and uplift them into health”.
Ultimately, I do understand cancer better now – its history, its variety, its methods and weaknesses – and I do believe I have what I need to combat the conspiracy theorists; so mission accomplished. As for the future of cancer, this thought was sobering:
Perhaps cancer, the scrappy, fecund, invasive, adaptable twin to our own scrappy, fecund, invasive, adaptable cells and genes, is impossible to disconnect from our bodies. Perhaps cancer defines the inherent outer limit of our survival. As our cells divide and our bodies age, and as mutations accumulate inexorably upon mutations, cancer might well be the final terminus in our development as organisms.We're all going to die of something. And as the population ages – having (in the West) mostly eliminated the historic midlife killers like cholera, typhus and tuberculosis – we're more and more likely to die of some form of cancer; even if that cancer is controllable and our deaths are delayed by decades, some novel mutation in our aging cells will likely make us vulnerable to some other form. I can make peace with that knowledge and am glad to have read the book that taught me this.
