The Emperor of All Maladies- A Biography of Cancer
by Siddhartha Mukherjee
By the end of our lives, one in two American men and one in three women will be afflicted by cancer. An estimated 600,000 people died here last year from the disease and about 7 million worldwide. Sometimes we can prevent it by eating well and avoiding known carcinogens, such as cigarettes. But most often, cancer is written into our genetic coding, an unwelcome guest in our DNA waiting to grow out of control and kill us.
When Siddhartha Mukherjee began The Emperor of All Maladies- A Biography of Cancer, he was training in cancer medicine at the Dana-Farber Cancer Institute in Boston, looking for a way to channel the soul-numbing days filled with facing people wasting away from cancer, consoling those struck ill by chemotherapy, sorting through the morass of different drugs he had in his armamentarium. So, he began this book, but rather than make it a cut-and-dry history of cancer, he decided to create a “biography,” a way “to understand its personality, to demystify its behavior.” Although many sections in Emperor do read like a straight telling of the race to cure cancer, Mukherjee does succeed in writing an accessible and thorough book about a sickness that may soon replace heart disease as the country’s primary killer.
Cancer may have reared its head throughout early history but the disease did not have a name until about 400 BC when the term karkinos first appeared, the Greek word for “crab.” Yet, this term was limited to tumors visible to eye, the surface malignancies that grew in the breast, neck, skin and eyes. More appropriate is the Greek word onkos, the word where oncology was born. It means a “load” or a “burden,” something that describes the disease on both a psychical and philosophical level. As Mukherjee goes on to explain, the stigma of cancer is a burden, even in modern society. If you are stricken with cancer, it becomes your world, trips to the doctor and the horrible routines of chemotherapy replacing anything that once gave you joy.
But despite its appearance in ancient medical writing, scientists did not understand cancer’s nature until they understood cells themselves in the early 19th century. Once they established that every living thing was made up of cells, early researchers realized that cancer came from a mutation in a cell that began to replicate out of control, a tiny section of our bodies growing out of concord with the rest.
I do not want to give the impression that Emperor is a chronological history of cancer because Mukherjee does not structure the book in that manner. Instead, he begins with the biography of Sidney Farber, a Boston pathologist who became interested in lethal forms of pediatric leukemia. Desperate to stop this disease that killed perfectly healthy children in a matter of weeks, Farber experimented with new drugs that sent the cancer into remission for a spell before exploding back in a more lethal form. Unwilling to give up, Farber began the Jimmy Fund, the first national push for funding to stop cancer, even enlisting celebrities such as the Boston Braves. But Farber would discover a key ally in socialite Mary Lasker, who helped him raise awareness for the cause, eventually pushing President Richard Nixon to enact the National Cancer Act in 1971.
But throughout most of history, doctors had no clear idea how to treat cancer or even what caused it. In the late 1800s, radical mastectomy appeared to be the only cure for breast cancer, a disfiguring procedure that not only cut away the malignant breast, but all the nearby lymph nodes, the ribs, the pectoral muscles and part of the neck. And let’s not forget the 1950s when the ex-GIs smoked cigarettes with abandon, a habit they passed on to their wives. Almost half of the American population smoked at that time. It is hard to imagine that there was a time when people did not know that smoking caused lung cancer. I often wonder if we’re in a similar state today with our addiction to cellular telephones.
Mukherjee’s book is a history of successes punctuated with multiple failures. When doctors discover a drug or treatment appears to cure cancer, the disease would often respond and find a way to survive. “If we seek immortality, then so, too, in a rather perverse sense, does the cancer cell,” he writes. Nothing is more heartrending than the cases Mukherjee describes of those who thought they beat the disease, only to have it come raging back in a more malignant form.
Mukherjee is at his most comfortable when recounting the evolution of our understanding of cancer and the arsenal of drugs doctors have tried against it. He does interlace the science with brief vignettes of patients he has treated, but despite their devastating respite from the science, he cannot quite weave these narratives in without appearing somewhat out of place. Perhaps it was his attempt to humanize his biography of a disease (his successful treatment of a seemingly doomed leukemia patient frames the entire book), but these sections appear suddenly and are somewhat jarring.
Cancer is a grim subject and spending close to 500 pages with it can be terrifying. But if we take a step back from our own mortality and look at not only the disease, but the progress we have made to combat it, Emperor of All Maladies is a fascinating work of pure science. Mukherjee states that mortality in numerous types of cancers has dropped 15% in the last 15 years. Researchers are learning more and more about genetics and finding ways to treat many malignancies. He ends the book with Atossa, a Persian queen from 500 BC who charged a slave to slice off her malignant breast. Mukherjee casts Atossa through different stages in our history, discussing her chances of survival until he lands in 2050 where a thumb drive will contain the entire sequence of her cancer’s genome, a cocktail of drugs almost guaranteeing her survival. Optimistic, but tempered with sobering news: if Atossa had pancreatic or gallbladder cancer her chances of survival are not much better now than 500 BC.
Mukherjee begins the book with a quote from Susan Sontag where she explains that “illness is the night-side of life,” that everyone holds a “dual citizenship in the kingdom of the well and in the kingdom of the sick.” It is Mukherjee’s hope that more and more people can be brought back from that second kingdom.
by David Harris