I also recently plowed through Siddhartha Mukherjee’s
“The Emperor of All Maladies: A Biography of Cancer”.
This is an imposing book. The text runs to 470 pages, and there are
no less than 60 pages of back-notes. It’s quite a lengthy
read.
On the other hand, the reviews I’d read were all effusively
positive, calling it touchingly personal, citing its approachability,
and even using the phrase “page-turner”.
I generally agree with that assessment. It’s very engaging and
readable, deftly melding the author’s first-person experiences in
his oncology residency with interesting stories of man’s early
history with this disease. It goes on to add more depth to
cancer’s more familiar recent narrative and solid insight into the
current state of the art. Although the later chapters tend to rely a bit
more on technical jargon, Mukherjee keeps things moving so that the
reader doesn’t lose interest.
Part of the reason why he undertook this work was because as a
neophyte oncologist, he was so buried in the tactical concerns of
fighting the disease that he was unable to answer his patients’
more strategic-level questions about where we are in the overall battle
and whether the increased attention of recent years has translated to
improvements in prevention, treatment, and outcomes.
Throughout its long course, the book hits on most major forms of
cancer—lung, breast, leukemia, Hodgkin’s Disease—and
several obscure ones. For a time it follows the search for a single root
cause, touching on carcinogenic chemicals like Asbestos and cigarette
smoke as well as the cancers precipitated by viral infections like
HPV.
But if I had to single out the primary theme of the book, however, it
would have to be the hubris of physicians throughout the ages in
misunderstanding and underestimating cancer, as well as overestimating
their ability to cure it with a single, massive intervention.
In Rome, Claudius Galen attributed the disease to an overabundance of
an unknown and unobserved liquid called “black bile”,
setting our understanding of cancer on a wrong track for the following
1500 years.
Next up were the surgeons, whose simplistic answer to recurrent
breast cancer was to cut deeper and deeper, until the standard
preventative practice was to remove the entire breast, the lymph nodes,
the muscles of the chest, the clavicle, several ribs, and part of the
lung. Better to cut too much than too little, right?
As surgery began to give way to chemotherapy in the 1950s, the next
group of oncologists fell for the same old “more is better”
fallacy, prescribing massive doses of multiple drugs, eventually
concluding that the best policy was to completely destroy the
patient’s ability to generate new blood cells, then rebuild it by
transplanting new stem cells (either one’s own, harvested before
treatment, or transfused from a donor).
Even today, with the mapping of the human genome and gene therapy
providing an historical breakthrough in cancer treatment, geneticists
have once again fallen into the same mental trap as Galen did 2000 years
ago, of thinking that this new technology would spell the end of cancer.
Cancer is an incredibly deft, diverse, adaptive, and opportunistic
disease, and its defeat is just not going to be that simple.
Despite all these unfortunate missteps, each generation of treatment
has produced significant improvements in outcomes. Surgery,
chemotherapy, radiation, gene therapy, targeted drugs, and combinations
of these can each be the right treatment for the right patient.
And Mukherjee’s book does do a wonderful job depicting some of
the fortuitous coincidences that led to the discovery of these new
treatments. For example, who knew that a humble jar of Marmite was the
key that unlocked the broad spectrum of chemotherapy drugs that have
saved so many lives?
Aside from the knowledge that cancer was the result of uncontrolled
growth, it wasn’t until the past twenty years that we actually
began to understand exactly how and why cancer works at a cellular and
genetic level. Before 1970, oncologists could only develop treatments by
trial and error. But armed with our new understanding of what cancer is,
researchers can now identify cancer’s specific biochemical
vulnerabilities and start developing therapies such as Herceptin that
precisely target those weaknesses.
In the end, the reader comes away from the book with a much better
understanding of why cancer is so difficult to combat, and that each
person’s instance of cancer is so unique that it requires an
entirely individual treatment.
As a Pan-Mass Challenge rider, I was proud to discover how central
Sidney Farber, the Dana-Farber Cancer Institute, and the Jimmy Fund have
been. They take center stage in much of Mukherjee’s narrative, as
does Mass General, MIT, and the American Cancer Society.
Before I picked up the book, I saw Dr. Mukherjee at an
author talk he gave at the BPL. I took the opportunity to ask him
whether the recent discovery that the human genome is not identical in
every cell had any implications for gene therapy.
Between his response and my readings, it was clear that it
isn’t the human genome that matters so much as the characteristic
modifications cancer makes to it. By designing drugs that recognize and
respond to the unique cancerous fingerprint of a particular genetic
alteration, it is possible to starve tumors or at least deactivate their
growth. The challenge right now is to catalog those fingerprints and
discover drugs that match them.
It’s probably true that you need some curiosity about cancer or
medicine to get through this book. But those with sufficient interest
will find it informative, entertaining, and very readable.