The Emperor of All Maladies: A Biography of Cancer
- Annotated by:
Carter, III, Albert Howard
- Alternative Medicine
- Chronic Illness/Chronic Disease
- Cross-Cultural Issues
- Death and Dying
- Disease and Health
- Doctor-Patient Relationship
- Genetic Engineering
- History of Medicine
- History of Science
- Human Worth
- Illness and the Family
- Medical Research
- Medical Testing
- Narrative as Method
- Physician Experience
- Psycho-social Medicine
- Public Health
- Date of entry: Dec-23-2011
- Last revised: Dec-20-2011
This is a huge and wonderful book about cancer, the collection of diseases that sickens people all over the globe and kills many of them. An epigraph to the book states, “A quarter of all American deaths, and about 15 percent of all deaths worldwide, will be attributed to cancer,” but the book also describes medical advances that now heal, prevent, or palliate most forms of cancer.
Mukherjee, a cancer physician and researcher, has several strong themes. He sees cancer as an affliction with a long history, a story worthy of a biography; indeed recent discoveries show it to be rooted in our genes (although external factors such as viruses, asbestos, and tobacco smoke can cause genetic disruption). The story of cancer implies a surrounding triangle, the stories of sick people, treating physicians, and biological researchers, all of which Mukherjee artfully weaves across 472 pages. Cancer has Rohrschach blot qualities: depending on time, place, and role in life, humans have perceived different attributes of cancer. As the book ends, however, there is a coalescence of scientific understanding that is satisfying—although there is certainly more to be learned and we are all still vulnerable to genetic errors and, of course, we are intractably mortal.
Another strand is the nature of stories themselves, their twists and turns, presumed early solutions, and personal and social values embedded in them. Mukherjee threads throughout the book the case of a contemporary kindergarten teacher, Carla Reed, who has a leukemia. He bookends his text with ancient Persian Queen Atossa with (presumably) breast cancer. Reed, healed by the end of the book, was Mukherjee’s patient; Atossa was described by Herodotus: both suffered emotional turmoil because of their disease. Mukherjee understands the affective dimensions of disease for patients and caregivers alike; literature represents these in various ways, and he quotes in his chapter epigraphs and in his prose many writers who describe human experience deeply: Aleksandr Solzhenitsyn , Susan Sontag , Charles Dickens , Thomas Mann , William Carlos Williams , Carlo Levi , and Italo Calvino, to name a few.
The primary story, however, is the interplay of cancer and a large cast of observers, investigators, doctors, scientists, activists, and government officials. Sidney Farber and Mary Lasker dominate the first 100 pages with their two-decade war against cancer. While surgery—historically dramatic and disfiguring—had been a mainstay for treatment of cancer, Farber pursued a biochemical route, which elaborated into chemotherapy, the second major approach of the late 20th century.
Mukherjee also explains ancient views, Hippocrates’, Galen’s humors, Vasealius’ anatomy, Hunter’s stages, Lister’s antisepsis, and Röntgen’s X-rays, which became the third major approach. By 1980, however, the American “War on Cancer” had not been won.
Further advances in cellular biology and genetics would be needed to make targeted molecular therapy possible. Mukherjee tells this complicated story clearly and engagingly, showing the human investigators to be personable and dogged in their pursuits.
Another important approach is prevention. The biostatistical work of Doll and Hill, for example, showed the links between tobacco and lung cancer. Screening, such as Pap smears and mammograms, also saved lives, but the basic cellular understanding still eluded investigators.
The final 150 pages explain the search for and discovery of genetic factors, specifically oncogenes. Harold Varmus and J. Michael Bishop were the leaders, winning a Nobel Prize in 1989. Bert Vogelstein, Judah Folkman, Robert Weinberg and Douglas Hanahan took the work further, opening the doors for such drugs as Herceptin, Gleevec, and Avastin.
This is a valuable book for many reasons. Mukherjee can draw on several roles: a physician who treats cancer patients, a researcher who understands (and can clearly explain) the complexities of experiments, and a writer who creates engaging prose and who constructs a well organized and deeply researched volume. The book is a pleasure to read for all these reasons and more. There are two dozen photographs, acknowledgments that reveal extensive background work, some 60 pages of notes, a glossary, and a 25-page index.
Perhaps the strongest appeal is a pervasive empathy for people working to understand cancer as well as for people who have the disease. Mukherjee criticizes simplistic notions of a single cure for cancer or a “war” that would conquer it; he understands that humans are more likely to have cancer as they age and that genetic errors (some of which cause cancer) are a fact of cellular reproduction: “Cancer, we have discovered, is stitched into our genome” (p. 462). Death in old age is inevitable, but Mukherjee sees hope for modern medicine: “if cancer deaths can be prevented before old age, if the terrifying game of treatment, resistance, recurrence and more treatment can be stretched out longer and longer, then it will transform the way we imagine this ancient illness” (pp. 462-63).
Is cancer the “emperor of all maladies?” The title, in all of its euphony and Latinate grandeur, is certainly arresting. (One website says that Mukherjee found it written on the frontispiece of an antiquarian book.) It fits well with his opening epigraph from Susan Sontag about the “kingdoms” of the sick and the well, but I wonder about such attributions of royalty to states of health or disease. We may ennoble cancer as a regal character worthy of a biography, but in the end it is still a cellular disease that functions without human wisdom. It seems to me that the heroic figures of the book are, rather, the doctors, the researchers, the patients, the involved family members, and the writer Mukherjee himself.