The Emperor of All Maladies is not a history of cancer. It’s a biography of a monster. What Siddhartha Mukherjee conveys in The Emperor of All Maladies is that cancer is a living, breathing, adapting, and insatiable illness. Mukherjee meticulously records every human attempt to make this monster extinct, all of them failures in their ultimate goal. But it doesn’t mean we haven’t made progress.
Mukherjee, for all his scientific intellect, is ultimately a caring physician. He starts with a personal story that carries on throughout the book. A patient of his, a young mother, is diagnosed with a rare and serious form of leukemia, cancer of the blood. Mukherjee does a great job of bringing his readers back to people. The story of cancer can’t be conveyed without a respect for all the people that it has affected. This is, after all, why we care so much about a cure.
Readers learn that cancer has been around, well, probably forever. Cancer was written about as far back as 1600 BC, when an Egyptian doctor noted how he treats cancer. The answer? He doesn’t. Nothing works. Amazingly, over 3,500 years later, this is still basically true for some cancers. The famous ancient Greek physician Hippocrates treated cancer based on the theory of bodily “humors” (fluids), which remained popular until the 19th century.
German zoologist Theodor Boveri was the first to suggest a genetic mechanism for cancer in 1902. He proposed that mutations in chromosomes could create a cell incapable of limiting growth, and that these mutations could be passed down from generation to generation. Boveri also correctly speculated that radiation could be a cause of these mutations.
Theodor Boveri. Image: Wikipedia
Ironically, around this time radiation was also discovered to be the first non-surgical cancer treatment. The dangers of scientific innovation are apparent in the lives of the discoverers, Marie and Pierre Curie. The whole Curie family suffered from their exposure to radiation, and Marie Curie died of anemia as a result of radiation. But their sacrifice set off a new era of cancer treatment that would eventually lead to the discovery of chemotherapy.
Until this time, surgeons had become embroiled in a dangerous race to cut out more and more tissue in cancer patients in order to prevent cancer recurrence. Unfortunately, the cancer kept coming back, but the patients’ removed body parts did not. Even when it was becoming clear that procedures, such as the radical mastectomy for breast cancer, were not working, surgeons stubbornly continued with the practice.
Marie Curie. Image: Encyclopedia Britannica
This was not the only time in the history of oncology where the egos of physicians and scientists were put ahead of the needs of the patients. After chemotherapy was discovered, oncologists pushed it too hard, giving larger and larger doses, and making patients sicker and sicker. This “kill the cancer at all costs” treatment strategy wasn’t quite my experience with my wife, Julia’s treatment. Julia did have two very intense surgeries, and I still wonder if these surgeries did more harm than good. But Julia never regretted having those surgeries and believed that they gave her more life. But I know there are patients to whom undue harm definitely was done in treatment. I can understand why physicians would go too far through a combination of wanting to do everything for the patient, and wanting the glory from saving a life. But as Mukherjee himself warns, this is something for which we constantly need to be holding our doctors accountable.
Chemotherapy was discovered thanks to the characteristics of one specific type of cancer: leukemia. Because leukemia is in the blood, the presence of cancer cells can be easily measured; just extract some blood and count the number of cancer cells. So it’s easy to see if a treatment has decreased the amount of cancer in leukemia patients. It’s also easy to experiment with new treatments because researchers can simply take blood, mix in some cocktail of chemical agents, and see what it does to the cancer cells (hopefully bad things) and the normal cells (hopefully less-bad things). Researchers found that there were chemicals that the human body could tolerate but also did significant damage to some cancer cells. However, the promise of chemotherapy was never quite fulfilled. There was a limit to how much the body could handle, and the body usually gave out before the cancer did.
After the much-hoped-for cure was not realized with chemotherapy there was a new push for prevention. The field of epidemiology was born and some ingenious new tactics were developed to find causes of cancer. This led to to the famous “British Doctors’ Study”, a cohort study published in 1956, which conclusively established the link between smoking and cancer.
Dr. Mukherjee goes on to chronicle the “War on Cancer”, signed into law by Richard Nixon in 1971. After America put a man on the moon in 1969, there was an immense optimism that if they could do that, curing a disease should be easy! One of the discoverers of chemotherapy, Sidney Farber, led the charge in rallying the public to lend their money and resources to make cancer extinct. Hundreds of billions of dollars have been devoted to this war.
Image: thepsychologyofcancer.com
How much territory have we taken on cancer since war was declared? In the US since 1950, adjusted for size and age of the population, the death rate for flu and pneumonia has dropped 58%. For heart disease it’s decreased 64%. For cancer?
5%.
Not good. At least not compared to other diseases. But cancer is not like other diseases. It’s the Goliath – the Emperor – of all diseases. This quote from Mukherjee, explains why:
“Indeed, cancer’s emergence in the world is the product of a double negative: it becomes common only when all other killers themselves have been killed.”
A common misconception is that cancer is a “new” disease because more people are dying of it than they did “back in the day”. But this is only because the diseases that used to kill people before they could get cancer are not killing them anymore. That’s the good news. The bad news is that now they live long enough to get killed by cancer instead. Most diseases have been no match for our thousands of years of medical innovation. But again, cancer is not most diseases.
Another quote from Mukherjee, referencing a famous novel, encapsulates one of the main messages of the book:
“In Lewis Carroll’s Through the Looking-Glass, the Red Queen tells Alice that the world keeps shifting so quickly under her feet that she has to keep running just to keep her position. This is our predicament with cancer: we are forced to keep running merely to keep still.”
Every time we’ve thrown some new treatment at cancer, it has pulled a Muhammad Ali rope-a-dope. This is the living, breathing, adapting part of cancer. It is always evading – mutating, metastasizing, looking for new places in which to thrive – and frustrating our attempts to discover its fundamental nature.
Almost always.
Like I said at the outset, despite all of these failures there are still a few reasons for optimism. Advances in technology have prolonged lives. Due to the introduction of one type of drug, tyrosine kinase inhibitors, Chronic Myeloid Leukemia patients’ average survival after diagnosis has increased from about 3 years to about 30 years.
The human genome is now fully mapped, and the entire cancer genome is in the process of being mapped. This is leading to therapies targeted to the genetic signature of each patient’s cancer. New advances in immunotherapy are leading to treatments where our own immune system is “trained” to attack and kill the cancer (I have a friend for whom this has worked well, even if the treatment almost killed her).
We can still taste victory in the war on cancer. But as Mukherjee cautions, “This war on cancer may best be ‘won’ by redefining victory.”