I was hesitant to pick up The Emperor of All Maladies; a quick glance at the dust jacket made me leery that the book would devolve into sickly-sweet sentiment. Cancer is, indeed, a terrible disease, and has wrecked havoc on millions of lives; at the same time, the very nature of this problem lends itself to hysterics and tearful reminiscences. I’m not so vain to think that my writings about my father mean as much to anyone else as they do to me, wonderful though my commenters may have been.
In other words, I feared that book All About Cancer would drift into histrionics and phrases like “The War on Cancer”1, and too many sad stories about individuals that would quick devolve into the incessantly maudlin. Mothers, brothers, sisters, children; all of this we know about cancer, but we know it also about death in general. What’s interesting to me is where cancer comes from, and where science is looking for answers. A skim through the chapters gave me hope, I gave it a try.
The bad news is that the phrase “War on Cancer” occurs almost a hundred times. The good news is that Mukherjee avoids the maudlin and uses personal stories only as frame narratives for what turns out to be a more intellectually-engaging history of oncology (the scientific study of cancer).
Mukherjee points out that cancer is, in a way, the most brutal of afflications if for no other reason that it is the body’s own resources turned against itself. Cancer cells, after all, are mutated cells whose rate of growth is no longer regulated. This torrent of mutated cells is what causes, e.g., tumors. In this respect, cancer seems particularly ignominious… though the same can be said for all autoimmune diseases.
I was surprised just how far back cancer stretches; even early Egyptian records note what is likely an abnormally large tumor. Yet our understanding of the fundamental forces behind such malignancy is a product of the last fifty years, when we came to under the relationships between genes, DNA, and chromosomes. Humanity has tried since its earliest “understanding” of the body, of course; for a long time, Galen’s2 model of bodily humors (i.e. black bile3, yellow bile, blood, and phlegm). Our understanding of cancer, in many ways, paralleled our understanding of the body in general; the first indication that cancer could be both caused by external factors and be studied epidemiologically was Percival Pott’s study of squamous cell scrotal cancer which was common among chimney sweeps in the 1800s (see Chimney Sweeps’ Carcinoma). This simple statistical correlation, regardless of the physical mechanism by which the cancer was created, was, in a sense, the first “treatment” of cancer, as it prompted a series of legislation protecting chimney sweepers to some degree, until the job itself eventually disappeared. Ironically, legislation as a form of treatment is revisited much later in the book, when Mukherjee spends no mean amount of time covering the emergence of lung cancer as an epidemic, and the long (and disgusting history) of tobacco advertisement, corporate and legislative backrubbing, and the various and sundry ways in which the U.S. is still laissez-faire about the marketing and distribution of cigarettes4.
Scrotal cancer and lung cancer are only two types which Mukherjee covers. Of particular note are leukemia and breast cancer; he both begins and ends the book with stories about leukemia, which he considers somehow representative the fundamental nature and challenge of cancer. Early “oncology”, after all, consisted of waiting until a tumor was big enough to notice, and then having a surgeon excise it and all its surrounding tissue. This “radical” surgery (from the Latin for “root”) was the de facto treatment for many years, especially for breast cancer. But of course leukemia had no tumors to excise until perhaps it had metasticized beyond all hope, and it seems only appropriate, then, that the treatment of leukemia spawned the field of chemotherapy; “aminopertin”, a vitamin derivative, was shown to have a beneficial effect in the treatment of certain types of leukemia.So it goes for various types of cancers and various types of treatments; as our knowledge of medicine in general and oncology in particular has grown and matured, so has our approach to the treatment of cancer. Whereas early treatments consisted of radical excision and intermediate treatments consisted of crude chemotherapy (administering undiscriminating cytotoxins, hoping to kill the cancer before killing the patient), later therapies tend to consist of special drugs which target a particular molecular receptor, protein, or vulnerable point of a cancerous mutation’s lifecycle. Relapse rates are still dismal, but are getting better all the time, and are certainly better than fifty years ago. Much of the problem now is that our prolonged lifespans tease out the increased statistical rates of cancer in the elderly (who, by sheer statistical force, are more likely to develop a carcinogenic mutation); it’s no wonder that cancer seems a product of the modern age, since antiquity bore witness to average life expectancies near to our middle age.
But cancer isn’t just about medicine. That’s true in two respects: one, which which Mukherjee mentions at several points but doesn’t dwell upon, is that the (terminal) nature of cancer tends to refocus the effort not on a cure as such, but on palliative and social care. The other (and more practical) respect is that way in which organized cancer awareness and research has required a dedicated body—specifically, the American Cancer Society, which arose out of the effort of the famous socialite Mary Lasker (1900-1994), and was the first (and remains the most visible and viable) major marketing and fundraising agency with respect to cancer. Arguably, the major advances made in the last fifty years would not have been made without the financial support and cultural clout of that organization.
It would be nice if The Emperor of All Maladies could end with an easy declaration of victory over cancer, but it doesn’t. It would also be nice, given our relatively recent discoveries (e.g., Mukherjee cites research up through about 2006) about the protein receptors in certain types of leukemia, if it estimate with some confidence that we’ll have the genes mapped and a suitable pharmacopiæ created within some convenient timeframe. Unfortunately, cancer is not a single disease with a single cause, even if all cancers share the same essential malady; similarly, when the body turns against itself in this way, it seems determined to see its betrayal through to the end. It’s sobering to realize that, in studies of cancer drugs, the elongation of remission by, e.g., a year (not a cure, but a slightly longer pause in active illness) is considered medically important and a victory for chemotherapy. Perhaps what’s so maddening about cancer and all it represents is that it haunts one like spectre; one can never be sure it’s been exorcised completely.
Mukherjee is not the most engaging writer ever to put pen to paper; nor should he be, nor supposes he to be, since his chosen profession is that of an oncologist rather than a popular science writer. Still, he does a bang-up job for all that, at least surpassing my expectations for the book. The Emperor of All Maladies, while perhaps no brilliant cultural exposé on cancer (not that it ever pretended to be), is a wonderful primer on the causes and history of the illness, with some marvelous scientific minutiæ for the patiently pedantic. It is worth it for no other reason than it’s much more insightful, far-reaching, and realistic than one is ever likely to receive in popular media.
- Declaring “War” on a concept is a pet peeve of mine[↩]
- Note: Hippocrates is generally credited with introducing the concept of systematic humorism, but Galen is generally credited with its popularization and longevity in the sphere of medicine. [↩]
- Fun fact: from the Greek melan chole, hence our modern “melancholy”.[↩]
- The giant class-action lawsuit against cigarette companies in the 1990s notwithstanding, since its judgement against said companies, while expensive, also indemnifies them against a wide swath of potential future litigation.[↩]