The Emperor of All Maladies
Author: Siddhartha Mukarjee

Background

This book is an exhaustive and detailed account of cancer, and of the endless battles waged by its victims, scientists, philanthropists, and leading health institutions to combat it. It is a graphic portrayal of the chilling impact of a disorder which the author describes as ‘an expansionist disease’ which ‘exploits the very features which make us successful as a species or as an organism’, and as a ‘pathology of excess‘ which ‘asphyxiates us by filling our bodies with too many cells’. The author’s depiction of cancer graphically conveyed its aggressiveness, such as when he referred to leukaemia as ‘cancer in one if it’s most explosive, violent incarnations…terrifying to experience, terrifying to observe, and terrifying to treat’. The book also evokes the fundamental paradox of cancer cells being both alien and indigenous, a point it illustrated rather ironically when it depicted cancer cells as ‘our desperate, malevolent, contemporary doppelganger‘ which, ‘down to their innate molecular core’ are ‘hyperactive, survival-endowed, scrappy, fecund, inventive copies of ourselves‘. The ominous and oppressive atmosphere of cancer was evident throughout the book, a sense which the author captured most eloquently when he portrayed it as the ‘the leaden counterweight to our aspirations for immortality‘. A book with many perspectives, it is on one hand ‘a story of inventiveness, resilience, and perseverance‘, but on the other, it is ‘a story of hubris, arrogance, paternalism, misperception, false hope, and hype‘ (pages 7, 3, 466, 388 and 38).

Synopsis

At the heart of any discourse on cancer is the tricky question of causation, an issue complicated by the existence of different types of cancer and the almost endless list of its risk factors. The author approached this theme by focusing on the more established association of cigarette smoking and lung cancer, and he justified this emphasis with his experience of witnessing ‘the range and depth of devastation…that could be directly attributed to cigarette smoking’. Noting a contradiction in the fact that cigarettes – ‘one of the most potent and common carcinogens known to humans’ – are freely available ‘at every corner store for a few dollars’, the author rebuked the tobacco industry for denying the role smoking plays in causing cancer, and the politicians who were ‘far more protective of the narrow interests of tobacco than of the broad interest of public health‘. Beyond cigarette smoking and lung cancer, the book also explored other definitive cancer associations such as estrogens and breast cancer; testosterone and prostate cancer, and chimney soot and scrotal cancer. The book also reviewed the history of several other carcinogens such as asbestos, diethylstilbesterol, hepatitis B virus, and helicobacter pylori (pages 274-285, 210-217, 237-239).

The author dedicated a substantial portion of the book to the evolution of cancer chemotherapy. In recounting this enlightening history, he recalled the emergence of nitrogen mustard – first used as a chemical warfare agent in the two World Wars –  after its potential as an anti-cancer agent was recognised by Edward and Helen Krumbhaar, Louis Goodman, and Alfred Gilman; they had observed that it ‘scorched‘ its victims bone marrows thereby ‘depleting’ them of their white blood cells. Other historical accounts of cancer chemotherapy in the book included the botanical origins of many early chemotherapy agents such as vincristine, cisplatin, and etoposide; and the development of more novel agents such as trans-retinoic acid for acute promyelocytic leukaemia; herception (trastuzumab) for Her-2 positive breast cancer; and gleevec (imatinib) for chronic myeloid leukaemia. Likening chemotherapists to ‘lunatic cartographers‘ who ‘frantically drew and redrew their strategies to annihilate cancer’, the author explained that the constant drive to develop new drugs is to overcome drug resistance; in this respect, he remarked that the ‘predicament with cancer’ is that ‘we are forced to keep running merely to keep still‘ (pages 89-90, 139, 203, 206-208, 407-443).

The history of surgery for cancer was also an important subject the book addressed with interesting anecdotes. One person who stood out prominently in this account – famously for his immense contributions to general surgery, and infamously for his wildly misguided approach to the surgical treatment of breast cancer – was William Halsted. Describing his strategy for treating cancer, the author said Halsted ‘attacked breast cancer with relentless energy‘ because he would ‘rather evacuate the entire contents of the body than be faced with cancer recurrences‘. The author maintained that Halsted’s ever-expanding concept of radical mastectomy lacked any evidence of efficacy because survival from breast cancer ‘had little to do with how extensively a surgeon operated on the breast’ but on ‘how extensively the cancer had spread before surgery’. However, the author pointed out that Halsted’s misguided approach held sway for decades until Jerzy Neyman and Ehon Pearson used the power to statistical analysis to show its inefficacy, with the result that ‘when radical surgery fell, an entire culture of surgery thus collapsed with it’. The book also depicted earlier surgical approaches to cancer, such as that of Ambroise Pare who was ‘charring tumors with a soldering iron heated on coals, or chemically searing them with a paste of sulphur acid‘ (pages 60-69, 197-201, and 40-49).

The book’s comprehensive account of the pioneers of the modern treatment approaches to cancer prominently featured Stanley Farber, the paediatric pathologist who radically transformed the treatment of childhood leukaemia. The book chronicled  Farber’s long and persistent quest to treat the blood disorder, from his initial failed efforts with folate, through to his first success with the anti-folate agent aminopterin. Faber’s influence however extended beyond the laboratory and into public advocacy, being a key actor in launching a national war on cancer and becoming the poster child for cancer cure. The book particularly highlighted his critical alliance with Mary Lasker, the ‘gracious, wealthy, and enterprising’ socialite who, ‘on a search for her own philanthropic cause‘, found in Farber ‘a scientific strategist‘. Other prominent pioneers of cancer treatment the book memorialised included Henry Kaplan, ‘the most dogged, the most methodical, and the most single-minded’ physician to study people with Hodgkin’s lymphoma, and Oscar Auerbach who demonstrated that cancer is ‘a disease unfolded slowly in time’ and ‘it did not run, but rather slouched to it’s birth’. Other trailblazers in the history of cancer the book highlighted were Arthur Walpole and Dora Richardson who developed drugs such as tamoxifen; George Papanicolaou who innovated the Pap smear cervical cancer screening test; and Albert Salomon and Robert Egan who established mammography (pages 19, 101, 29-36, 94-114, 158-162, 259, 210-217, and 286-302).

In contrast to the brutal nature of cancer is the book’s sensitive and compassionate account of its victims, an approach that suited the author’s stated goal of making the book as much ‘the story of patients who struggle and survive, moving from one embankment of illness to another’. In documenting the lives of those afflicted by cancer, the author conveyed many of the sterling qualities that enabled them to confront the disorder. In this vein, he praised their resilience, inventiveness, and survivorship, noting that these are reflected qualities which emanate ‘from those who struggle with illness and only then mirrored by those who treat them’. It is in this spirit that he narrated the cancer survival story of Ben Orman, whose Hodgkin’s lymphoma had presented as a neck lump which turned out to be ‘merely the tip of a much deeper iceberg of lumps’; of Beatrice Sorenson, whose pancreatic cancer ‘had grown right through all the treatments’, and ‘shrugged the new drug off – instead mockingly sending a shower of metastases into her liver’; of Steve Harmon who ‘soldiered through chemotherapy as if caught in a mythical punishment cycle devised by the Greeks’; of Germaine, who ‘fought cancer obsessively, cannily, desperately, fiercely, madly, brilliantly, and zealously’; and of Carla whose leukaemia had pushed her to ‘the edge of a physiological abyss‘, and whose aggressive treatment pushed her even ‘deeper into the abyss’ before it could rescue her (pages 148-154, 305, 470 and 18).

Opinion

This is a fast-paced and extensively researched biography of the plague that is cancer. In charting the historical course of this scourge, the author, a haematologist, also painted the portraits of the passionate and dedicated actors who have aided our understanding of the beast, and led the fight to tame it. With unimpeachable prose – one of the best in medical writing – this book more than achieved its goal of tracking the history of a truly menacing and dehumanising disorder. Although the prose is suffused with a plethora of descriptive adjectives, this somehow worked well in the context of cancer. The book however overemphasised some forms of cancer, such as leukaemia, over others, such as brain tumours; this may be a reflection of the author’s specialty background, but it may also just be the inevitable outcome of attempting to cover such a disparate group of diseases under one umbrella. 

Overall assessment

This book is a lengthy but enlightening read which presents a magisterial sweep of a gripping medical history which is delivered with excellent prose. The author is a veritable wordsmith, and with pleasant narrative, he engages the reader from the start. The book exhaustively covers a wide range of cancers, and it provides the relevant historical contexts. The book is relevant to all doctors and healthcare practitioners who frequently encounter cancer in one form or the other in their practice, and I emphatically recommend it to all doctors.

Book details

Publisher, Place, Year: Fourth Estate , London, 2011
Number of parts: 6
Number of pages: 571
ISBN: 978-0-00-725092-9
Star rating: 5
Price: £10.55