The Emperor of All Maladies is a billed as a biography of cancer and author Siddhartha Mukherjee treats his subject with all the reverence of a living subject.
“Cancer cells grow faster, adapt better,” he writes. “They are better versions of ourselves.”
In this sweeping, Pulitzer Prize-winning epic of inner-space the former Massachusetts General Hospital fellow and professor of medicine at Columbia University traces our endless fight with cancer that, mirroring the disease itself, is constantly shifting in its tactics and goals, full of stalemates, breakthroughs and mutations.
The book charts the genesis of the modern cocktail of cancer-specific drugs as they emerged from a ghastly forge of medical experimentation over several centuries. When a tradition of localized surgery to excise tumors — without modern antiseptics and often resulting in death — proved an insufficient cure, William Halsted, a 19th century American surgeon who pioneered the use of cocaine as an analgesic (and subsequently became famously addicted to it) launched what amounted to a near-religious faith in the purgative effects of radical surgery. In an attempt to once and for all extirpate the scourge of breast cancers, Mr. Halsted pushed the limits of the mastectomy, removing chest muscles, lymph nodes and sometimes even the collarbones of young women whom he was nonetheless “loath to disfigure.” Of course, Mr. Halsted knew nothing about the body-wide implications of metastasis and as radical surgery was revealed as largely ineffectual butchery, a new, equally destructive “cure” in cancer treatment would come to take its place in the 20th century.
Chemotherapy, which began with great promise in the leukemia wards of Children’s Hospital in Boston, would reach its potential long before its practitioners would recognize it. Dr. Mukherjee documents the stubborness of a medical community that strained the limits of reason throughout the 1960s and 1970s prescribing increasingly lethal doses of chemicals to, in effect, kill both the cancer and the patient before trying to coax the latter back from the brink. With a disease that so closely mimics, even mocks, the biology of its hosts, the blunt axe of chemotherapy, administered in fiercer and fiercer blows, was the oncologist’s only tool for much of the last half century.
The book’s final act, when Dr. Mukherjee patiently explains the new 21st century landscape of gene-based cancer treatment, threatens to devolve into a jargon-filled treatise understandable only to specialists of the author’s rank. But somehow he manages to render the world of kinase inhibitors, phosphorylation and endogenous oncogenes in a stirring and comprehensible narrative of progress, still beat back by the disease’s ceaseless invention and fecundity. This final section is the most hopeful as Dr. Mukherjee documents researchers’ growing ability to understand the genetic “grammar” of cancer and he points to a new generation of drugs that could specifically target the wayward cells.
Dr. Mukherjee does not forget to pan out from the cellular level and renders in heartbreaking relief the all-consuming, myopic sense of isolation of patients locked in mortal combat with the disease, and the sterile inhuman world of the cancer ward.
The book is also a meditation on the hazy, undefined borders of medical ethics. From doctors, presumably armed with good intentions, putting hopeless patients through increasingly poisonous regimens to the exigencies of clinical trials which require half their patients to forego possibly life-saving new drugs for placebos, Dr. Mukherjee offers a nonjudgmental bird’s-eye view of human actors put in unimaginable moral and professional straits.
The dreaded disease, once posited by Galen to be the result of “black bile,” it turns out was never one disease and will never be conquerable by the universal cure envisioned by oncology pioneer Sidney Farber or socialite-activist Mary Lasker when they persuaded Richard Nixon to launch the national War on Cancer in 1971. The story is filled with medicinal dead ends, misguided idealogues and, most heartbreakingly, countless patients sacrificed for scientific discovery.
Dr. Mukherjee often describes the disease in lyrical terms, as a formidable adversary that may never tire of our “War.” It is, he writes, imbued with “the animus, so inextricably human, to outwit, to outlive and survive.” A “disease on a quest for immortality” ingeniously circumventing and perverting the body’s own defenses and thwarting, through relentless mutation, even our own most technologically-sophisticated attacks.
“Perhaps cancer defines the inherent outer limit of our survival,” Dr. Mukherjee muses. “As our cells divide and our bodies age, and as mutations accumulate inexorably upon mutations, cancer might well be the final terminus in our development as organisms.”