Inverarity (inverarity) wrote,

Book Review: The Emperor of All Maladies, by Siddhartha Mukherjee

The so-called "biography" of cancer documents our successes and failures against the beast.

The Emperor of All Maladies

Scribner, 2010, 592 pages

Written by cancer physician, researcher, and award-winning science writer Siddhartha Mukherjee, The Emperor of All Maladies is a stunning combination of medical history, cutting-edge science, and narrative journalism that transforms our understanding of cancer and much of the world around us. Mukherjee examines cancer with a cellular biologist's precision, a novelist's richness of detail, a historian's range, and a biographer's passion. The story of cancer is one of human ingenuity, resilience, and perseverance, but also of hubris, arrogance, paternalism, and misperception, all leveraged against a disease that, just decades ago, was thought to be easily vanquished in an all-out "war against cancer." It's a story of science and scientists, of centuries of discoveries, of setbacks and victories and deaths, told through the eyes of Mukherjee's predecessors and peers, training their wits against an infinitely resourceful adversary.

From the Persian Queen Atossa, who instructed her Greek slave to cut off her malignant breast, to the radical surgeries of the 19th century, to the first recipients of primitive radiation and chemotherapy, to Mukherjee's own leukemia patient, Carla, The Emperor of All Maladies is a story of people---and their families---who soldier through toxic, bruising, and draining regimens to survive and to increase the store of human knowledge.

Riveting and magisterial, The Emperor of All Maladies provides a fascinating glimpse into the future of cancer treatments and offers a bold new perspective on the way doctors, scientists, philosophers, and lay people have observed and understood the human body for millennia.

What is it about cancer that makes it "the emperor of all maladies"? The fact that until recently, it was nearly always fatal? And more often than not, inflicts a really ugly death? Or the insidious nature of it, the enemy within, your own body's cells run amok?

The author draws an interesting comparison between the horror movies of the 50s, which were mostly alien invasions, monsters from space or deep underwater, threatening apocalypse from beyond as a metaphor for cold war fears, and the horror movies of the 60s and 70s, when cancer came into the spotlight, which tended to be more about internal threats, mutants, and bodily horror. I am not sure I buy his metaphors or his timeline, but it did illustrate what people were relatively more afraid of.

The Emperor of All Maladies won the 2011 Pulitzer Prize for non-fiction. It is a combination history and science book, by a research oncologist who mixes his own cases into a comprehensive study of cancer as it has been studied for thousands of years.

One of the things I had always wondered about was whether cancer has been around as long as we think it has. Given that we now know many cancers are caused by the prevalence of modern artifacts — chemicals, industrial pollutants, radiation, and of course, cigarettes (really just a subset of the first category), have people always been dying of lung cancer, for example? And testicular cancer and breast cancer and all the other places in the body that can sprout cancer (which is basically everywhere).

The answer is yes, but of course in earlier eras people would just die without "cancer" necessarily being identified. And carcinogens were less common, but most importantly, cancer is more common now because more people are still alive with cancer — either surviving with it still in their body, or being "cured" (which is to say, put in remission since cancer is a tricky beast and it's hard to say anyone is ever fully "cured"), whereas until modern medicine began developing treatments that occasionally worked, cancer was usually something that simply killed you, usually soon after you realized you were sick.

Mukherjee documents the earliest cases of cancer, identified by the ancient Egyptians, then blamed by Hippocrates on "black bile," and a growing understanding of the disease as the earliest surgeons tried to cut it out (and found that this usually doesn't work). We didn't really start understanding what cancer is until we had the science to study cell biology, and genetics, and the greatest successes against it came when someone had the idea of poisoning the toxic cells — chemotherapy. A nasty cure that can be literally worse than the disease, but often the only thing that does work. Radiation came a little later, and now there are some promising gene therapies.

But, cancer is not one disease, a point Mukherjee makes repeatedly. Finding a drug cocktail that is effective against one particular type of cancer often does nothing for any of the others. There will never be a magic bullet that "cures cancer." There will just be more and more cancers that get shifted from the "Nearly always fatal" column to the "Usually survivable" column.

Besides covering the grim history of surgical, chemical, and radiation treatments, Mukherjee also spends a couple of chapters on cigarettes and the war on tobacco companies, of course. He also draws parallels between cancer research and AIDS research. Both diseases are often treated with chemo, both have provoked bitter battles over medical ethics (people with terminal illnesses, hearing that some laboratory has an experimental drug that might be a cure, of course want to be guinea pigs, and it's been a long, evolving road to develop suitable protocols to balance science, ethics, and compassionate care, all complicated in America by the insurance industry). Both are diseases that were once pretty much a death sentence, and now are, in many cases, diseases that never go away, but can be managed with treatment and life extended to the point that they are more like chronic illnesses than terminal ones.

Not always, of course. There are cancers like testicular and Hodgkin's that have a very high remission rate, when caught early, but there are also a lot of cancers that are still killing hundreds of thousands every year. (And plenty of people still die of testicular and Hodgkin's lymphoma.)

The Emperor of All Maladies is quite readable, but it is thick, with Mukherjee documenting all his research and diving deep into DNA, RNA, cellular biology, and biochemistry. It's a book for laymen, but laymen with a fairly good grasp of, and serious interest in, science. I found Mukherjee's writing style engaging if a bit portentous, as befits a book about cancer, a doctor trying hard to write a big important but popular book. He mostly succeeds, and anyone who has an interest in the topic — whether academic or for more personal reasons (most of us will know someone with cancer if we do not experience it ourselves) — will find this a good starting point.

Rating: 8/10.

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Tags: books, non-fiction, reviews, science

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