November 10th, 2024
A BIOGRAPHY OF A MOST COMPLEX EMPEROR, a book review by Jim Vogele
THE EMPEROR OF ALL MALADIES, a Biography of Cancer, Siddhartha Mukherjee (Publisher: Scribner, a Division of Simon & Schuster, Inc.) (2010) ISBN 978-1-4391-0795-9
A book review by Jim Vogele
INTRODUCTION
Like many families, mine has confronted the emperor of all maladies. Thus, I was initially apprehensive about reading a book – indeed a biography of sorts – about cancer. Nonetheless, I saw that the New York Times Book Review had named THE EMPEROR OF ALL MALADIES one of the Top 10 Books of 2010 and that The New Yorker, NPR, The Economist, Kirkus Reviews and others had also named the book one of the Best Books of 2010. Based on those commendations, I decided to read the book.
Or, more aptly, I decided I would attempt to do so: The book is a semi-daunting 470 pages of text along with another 100 pages of Notes, Bibliography, and Index. It is also filled with discussion of angiogenesis, deoxyribonucleic acid (aka DNA), glioblastomas, hematopoietic stem cells, pathological hyperplasia as induced by oncogenes, and genetic mutation as a mechanism of carcinogenesis. The words suggest a certain inscrutability to the non-doctor, non-scientist, physician contract lawyer such as myself.
But sure enough, as the blurbs on the cover promised, THE EMPEROR OF ALL MALADIES is eminently readable, indeed praiseworthy, and I found the perusal to be rewarding and educational, and only slightly laborious as the Mukherjee is a strong and fluid writer. The book covers the history of cancer, its treatment options over the course of that history, and the monumental efforts to research, understand, and develop surgical, pharmaceutical, and preventive approaches to the emperor of all maladies.
Siddhartha Mukherjee is a storyteller and he emphasizes how all cancer patients – indeed all patients – are storytellers. How else could patients obtain their hoped-for treatments or healing protocols if they do not tell their stories? And oftentimes the body itself and tests conducted will confirm the complete story. Happy endings abound, as do the tragic and sad.
Mukherjee’s excellent insight is that cancer itself has a story to tell, indeed is worthy of a full-blown, magnificently detailed biography. And telling that story requires the inspiration and discipline of a conscientious storyteller like Mukherjee. And lest hyperbole takes control when I say “magnificently detailed,” keep in mind that Mukherjee, in an interview included with the Scribner volume I read (the interview was originally published in February 2011 in OncNurse magazine) noted that in the year prior to that interview, “more than 100,000 journal articles were published on cancer.” And the NHS estimates that 1 in 2 people worldwide will develop cancer at some point during their lifetime. This is all just a reminder that “magnificently-detailed” is a relative concept applied to the vastly complex and widespread phenomenon that is cancer.
THE BOOK
In 1847, the term “leukemia” was coined by a German researcher, Rudolf Virchow, from leukos which means white in Greek. Just 10 years earlier, the cell theory had developed, with Theodor Schwann and Matthias Schweiden announcing that all living organisms were built out of cells, a ground-breaking proposition indeed. (although not mentioned in Mukherjee’s book, cells were first discovered nearly two centuries earlier, in 1665, by Robert Hooke, with the aid of the microscope which appears to have been invented in the 1590s).
As Mukherjee says:
“Even an ancient monster needs a name. To name an illness is to describe a certain condition of suffering – a literary act before it becomes a medical one. A patient, long before he becomes the subject of medical scrutiny, is, at first, simply a storyteller, a narrator of suffering – a traveler who has visited the kingdom of the ill. To relieve an illness, one must begin, then, by unburdening its story.”
For a cheat sheet’ on the earliest (and ancient) historical detection and eventual treatments, or sorts, for cancer through the 18th century, see:
https://canceratlas.cancer.org/history-cancer/
A century after Rudolf Virchow bestowed a name upon “leukemia,” Dr. Sydney Farber was experimenting with the pharmaceutical treatment of childhood leukemia, while the development of penicillin around the same time in the 1940s heralded a burgeoning of drugs. Indeed, half of the common drugs in 1950 had been unknown just 10 years before. But in December 1947, as Mukherjee explains, when Farber tore open a package filled with “glass vials of chemicals, he scarcely realized that he was throwing open an entirely new way of thinking about cancer.”
Mukherjee is particularly adept at sketching the milieu of dingy or dark work spaces where early cancer researchers labored; with space seemingly allocated on a whatever no one is using or wants to use basis. Farber’s space is an example:
“In a damp fourteen-by-twenty-foot laboratory in Boston on a December morning in 1947, a man named Sidney Farber waited impatiently for the arrival of a parcel from New York. The ‘laboratory’ was little more than a chemist’s closet, a poorly ventilated room buried in a half-basement of the Children’s Hospital, almost thrust into its back alley. . . . Farber outfitted a back room of a ward near the bathrooms into a makeshift clinic. His small staff was housed in various unused spaces in the Department of Pathology – in back rooms, stairwell shafts, and empty offices. Institutional support was minimal. Farber’s assistants sharpened their own bone marrow needles, a practice as antiquated as a surgeon whetting his knives on a wheel.”
Mukherjee is also effective in portraying the ebb and flow of treatment strategies for cancer as our understanding expanded concerning the large group of diseases that make up “cancer.” This insight, that cancer is not a single disease but rather a plethora of ailments that can originate in virtually all organs, cells, tissues is key; and, ultimately, is distressing because there is no magic key to unlock a treasure chest and reveal a ‘cure’ of treatment; much as we would wish it were so, cancer is a challenge far too complicated for a single key to ever provide a solution.
THE EMPEROR OF ALL MALADIES is excellent in sketching the innovations in treatment – radical surgery (the “allure and glamour of radical surgery . . .”) and the advent of x-rays (the “ability of X-rays to selectively kill rapidly dividing cells did not go unnoticed – especially by cancer researchers.”).
And, of course, the drugs that finally lead to positive responses, such as when the first metastasized solid tumor responded to chemotherapy. Then more and more drugs were developed, with their development particularly benefiting from the introduction, in the 1940s as proposed by the English statistician, Bradford Hill, of “randomized” testing: “For medical scientists, the randomized trial became the most stringent means to evaluate the efficacy of any intervention in the most unbiased manner.”
Then, in the second half of the 20th century, the funding began to flow, and not without all of the complications, strings, and unintended consequences that often accompany money – even in an arena where the better good for all humanity is at stake. It’s complicated, again, as one might imagine, and Mukherjee does not suggest otherwise. The funding saga is a story well told through one of its most important figures, Mary Lasker (with the support of her husband, Albert Lasker, an extremely successful and innovating advertising executive as President of Lord and Thomas in Chicago):
“ ‘If a toothpaste . . . deserved advertising at the rate of two or three or four million dollars a year,’ Mary Lasker reasoned, ‘then research against diseases maiming and crippling people in the United States and in the rest of the world deserved hundreds of millions of dollars.’ Within just a few years, she transferred, as Business Week once put it, into ‘the fairy godmother of medical research.
The ‘fairy godmother’ blew into the world of cancer research one morning with the force of an unexpected typhoon. In April 1943, Mary Lasker visited the office of Dr. Clarence Cook Little, the director of the American Society for the Control of Cancer in New York. Lasker was interested in finding out what exactly his society was doing to advance cancer research, and how her foundation could help. . . .
In five years, Mary Lasker had raised the cancer society from the dead. Her ‘shorter-range pressure group’ was working in full force. The Laskerites now had their long-range target: Congress. If they could obtain federal backing for a War on Cancer, then the scale and scope of their campaign would be astronomically multiplied.”
And so it was, particularly when Lasker and Sydney Farber teamed up in a collaboration for the good of the world which lasted for decades. For example, after America’s historic moon landing on July 20, 1969, four months later a full-page epistolary ad appeared in the Washington Post which began: “Mr. Nixon: You can cure cancer . . . .”
* * *
In a recent conversation with a neighbor who has published numerous books over the course of several decades, I mentioned reading THE EMPEROR OF ALL MALADIES. I told him it was a great book and that my few quibbles were minor issues of style, e.g. noting the use of the word “launched” twice in the same sentence or use of “exquisitely” on successive pages. Or the use of “surcharged” in two different instances when it certainly would appear that “supercharged” was the intended word.
See? Minor quibbles. My neighbor observed that publishers simply don’t rely upon copy editors as they did in the past.
But Mukherjee’s book absolutely shines on the important stuff. For example, as he explains:
“Cancer is an expansionist disease; it invades through tissues, sets up colonies in hostile landscapes, seeking ‘sanctuary’ in one organ and then immigrating to another. It lives desperately, inventively, fiercely, territorially, cannily, and defensively – at times, as if teaching us how to survive. To confront cancer is to encounter a parallel species, one perhaps more adapted to survival than even we are.
This image – of cancer as our desperate, malevolent, contemporary doppelganger – is so haunting because it is at least partly true. A cancer cell is an astonishing perversion of the normal cell. Cancer is a phenomenally successful invader and colonizer in part because it exploits the very features that make us successful as a species or as an organism.”
That is haunting stuff. Indeed, excerpting the passage here inspired me to search online: Is there any good cancer? By this I mean that is ‘good for you’? Of course there is not; cancer is a disease; among the results, however, were discussions of the ‘friendliest’ cancer or most treatable, e.g. thyroid disease. For a discussion of the downside to such labeling, see:
https://www.fredhutch.org/en/news/center-news/2016/11/good-cancer-views-vary-on-sunny-phrase.html
Ultimately, Mukherjee piercingly and expressly embraces the “notion of cancer as an affliction that belongs paradigmatically to the twentieth century” as reminiscent of Susan Sontag’s analogizing, in Illness as Metaphor, of cancer to tuberculosis: “Both diseases, as Sontag pointedly noted, were similarly ‘obscene – in the original meaning of that word: ill-omened, abominable, repugnant to the senses.’ Both drain vitality; both stretch out the encounter with death; in both cases, dying , even more than death, defines the illness.”
And while the analogy holds water, they are not the same:
“But despite such parallels, tuberculosis belongs to another century. TB (0r consumption) was Victorian romanticism brought to its pathological expreme – febrile, unrelenting, breathless, and obsessive. It was a disease of poets: John Keats involuting silently toward death in a small room overlooking the Spanish Steps in Rome, or Byron, an obsessive romantic, who fantasized about dying of the disease to impress his mistresses.”
Adding Thoreau and Thomas Mann’s The Magic Mountain, as Mukherjee does, and I am thankful for the Romantic Poetry course I had in my English Lit major (Mann is not a Romantic poet, but I agree that The Magic Mountain is just the right novel to invoke in THE EMPEROR OF ALL MALADIES).
Besides the surgeries, radical and otherwise, the radiation and the drugs, the other pillar of the battle against cancer is, of course, prevention. Tobacco is the grim and the ultimately hopeful poster child of prevention possibilities (and speaking of poster children, consider the sad, sad story of chimney sweeps in England, of which the book reminds us, including the terrible incidence of cancer in the young sweeps – only in 1788 did Parliament pass the Chimney Sweepers Act preventing the engagement of children under the age of eight to work in the filthy, sooty chimneys).
As Part Four of THE EMPEROR OF ALL MALADIES is named, “Prevention is the Cure,” Mukherjee spends a solid chunk of pages on the important topic of prevention. As the Harvard biologist, John Cairns, explained: “[T]he only intervention ever known to reduce the aggregate mortality for a disease – any disease – at a population level was prevention. Even if other measures were chosen to evaluate our progress against cancer, Bailar argued that it was indubitably true that prevention, as a strategy, had been neglected by the NCI in its ever-manic pursuit of cures.”
The revelations in the field of cancer research, science, treatment, and prevention keep coming, as you might expect, as the book surveys in ‘biographical’ fashion the story of cancer. Consider, for example, the multivariate nature of the disease, which Mukherjee illustrates with a quote from Richard Klausner, the director of the NCI:
“ ‘Cancer,’ is, in truth, a variety of diseases. Viewing it as a single disease that will yield to a single approach is no more logical than viewing neuropsychiatric disease as a single entity that will respond to one strategy. It is unlikely that we will soon see a ‘magic bullet’ for the treatment of cancer. But it is just as unlikely that there will be a magic bullet of prevention or early detection that will knock out the full spectrum of cancers . . . We are making progress. Although we also have a long way to go, it is facile to claim that the pace of favorable trends in mortality reflects poor policies or mistaken priorities.”
I slowed the pace of my reading in the latter portion of the book, to better follow the discussion of cells and genes, and, again, on these topics Mukherjee includes passages that shine a light on the subjects, providing some clarity to the non-scientists among us, such as myself. One such passage to sum the discoveries based on genetics and genes:
“‘Positive’ genes such as arc, are mutant activated versions of normal cellular genes. In normal cells, these genes accelerate cell division, but only when the cell receives an appropriate growth signal. In their mutant form, these genes are driven into perpetual hyperactivity, unleashing cell division beyond control. An activated proto-oncogene, to use Bishop’s analogy, is a ‘jammed accelerator’ in a car. A cell with such a jammed accelerator careens down the path of cell division, unable to cease mitosis, dividing and dividing again relentlessly
‘Negative’ genes, such as Rb, suppress cell division. In normal cells, the anti-oncogenes, or tumor suppressor genes, provide the ‘brakes’ to cellular proliferation, shutting down cell division when the cell receives appropriate signals. In cancer cells, these brakes have been inactivated by mutations. In cells with missing brakes, to use Bishop’s analogy again, the ‘stop’ signals for mitosis can no longer be registered. Again, the cell divides and keeps dividing, defying all signals to stop.”
CONCLUSION
In a book of this scope and sheer length and density, there is so much to appreciate that it’s hard to know where to start. For this reader, as a physician contract review lawyer, I always appreciate any insight into the medical profession and its practitioners. Physicians and the medical students they were before – or as you may be right now yourself – are smart. That’s a fact. But as I’ve noted elsewhere, individuals who are drawn to the profession are often multi-talented and in many instances likely could have seen success and fulfillment by making contributions in a wide variety of fields. In referring to Viennese surgeon Theodor Billroth, Mukherjee notes, “Billroth studied music and surgery with almost equal verve. (The professions still often go hand in hand. Both push manual skill to its limit; both mature with practice and age; both depend on immediacy, precision, and opposable thumbs.”
Well, as someone who has just recently benefited in a major way from those opposable thumbs, along with practice and precision, employed by an orthopedic surgeon and surgical team, count me as thankful for both and all of the above. I began this review by noting my own family’s enounters (multiple, unfortunately) with the emperor of all maladies. Not to be maudlin, at a time when it appears that over 40% of Americans may be expected to develop cancer in their lifetimes, but I also have deep gratitude for the practitioners, the researchers, scientists, physicians and everyone involved, who contribute to treatments for cancer. My thankfulness is without bounds. I know there are many frustrations in the practice and in the experiences of patients receiving medical care. Just as there are in the legal profession, I will note. We all know about them. But let’s also be thankful for what we have as well as aspire for improvements.
The writing in this website often tries to answer the question of: Why should I have an attorney review my physician employment contract? And that is the focus and subject of this website. But as mentioned above and as I’ve discussed elsewhere, I will always be thankful that so many of you make the sacrifices toward studying and striving to master the various disciplines of medicine and healthcare that you do – the training is arduous and not always for the faint of heart. Speaking as one of them, however, I am happy to report that your patients appreciate you and the work you do.
I believe that what THE EMPEROR OF ALL MALADIES illuminates most brightly, for me, is the aspiration for a better world, for better health and happiness for all of us. Rather than finding myself more or less afraid of the emperor of all maladies, reading this book has given me a more mature understanding of both the disease cancer and of medicine itself.
