What makes a nemesis? This question comes to mind almost immediately upon reading the title of Siddhartha Mukherjee’s The Emperor of All Maladies: A Biography of Cancer . Mukherjee writes that he “felt, inescapably, as if [he] were writing not about something but someone. ” Primed from the outset to view cancer as a bête noire pursued by clever scientists, I could not help but be reminded of the perpetual cat-and-mouse game between Sherlock Holmes and Professor Moriarty. “The man had hereditary tendencies of the most diabolical kind,” Holmes remarks, he is “the Napoleon of crime.”
It was not long into this engaging chronicle that the analogy (and perhaps the title) felt inapt. “Medicine ... begins with storytelling,” Mukherjee writes. “Patients tell stories to describe illness; doctors tell stories to understand it. Science tells its own story to explain diseases.” If anything, Emperor is less Baker Street detective and more a compendium of these myriad stories in orbit around cancer. The book is organized into six sections, each of which describes some element of our relationship to cancer from beginning to end, sometimes stretching from the dawn of recorded history to the present. As such, the story often loops back onto itself, with episodes repeated and quotations recycled, occasionally evoking a sense of déjà vu. However, some repetition seems unavoidable for a work this ambitious; the tapestry really cannot be fully appreciated without examining the individual threads, which cross each other from time to time.
What is most remarkable about the book is the breadth and depth of these stories. Emperor is about the history of medicine’s relationship with cancer, but it is also about politics, ethics, economics, sociology, philosophy, statistics, molecular biology, and genetics. Mukherjee has a talent for helping the reader to enter those spheres. We meet scientists in their labs and are immersed in thrills of victory and the crush of defeat.
In the folklore of science, there is the often-told story of the moment of discovery: the quickening of the pulse, the spectral luminosity of ordinary facts, the overheated, standstill second when observations crystallize and fall together into patterns, like the pieces of a kaleidoscope. The apple drops from the tree. The man jumps up from a bathtub; the slippery equation balances itself. But there is another moment of discovery – its antithesis – that is rarely recorded: the discovery of failure. It is a moment that a scientist often encounters alone. A patient’s computed tomography scan shows a relapsed lymphoma. A cell once killed by a drug begins to grow back. A child returns to the National Cancer Institute with a headache.
We enter the chemotherapy wards and touch the devastation there through the eyes of Mukherjee’s patients, like Carla, who even on the path to cure “lost her sleep, her hair, and her appetite and then something more important and ineffable – her animus, her drive, her will.” We meet epidemiologists who developed randomized trials and prospective cohort studies. We attend cocktail parties with Mary Lasker (1900–1994), the champion fundraiser for cancer research in the mid-20th century, or travel back to ancient Egypt to meet Atossa, one of the first cancer patients in recorded history. Like the disease itself, Emperor regularly crosses geographical and social boundaries, unexpectedly linking disparate places, people, and times.
Given the prevalence of different forms of cancer, the book will be of interest to anesthesiologists both as medical practitioners and as men and women who will undoubtedly face the disease personally or with loved ones. Understanding medicine’s long relationship with cancer places our patients in an historical context that deepens our appreciation of their victories and suffering. Emperor gives a clear sense of medicine’s accomplishments in treating cancer and, most recently, in learning to provide humane palliation of incurable disease. It also provides an antidote to premature celebration, reminding us that there are still miles to go before we sleep. This book may be especially interesting to anesthesiologists on multiple fronts. Historically, anesthesia was critical in the development of surgical oncology and has played a major role in the implementation of appropriate palliative care. Scientifically, recent publications suggest a relationship between outcomes in treatment of various cancers and the choice of surgical or pain-relieving anesthetic. The link between anesthesia and oncology is crucial to cancer care and grows stronger by the day.
The most satisfying points in the book were the segments describing the development of the “War on Cancer” and the concurrent discovery that smoking leads to lung cancer. Here Mukherjee really shines, weaving disparate elements together to paint a complete picture of how our forebears responded to the disease. He gives us their hypotheses and disagreements, their surgeries and chemotherapies, and their explanations and metaphors. As though viewing a film, we cut to chimney sweeps in London and the discovery that environmental exposures can produce cancer, then flash to the first prospective cohort studies of smoking and their sledgehammer conclusions, then end with the ironic tragedy of metastatic lung cancer enveloping one of that study’s investigators. In these segments, the threads weave around each other most cleanly, producing a gestalt of scientific, medical, and societal attitudes about cancer at different points in its history.
But is Emperor really cancer’s history? What was inapt about the title is that the book felt more like our history than the disease’s. Cancer appears to have been with us since ancient times, its form changing little. Yet, as improvements in our lifespan unmasked the disease, we have responded to it, and it is this story that Mukherjee tells. Early in the 20th century, when cancer was cast as an execrable foe, patients became a lonely farmhouse on a great battlefield; we blasted them with chemotherapy, radical surgery, and radiation. But when the artillery had gone silent, the farmhouse was often wrecked and the “enemy” returned to the field with even greater ferocity. How? In his Nobel Prize acceptance speech, scientist and current National Cancer Institute director Harold Varmus, M.D., noted that the biology of cancer reveals the “cancer cell to be, like Grendel, a distorted version of our normal selves.” What makes cancer so fearful and evocative, Mukherjee writes, is that it is “our desperate, malevolent, contemporary doppelganger ... it exploits the very features that make us successful as a species.”
Much of the book focuses on valiant efforts from all quadrants of society to “defeat” cancer. Fittingly, though, the tale concludes in the present day, with a dying patient named Germaine. Mukherjee echoes lessons learned from Vivian Bearing, Ph.D., when he notes that the “War on Cancer may best be ‘won’ by redefining victory.” As the study of oncology matures and departs its “fiery adolescence, entrance[d] with universal solutions and radical cures,”The Emperor of All Maladies will serve as a guidepost to physicians, researchers, patients, and anyone else with an interest in cancer. In leaving us seated there, at Germaine’s bedside, Emperor reveals its greatest treasure: a sense that death is not a loss or a failure, but rather the only unequivocal fact of human existence, and that strength and dignity is found there. On this no additional research need be conducted.
Northwestern University Feinberg School of Medicine, Chicago, Illinois. pdt@fsm.northwestern.edu
