The Emperor of all Maladies – A Biography of Cancer

The Emperor of All Maladies by Dr. Siddhartha Mukherjee

The year was 1994. The scene was the Johns Hopkins Hospital Oncology ward. I was on call for the 2^nd week as an intern accepting admissions to the Solid Tumor Service. The fellow in Oncology asked me to journey to the dark basement where the Emergency Department was located to evaluate a patient. It turned out this patient was being turned down by the general medicine ward because he had laryngeal cancer (throat cancer). He had not followed up for care, and in fact, he had turned down treatment of his tumor for reasons unknown. Currently he could not swallow and could barely speak. He was dying, and his family did not want him to die at home.

As the intern on call that night, I admitted him because he had no place else to go, and he needed comfort and care. He was not being admitted so he could improve, or that we would give him chemotherapy or radiation, unlike most of the patients on our ward. While I asked his wife questions, she suddenly said, “This is my best friend in the whole world since we were 16. What am I going to do without him?” She could not finish talking without sobbing. This revelation touched me deeply and made me realize how little of people’s lives we actually see at the hospital. It also reinforced how important it was to care for patients as best we could, even if they were not always compliant. It turns out that night, I signed 6 death certificates. I learned what it was like to mourn for people I didn’t know and to try to comfort families in significant grief.

During that month on the Cancer Service, I realized I could not be an oncologist. But it made me appreciate the patients and the physicians who grapple with cancer every day. So when the book Emperor of All Maladies was published, and I saw it prominently displayed at the public library, I had to read it. I hope you will consider reading it as well, since it turns what could be a very dry topic into an incredibly engaging narrative of the history of cancer from the beginning of human history to the current age. Do not be daunted by the length of the book. It reads quickly, like a collection of interwoven stories.

The subtitle is The Biography of Cancer, and what a well written biography it is! Dr. Mukherjee recounts the history of how cancer treatment, prevention, and research evolved by using patient vignettes as well as stories of researchers. We all know that we treat cancer with surgery, chemotherapy and radiation. But how did those treatments start? And how have they changed over the history of humankind? Readers learn that World War I mustard gas gave rise to modern chemotherapeutic agents. The author also tackles the difficulties of screening for cancer and does a wonderful job of explaining, using statistics, why it is so difficult to develop effective screening tests. He also details the reasons it complicated to prove what actually causes a type of cancer. For example, why did it take so long to prove that smoking causes cancer?

He devotes many chapters to the history of the “War on Cancer” and specifically to early crusaders in research and funding of cancer treatments, such as Sidney Farber (one of the founders of the Dana Farber Cancer Center in Boston) and Mary Lasker, a wealthy benefactor of cancer research. We learn how the Jimmy Fund was founded, and how many of the early breakthroughs in childhood leukemia were made. In later chapters, Dr. Mukherjee engages the reader with more recent advances in genetic and targeted therapies, which give hope for future research breakthroughs. He details the development of Gleevec, the first of molecular targeted therapies for chronic myelogenous leukemia, which is truly a miracle drug. He compares the use of Gleevec to Roger Bannister breaking the long held barrier of the 4 minute mile.

Brilliantly written with imagery and stories interwoven with scientific details, it is easy to see how Emperor of All Maladies won the 2011 Pulitzer Prize for nonfiction. An excerpt from the book quoting a Nobel Prize winner compares cancer to the epic poem Beowulf: “We have not slain our enemy, the cancer cell, or figuratively torn the limbs from his body,” Varmus said. “In our adventures, we have only seen our monster more clearly and described his scales and fangs in new ways—ways that reveal a cancer cell to be, like Grendel, a distorted version of our normal selves.” Throughout the book he tells the riveting story of a thirty-one year old mother of three who is diagnosed with acute leukemia. This story, plus many references to art, literature and culture help the reader understand the long battle against cancer. In his introduction, Dr. Mukherjee describes how as a fellow in oncology, he felt that he was drowning literally and figuratively because of the emotional toll of caring for dozens of patients who had died. This book is his answer to that experience. Many years after my internship, this book wonderfully reinforces my emotional response to the many brave oncology patients and cancer researchers that have battled this fierce disease.