Book review: The Emperor of All Maladies

Why read a 571-page book about cancer? Two reasons. First, The Emperor of All Maladies: A Biography of Cancer (Scribner, 2010) takes the reader back in scientific time, in a way that’s actually convincing. With well-chosen words, author Siddhartha Mukherjee describes the practical and intellectual problems facing cancer researchers who did not yet possess the concept of, say, abnormal cell growth. Second, Mukherjee provides excellent examples of the creativity that these researchers used to solve such problems, and shows how they drew ideas from diverse corners of the known world, including dyes, weapons, and bacteria. Okay, make that three reasons. Third, and perhaps most importantly, Mukherjee depicts how a decidedly emergent process – in which we cannot point to a single pivotal discovery about cancer, only to a series of smaller, sometimes disparate findings – can nevertheless yield tangible and important results.

In 1964, the U.S. government issued a report which stated, in unequivocal terms, that smoking causes cancer. Multiple epidemiological studies, with thousands of patients, supported this statement. Nevertheless, researchers at that time still did not understand what tobacco had in common with other carcinogens. “How could DES [diethylstilbestorl, a medicine prescribed to prevent premature births], asbestos, radiation, hepatitis virus, and a stomach bacterium all converge on the same pathological state, although in different populations and in different organs?” No other disease troubled doctors and researchers with such a profound diversity of causes.

Rudolf Virchow, a researcher who renamed leukemia weisses Blut (white blood). "By wiping the slate clean of all preconceptions," writes Mukherjee, "he cleared the field for thought."

Around the same time, a scientist named Bruce Ames was studying Salmonella bacteria at Berkeley. Ames observed that certain chemicals caused the bacteria’s genes to mutate, and some of these mutations affected the bacteria’s growth. By exposing bacteria to various chemicals and quantifying the subsequent growth of the bacteria, he could create a catalog of “mutagens” – chemicals that increase mutation rate. That’s neat, but here’s the connection that Ames made: more often than not, the mutagens (in bacteria!) were also carcinogens (in people!). Based on events occurring in a petri dish, researchers could start to offer a unified definition of an elusive concept for the first time. Carcinogens behave similarly because they alter genes.

That’s a tiny glimpse into The Emperor of All Maladies: A Biography of Cancer. Readers who finish the book will also learn how the Jimmy Fund got its name, why Sidney Farber chose leukeumia as a starting point in his quest to cure cancer, how the medical establishment finally stopped performing radical mastectomies, which techniques cancer activists borrowed from AIDS activists, why many scientists thought the 1971 National Cancer Act was premature, and how the word cause got re-defined. This list of events seems disparate, and in another book, it might remain so. But Mukherjee ably synthesizes them and shows how each event played a role in the emerging understanding of cancer that we have today. In doing so, he demonstrates the advantage of treating cancer like a person, and writing its history like a biography.

Some other reviews of this book…

NPR: An oncologist’s Pulitzer-winning cancer biography

The New Yorker: Cancer world: The making of a modern disease

The New York Times: Cancer as old foe and goad to science

(Image from Clipart ETC)

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