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The Emperor of All Maladies, by Siddhartha Mukherjee

December 18, 2012

I’ve been meaning to read this book for a while now, hearing generally positive things from various sources. Finally, a recommendation by Dom was the final straw which resolved my inertia.

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The Emperor of All Maladies is, as the author describes it, a biography of cancer. Driven by an apparent fascination with the disease, Siddhartha Mukherjee brings together a detailed history of cancer and oncology in the past hundred years or so. In addition, Mukherjee draws on the long history and culture around cancer, and his own experiences in oncology.

The book can largely be split into three narratives. The first describes the ascent of chemotherapy, beginning with a few incidental observations, such as the leucopenia of survivors of the chemical disaster at Bari in World War II, before moving into the first ad hoc clinical trials by Sidney Farber and on to the expanding field of chemotherapy, which was as much a political movement as a medical one. It is a helter-skelter journey as doctors scrambled to try greater doses of different cocktails of ludicrously toxic drugs, spurred on by the apparent cures they couldn’t fully explain. Less time is given to surgery and radiotherapy but they are each given their due. For a shockingly long time, the three approaches stood bristling in a Mexican stand-off. Only relatively recently have they come together for a cohesive approach.

The second narrative looks at the epidemiology of cancer, jumping right back to the 18th century when Percivall Pott suggested a link between scrotal cancer in chimney sweeps and the soot that they were perpetually covered in. This marked the first time that cancer was linked to an environmental carcinogen. However, this environmental theory did not gather any momentum for another 150 years. Instead, everyone was chasing down non-existent carcinogenic viruses. However, it was revived when Bradford Hill and Richard Dollis demonstrated an incontrovertible link between cigarette smoking and lung cancer. In the same way that Mukherjee lionises Farber for chemotherapy, he raises up Hill as the father of cancer epidemiology. This narrative then forks slightly, with one tine detailing the decades’ long efforts of the tobacco industry to discredit and dismiss the carcinogenicity of their products. This is depressing more than anything else, especially since the tricks of 50 years ago are now being peddled in the developing world, where public health campaigns have little reach. The other tine of narrative details further advances in epidemiology such as the link between Hepatitis B and Epstein-Barr viruses with liver cancer and Burkitt’s Lymphoma respectively. While viruses had finally been found as a cause for cancer, they were only specific cases and not the grand unifying theory that people had believe with a fervour. This was part of a larger problem – that cancer itself was still so poorly understood.

The third and final narrative tackles the biology of cancer, the black box after epidemiology but before chemotherapy. Mukherjee again returns to Victorian observations of relationships between hormones and cancer before slowly building on the genetic and cellular basis for cancer. While vitally important, this aspect of cancer lacks much of the excitement of chemotherapy or epidemiology. I can understand why Mukherjee left this until last. However, that is not to say that this book becomes dry or boring in the home strait. Instead, it serves to join up the disparate observations, the loose ends and nagging questions and Mukherjee drops throughout the book, nicely linking up epidemiology with chemotherapy. Furthermore, this narrative ends on the development of Herceptin and imatinib, cancer-fighting treatments that aren’t horrendously toxic poisons. Rightly, Mukherjee points to drugs like these as future of cancer treatment, in combination with chemotherapy, surgery and radiotherapy.

This is long book, and incredibly dense. If you pick this up, be prepared to read a lot about cancer. In fact, this book covers a surprising amount of the material I had to learn during our cancer modules in second year medicine. What’s more, it does so in a far more entertaining fashion. It may be cliché, but Mukherjee strives to bring the human story out of oncology. This is done partly through the lives and personalities of the doctors and scientists behind the progressive discoveries but also through select case histories of patients Mukherjee met and treated as an oncology fellow. It is a necessary safety valve to prevent the book losing its human touch and becoming a purely academic adventure. Chemotherapy is intended to help patients, save them, but at the cost pumping the worst drugs in our armamentarium through their veins. If we reduce this to just a drug and dose, we miss the entire point.

Mukherjee pulls off this colossal undertaking through the strength of his writing. It is academic with a touch of warmth, empathetic at arm’s length. In some ways, much like the ideal doctor in some people’s opinions. Furthermore, his fascination with oncology bleeds through each page. However, at times, his prosaicism spills over into acute purple prose, which can be a bit much. But this is nitpicking on what is otherwise a very fine book.

In my opinion, this book is equally engaging to a lay or medical readership. Anyone who has any meaningful form of contact with cancer. More than that, I can highly recommend it for medical students currently learning about cancer and cancer biology. It has been a depressingly long time since my own lectures but I would be interested to see if the second year course has altered to accommodate this book. It certainly deserves a place on the recommended reading list.

But, then again, if you want something to be read, never put it on a reading list.

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