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Oncology Times:
doi: 10.1097/01.COT.0000394948.07481.7c
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Review: ‘The Emperor of All Maladies: A Biography of Cancer,’ by Siddhartha Mukherjee (Also see related news article in this issue): Scribner, hardcover, 592 pages, November 2010, ISBN 1439107955; also available in digital and audio editions

Young, Robert C. MD

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Siddhartha Mukherjee, MD, DPhil (PhD) a former fellow at Dana-Farber and now an Assistant Professor of Medicine at Columbia, has written an extraordinary account of the history of cancer.

Emperor of All Malad...
Emperor of All Malad...
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Chock-full of early history, facts, figures, personal anecdotes, and scientific insights, the book tells the story of the slow, painful, and often erratic path toward progress accomplished by brilliant, passionate, and dedicated leaders also burdened with the typical human flaws of arrogance, hubris, self-promotion, and naiveté thrown in.

Very enthusiastically praised by most of the major newspapers and news magazines, The Emperor of all Maladies was selected by both The New York Times and Time Magazine as one of the top 10 books of the year. The book clearly resonates with a very broad readership.

That said, does it provide equally compelling reading for experienced oncologists already deeply familiar with many of the unique oncology stories likely to be so intriguing when freshly introduced to lay audiences? After all, every oncologist knows the story of Sir Percival Pott, the chimney sweeps, and scrotal cancer, as well as the political and scientific duopoly that brought about the transformation of smoking attitudes in this country.

This reader's answer is an emphatic yes. In each section so familiar to all oncologists, Mukherjee peppers the text with fascinating anecdotes that make old stories come alive. For example: Pott, a compulsive, reclusive surgeon at Saint Bartholomew's Hospital, “rather than devising new methods to operate on scrotal tumors, was transformed into a reluctant epidemiologist.” Or, in the well-traveled history of the tobacco wars, Mukherjee highlights John Blatnik, an obscure Minnesota chemistry teacher turned Congressman, who proposed that since the Federal Trade Commission could regulate tobacco advertising, it could also investigate whether “filtered” cigarettes were safe.

These are just two examples of Cancer's history, definitely extremely well-known to oncologists, that are enhanced by Mukherjee's elegant storytelling skills coupled with little-known details and anecdotes.

The central figures in the book are Sidney Farber and Mary Lasker. About the latter, no one could quibble. She was, after all, “the fairy godmother of medical research.”

However, reasonable oncologists might substitute Joseph Burchenal, Don Pinkel, or even David Karnofsky, who was not even mentioned in the book, as more fitting symbols of early oncology pioneers. Nevertheless the Boston-centric focus of the author is understandable, and indeed, tremendous oncology progress has arisen from Boston labs and clinics.

Two themes of the book seemed somewhat problematic. The author deals in excruciating detail with the shortcomings of surgery, personified by the drug-addicted, obsessive-compulsive William Halsted, and with radiation therapy, where Mukherjee suggests that Henry Kaplan happened to pick the right disease (Hodgkin's disease) for the right therapy.

Mukherjee emphasizes the limited scope of both modalities but does not mention that surgery and radiation therapy, until the advent of adjuvant chemotherapy, had cured more cancer patients than chemotherapy ever had. It is also worth noting that these therapies have major roles in the cure of localized disease and that modern techniques have dramatically reduced the morbidity of treatment.

The other disquieting theme is highlighted in the subtitle of the book: “A Biography of Cancer.” In a effort to make the subject more alive and therefore more understandable, Mukherjee wants to write “not about something, but about someone.” Although for the most part this strategy succeeds, at times he slips into anthropomorphic language that stretches Darwinian principles.

For example, in describing early leukemia work at the National Cancer Institute, he highlights the problem of central nervous system relapse in the following manner: “The leukemia, sensing an opportunity in that sanctuary, had furtively climbed in, colonizing the one place that is fundamentally unreachable by chemotherapy.” Or this one about a patient with pancreatic cancer: “The tumor cells had shrugged the new drug off—instead mockingly sending a shower of painful metastasis into her liver.” In both instances, these phrases make for better prose than they do science.

REVIEWED BY ROBERT C...
REVIEWED BY ROBERT C...
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However, these two annoyances are like fleas on the hide of an elephant when balanced against all that is meritorious and enlightening within the book.

Mukherjee is a wonderful storyteller with a gift for interweaving elegant science with clear and concise explanation. He leaves the reader with unique and fresh details, even new to the most accomplished oncologist. He may be understandably over-optimistic about tumor genetics and the prospect of personalized oncology transforming cancer treatment (they have after all not been around long enough to have displayed their shortcomings like earlier “great ideas,” and, as he so persuasively illustrates throughout the book, we have been down this optimistic trail before).

However, he is candid and self-analytical about our own personal limits as oncologists. He writes with fervor and fascination about both the science and art of oncology, which is the reason most of us entered this field.

This passion, curiosity, frustration, and dogged determination will be what continue to advance the science of oncology and the cure of cancer patients. But the relationship between the art and science of cancer, critical for our ultimate success, has always been precarious, and the two disciplines have always struggled to make the other understand and apply their contributions.

As Mukherjee highlights in a beautiful description of a General Motors prize dinner where Ray Erikson was recognized for his work on src and Tom Frei for leukemia, “The two halves of Cancer, cause and cure, having feasted and been fated together, sped off in separate taxis into the night.”

At the end of the book, Mukhurjee returns to Carla Reed, his leukemia patient whose personal story weaves throughout the book. While writing the book, he notes, many colleagues inquired about how the book would end. Mukherjee always said he didn't know, even though he thought he actually did: He anticipated having to end the book with Carla losing her battle with cancer. However, due to the progress so beautifully summarized in this remarkable book, Mukherjee and Carla Reed celebrated her five-year disease-free survival with a bouquet of flowers in her Ipswich, Massachusetts home.

Dr. Mukherjee says it best: “The story of cancer isn't the story of doctors who struggle and survive. It is the story of patients who struggle and survive. Resilience, inventiveness, and survivorship—qualities often ascribed to great physicians—are reflected qualities, emanating first from those who struggle with illness and only then mirrored by those who treat them.

“If the history of medicine is told through the stories of doctors, it is because their contributions stand in place of the more substantive heroism of their patients.”

© 2011 Lippincott Williams & Wilkins, Inc.

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