November 10, 2010
Cancer as Old Foe and Goad to Science
By JANET MASLIN

THE EMPEROR OF ALL MALADIES

A Biography of Cancer

By Siddhartha Mukherjee

Illustrated. 571 pages. Scribner. $30.

On its first page “The Emperor of All Maladies” sets forth its intention: to be a definitive history of how cancer has been understood, treated, feared and politicized throughout all of recorded human history. That’s a staggeringly tall order. Yet the author, Dr. Siddhartha Mukherjee, seeks to make it even taller. His book also aspires to be “a biography of cancer,” even though Dr. Mukherjee (a cancer specialist and researcher with stellar credentials) cannot exactly explain what that phrase means.

“This book is a ‘biography’ in the truest sense of the word,” he claims at the outset. It is “an attempt to enter the mind of this immortal illness, to understand its personality, to demystify its behavior.” He ventures even farther into the realm of the impossible when he promises to address these two questions: “Is cancer’s end conceivable in the future? Is it possible to eradicate this disease from our bodies and societies forever?”

With objectives so vast, and with such an beautiful title, “The Emperor of All Maladies” is poised to attract a serious and substantial readership. And it is an informative, well-researched study. But it is in no way a biography of anyone or anything, and Dr. Mukherjee winds up acknowledging as much before his book is over.

He points out that there is both folly and scientific partisanship in treating “cancer, a shape-shifting disease of colossal diversity,” as “a single, monolithic entity.”

Likewise, questions about whether cancer can be eradicated eventually run up against hard reality. “Cancer is a flaw in our growth, but this flaw is deeply entrenched in ourselves,” the book says. “We can rid ourselves of cancer, then, only as much as we can rid ourselves of the processes in our physiology that depend on growth — aging, regeneration, healing, reproduction.”

How did Dr. Mukherjee allow his otherwise sophisticated book to be presented so reductively? It’s an all too fitting flaw, since the same kind of oversimplification has long been the bane of cancer theory. “The Emperor of All Maladies” provides a survey of the different ways in which cancer has been understood in different eras, from the Greeks’ idea that it was caused by black bile, one of the four liquid humors, to the 19th-century conviction that the most drastic and disfiguring surgery would lead to the best cure. He also writes about the fund-raising, Nixon-era idea of waging war on cancer as if illness were an enemy to be faced in battle.

The biographical aspects of “The Emperor of All Maladies” have more to do with the personalities of anti-cancer combatants than with concocting one for cancer itself. This book pays considerable attention to pioneering figures like William Stewart Halsted, an advocate in the 1870s and 1880s of extreme breast cancer surgery; Sidney Farber, who in the 1940s made great breakthroughs in treating childhood leukemia with dangerously toxic chemicals; and Min Chiu Li, who in the 1950s lost his job at the National Cancer Institute for providing chemotherapy to patients whose symptoms had receded, even though this extended therapy meant the first chemotherapeutic cure of cancer in adults.

In a maneuver as transparently glib as that of calling his book a biography, Dr. Mukherjee also inserts occasional glimpses of his own patients, whose experiences are markedly overdramatized. (“It was now 9:30 in the morning. The city below us had stirred fully awake. The door shut behind me as I left, and a whoosh of air blew me outward and sealed Carla in.”) But none of this personal material is as compelling as the story of how cancer research has progressed through so many different phases.

Here Dr. Mukherjee’s writing is at its most candid and grim. The overarching point made by his narrative is that the whole subject of cancer is dauntingly complex. Even the statistics about mortality rates are tricky, since so much of researchers’ thinking about the prevalence of cancer depends on how they measure progress. And the unmistakable effect of our progress in curing other previously fatal diseases is to make cancer, which is most often found in older patients, look more prevalent than ever.

“The Emperor of All Maladies” is at its most honest in describing the push-pull dynamics of scientific progress. Dr. Mukherjee links a decline in extremely punishing chemotherapy regimens to the fact that patients became less passive. (He credits much of this forcefulness to AIDS activists.) He describes the conflicting interests of surgeons and chemotherapists. He writes most promisingly about the effects of genome mapping on scientists’ ability to understand how cancers progress, and he cites the similar ways in which different cancers create genetic pathways within mutating cells. He is confounding yet fair in writing that “this is either very good news or very bad news.”

Late in “The Emperor of All Maladies” Dr. Mukherjee provides especially apt metaphors for a subject so difficult to grasp. He quotes the Red Queen from Lewis Carroll’s “Through the Looking Glass” to describe the alacrity with which research must move: “It takes all the running you can do, to keep in the same place.” He describes one patient’s maneuvers to keep up with her illness as “like watching someone locked in a chess game.” And he says that the patterns in cancer research repeat themselves just as history does. Among the constants in this struggle are “the hypnotic drive for universal solutions” and “the queasy pivoting between defeatism and hope.”