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Review: 'The Emperor of All Diseases'

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A biography of cancer , by Siddhartha Mukherjee (Scribner).

By Julia Klein |Spring 2011

IIt's difficult, if not impossible, to reach middle age without first-hand experience of the ravages of cancer. In my case, the litany of loss includes a grandmother who died of colon cancer, a longtime friend who succumbed to metastatic breast cancer, and a mother who survived breast cancer in her 60s but died of stomach cancer two years ago.

At the time of diagnosis, my mother's disease was advanced, metastatic, and therefore inevitably fatal. Even so, she was offered chemotherapy that could have slowed the progression of her cancer; there is no way of knowing for sure. My mother, in her early 80s, was both brave and hopeful about her treatment. I want to live, she told the oncologist. She insisted that somehow she could be healed, even though she was told that healing was impossible. Her belief in modern cancer medicine was as deep as it was misplaced. About nine months after she was diagnosed, shortly after we decided to put her on a hospice program, she asked me heartbreakingly: Julia, when are we going to see the doctor? A week later she was dead.

With this dark personal story as a context, I praised Siddhartha Mukherjees a lot The Emperor of All Diseases: A Biography of Cancer . Mukherjee, assistant professor of medicine at Columbia University and a physician at Columbia University Medical Center, writes that he originally intended the book as a journal for his two-year oncology fellowship at Massachusetts General Hospital in Boston.

In the end, he produced something far more ambitious: an eloquent and indispensable cancer story. (The biographical conceit of the subtitle is smart without being particularly revealing.) The emperor of all diseases traces the first historical glimpses of the disease, the development of treatment regimens, the role of prevention, and the biological mechanisms by which cancer wields its various forms of destruction. Anchoring the story and giving it a human face are case studies of patients who lived to tell their stories - and others who didn't.

Because of its subject, The emperor of all diseases can be difficult to read at times. The vivid suffering of patients like Carla Reed, who has aggressive leukemia, or Barbara Bradfield, who is battling metastatic breast cancer, could evoke painful associations. (It did for me.) And Mukherjee's elegant portrayal of the science of cancer - which touches on retroviruses, proto-oncogenes, tumor suppressors, genetic mutations, biochemical pathways, and more - will prove challenging for readers without a reasonable background in biology.

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It's worth it to persevere. A remarkable book: convincingly written, impressively researched and inspired by a sensitivity that is both skeptical and empathetic. Mukherjee tells the story of cancer like a thriller, and his narrative command is as thorough as his scientific expertise. This is not a full cultural story, but it is enriched by Mukherjee's literary leanings. He starts each chapter with epigraphs, and names like Czeslaw Milosz, T.S. Eliot, and Jack London appear alongside quotes from cancer researchers.

After immersing the reader in Carla Reed's plight, Mukherjee returns to the 1940s Boston laboratory of Sidney Farber, a chemotherapy pioneer, and then to the writings of the Egyptian doctor Imhotep. In a manuscript from around 2500 BC. Imhotep describes a case of breast cancer; he simply writes about treatment: There are none.

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This is the first record of cancer in the medical literature. Over the centuries, says Mukherjee, cancer seemed to play a minor role. Although it can affect children and young adults, cancer, a rampant disease of cell division, is strongly correlated with age. In the past, infectious diseases decimated large parts of the population before cancer could develop. It follows that as our population ages, the prevalence of cancer will increase and the need for effective treatments and preventive measures will increase even more urgently.

Mukherjee is aware that the healings have not kept pace with the escalation of cancer cases. While he views cancer researchers as heroic, he is less confident when it comes to practitioners who have willingly used radical surgery and radical chemotherapy.

In the past, being diagnosed with cancer raised anxiety not only because of the painful course of the disease and the high mortality rate, but also because of the arduous treatment. Cures, often of dubious effectiveness, included surgical disfigurement, ingestion of highly toxic chemicals with debilitating side effects, potentially harmful radiation, or a combination of the three. (My mother's oncologist described her subconscious decline and shared the blame on her cancer and the drugs she was taking to fight it.)

Mukherjee compares cancer treatment to the mystery of Lewis Carroll's Red Queen, where both doctors and patients pedal angrily just to stay still in one place. And yet the situation was much worse just a few decades ago. Some types of cancer that were once fatal, including childhood leukemia, are now curable. And the arsenal has expanded. William S. Halsted's radical mastectomy in the late 19th century, in which both lymph nodes and breasts were removed, has been largely replaced by simple mastectomy and, in some cases, breast-conserving lumpectomy. High-dose chemotherapy cocktails are supplemented - if not completely eliminated - with less toxic and more targeted drugs, including Herceptin (for breast cancer) and Gleevec (for leukemia).

It is in these more subtle remedies, along with better prevention against carcinogens, that the future of oncology lies, suggests Mukherjee. A simple, universal or final cure is not in sight, he writes. But as cancer research becomes more sophisticated, it will produce a more sophisticated oncological medicine, an ever-evolving set of specific treatments and cures.

Mukherjee shies away from utopian predictions. Technology, he writes, dissolves its own past and makes such predictions difficult. But neither human nature nor the nature of cancer are likely to change. He writes the relentlessness, the inventiveness, the resilience, the queasy oscillation between defeatism and hope, the hypnotic urge for universal solutions, the disappointment over defeat, the arrogance and the hubris that have shaped the fight against cancer to this day , surely will be part of his future too.

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