Book Review: The Emperor of All Maladies, a Biography of Cancer

by Warren Ross

Following the Enlightenment and the Industrial Revolution, medical science advanced at a pace inconceivable even a few centuries before.  For ten thousand years, so little was known about a rational scientific methodology, and about the human body, that medicine was mired in superstition and ignorance.  Until the time of ancient Greece, it was common to call upon supernatural forces for cures to disease (and the loss of Greek reason in the Dark Ages returned men to this primitive habit).  Building on the observational and scientific foundation that Greece provided, and culminating with the accelerating advances in the late 20th and early 21st centuries, medicine more than doubled the human lifespan and began to conquer the most dreaded diseases.

Few developments illustrate this progress better than the fight against cancer, and the 2010 book The Emperor of All Maladies, a Biography of Cancer, by Siddhartha Mukherjee, captures that development in a dramatic, educational and inspiring way.  Mukherjee, an oncologist and cancer researcher, surveys the history of cancer going back to the time of the ancient Egyptian Imhotep, who declared that “there is none” when listing the therapy for cancer.  Remarkably, though, with the exception of a few isolated historical cases, cancer is rare in history.   The reason highlights the most fundamental fact about cancer:  it is a disease predominantly of older age, and only in the last century have men lived long enough to fall the victim of cancer rather than any one of the scourges that killed them in earlier times (TB, bacterial infection, starvation and malnutrition to name just a few).  To his credit, and indicative of the predominantly rational approach he takes, Mukherjee rejects one view among intellectuals that our modern civilization is the cause of cancer (via hectic lifestyle, chemical bombardment, etc).  Instead, he identifies our modern civilization as revealing cancer – it had previously been invisible due to man’s short lifespan, and our unprecedented progress in curing other diseases left fewer maladies to take us before cancer could predominate.

Mukherjee summarizes the depressingly small number of remedies for cancer that were available before mid 20th century – basically surgery and radiation (the latter already a major advance of science and a less deadly complement to the surgeon’s knife).  He details in horrifying terms the increase in radicalism of surgery required to provide any hope of recovery with such a limited number of options.

And then, in the 1940’s, due to the insight and brilliance of a young pathologist named Sidney Farber, a completely new method of treating cancer was invented:  chemotherapy.  Chemotherapy was the first systemic method of treating cancer, i.e. the only possibility of treatment for those cancer sufferers who do not have highly localized disease treatable by surgery and radiation.  We all have heard of the ravages of chemotherapy – the horrible side effects (nausea, gastro-intestinal problems, especially in the early days), and the toxicity to normal, non-cancerous, cells.  But the breakthrough that chemotherapy represented cannot be underestimated because cancer is only very rarely a localized disease, and in cases like leukemia and lymphoma it is inherently systemic.

Mukherjee covers the development of chemotherapy, emphasizing how it relied on the growing chemical scientific knowledge of the time, as well as the expanding industrialization of the Western world.  The contribution of large chemical and pharmaceutical firms is highlighted, and Mukherjee shows how their drive to make profits and find markets fundamentally changed medicine and expanded man’s lifespan.  When Farber had an idea for chemical compounds that could reverse leukemia, it was Lederle Labs that provided them.

More generally, as Mukherjee says in a particularly admirable passage,

In the late 1940’s, a cornucopia of pharmaceutical discoveries was tumbling open in labs and clinics around the nation.  The most iconic of these new drugs were the antibiotics.

Penicillin, which was milked to the last drop during World War II (it was re-extracted from the urine of soldiers treated with it, to be provided to the next dose recipient), is the most clear-cut example of the power of industrialization.  By the early fifties it was being produced in thousand-gallon vats.

In 1942, when Merck had shipped out its first batch of penicillin—a mere five and a half grams of the drug—that amount had represented half of the entire stock of the antibiotic in America.  A decade later, penicillin was being mass-produced so effectively that its price had sunk to four cents for a dose…

New drugs appeared at an astonishing rate: by 1950, more than half the medicines in common medical use had been unknown merely a decade earlier.

In other words, the selfish greed of the pharmaceutical companies (to use here favorably the accusatory language of the Left) showered the American public with an overwhelming supply of lifesaving medical products, so that when they were needed, medical cures were there.  The consequence:  life expectancy expanded from 47 to 68 in half a century, a greater improvement in 50 years than had occurred in the previous millennium.

Major improvements were made over several decades in treating cancer as well, but because of the complexity of cancer, and because of the limited knowledge of cell biology, progress was slow, incremental and limited.

Farber knew that to make progress, more investment and research was needed.   At first, Farber solicited private donations, and by a very successful publicity campaign called “The Jimmy Fund,” enabled an expanded research program.  In the 1960’s, however, the socialite Mary Lasker came up with the idea of a political campaign to loot the public treasury to fund research.  Unfortunately, Farber chose to join the campaign, dubbed the “War on Cancer.”  Billions were ultimately allocated by Congress during Nixon’s years in office to fund the National Cancer Institute (NCI).

Mukherjee draws an insightful and startling picture of this phase of “government medicine.”  Rather than uncritically laud this development, he details the bureaucratic, brute force and politically motivated type of research that was conducted at the NCI.  The NCI was mostly concerned with staying within boundaries so no one would accuse it of harming anyone with its treatments.  Innovative treatments that were higher risk (such as continuing chemotherapy beyond a few treatments to ensure cancer cells were really eradicated) were suppressed, and researchers who proposed or tried them punished.   Some of the most innovative researchers left NCI to join outside labs like Dana Farber in Boston, Memorial Sloan Kettering in New York, and MD Anderson in Houston.   Several useful treatments were developed by NCI, usually by simply trial and error tests with hundreds of thousands of compounds.   But beyond this Soviet-style brute force approach, most of the highly creative cell biology and genetic research of the 1980’s and 90’s were conducted at universities and labs outside NCI.  (The sequencing of the human genome, ultimately accomplished by a small private company rejecting the brute force approach of “government science,” is another example of this contrast between creative reason and politics.)

The most exciting and instructive parts of the book are Parts 4 and 5, where Mukherjee covers those more recent developments.  These parts are a mix of tutorial on genetics and microbiology and a mystery story.  As layer after layer of the cancer cell’s underlying complexity is revealed, the reader becomes convinced that cancer will one day be cured (even if Mukherjee himself has reservations about making such a bold declaration).  The exposition is lucid, well paced and highly integrated around genetics, and it is enhanced fundamentally by Mukherjee’s provision of essentialized and well concretized definitions of key biological terms (e.g. “kinase,” “oncogene,” and “angiogenesis”).

The author does have several views that are philosophically false, and confuse his primary theme.  One such view is a theory-practice dichotomy, which makes it hard for him to understand the work of medical researchers and pharmaceutical companies as an integrated whole with a valid division of labor between science and business.  He criticizes scientists when they choose to focus on fundamentals of biology, leaving treatment development to companies.  And he overemphasizes the turmoil within pharmaceutical companies (e.g. Sandoz) when they choose to reorganize lines of business for profitability.  He even implies that there is something wrong when a company chooses not to develop an unprofitable product (due to a small market), implying that patients have a right to such products.  His apparent favorability towards lawsuits requiring companies to provide treatments is one shameful consequence of that view.

Mukherjee also confuses FDA intervention in the market (which he rightly criticizes) with private action of a company in delaying bringing a product to market when it judges the scientific evidence does not yet warrant it.  (In one respect, though, Mukherjee cannot be blamed – with government approval serving in the last half-century as the virtual standard of readiness for market, replacing scientific judgment with politics, the confusion between private and government action is indecipherable, and such dilemmas are virtually insoluble.)

Despite these flaws, and if the book is read critically, this biography of cancer is highly recommended.  For an inspiring and educational excursion into medicine’s most intractable disease, and for a story that highlights creativeness, unimaginable perseverance, and the lifesaving contributions of great medical researchers and pharmaceutical giants, there is not a better book available today than Emperor of All Maladies.


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