Karela Fry

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Cancer, and its biographer

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Siddhartha Mukherjee, the biographer of cancer

India Today carried a little report on Siddhartha Mukherjee:

A Delhi-born cancer specialist – Siddhartha Mukherjee – won the 2011 Pulitzer Prize in general non-fiction category to become only the fourth person of Indian origin to get the honour.

The Indian-American physician’s acclaimed book on cancer, The Emperor of All Maladies: A Biography of Cancer, won the prestigious award.

The prize carries a $10,000 award.

The book was released a few months back. I’ve seen it in bookshops, picked it up and browsed through it. I thought it looked interesting and read well, but decided to buy it when I’ve reduced the pile of unread books beside my bed a little. So I have to fall back on this occassion on book reviews, and other second hand sources of information.

The New York Academy of Sciences has a little bio of the author:

Siddhartha Mukherjee, MD, is a cancer physician and researcher. He is an assistant professor of medicine at Columbia University and a staff cancer physician at Columbia University Medical Center. A Rhodes scholar, he graduated from Stanford University, University of Oxford, Harvard Medical School. He has published articles in Nature, The New England Journal of Medicine, The New York Times, and The New Republic. He lives in New York with his wife and daughters.

The review in the Guardian gushes:

The yoking of scientific expertise to narrative talent is rare enough, but the literary echoes of The Emperor of All Maladies suggest a desire to go further even than fine, accessible explanation. “Normal cells are identically normal; malignant cells become unhappily malignant in unique ways.”

It takes some nerve to echo the first line of Anna Karenina and infer that the story of a disease is capable of bearing a Tolstoyan treatment. But that is, breathtakingly, what Mukherjee pulls off.

The book review in NYT reports how and why Dr. Mukherjee started writing the book:

Mukherjee started on the road to this book when he began advanced training in cancer medicine at the Dana-Farber Cancer Institute in Boston in the summer of 2003. During his first week, a colleague who’d just completed the program took him aside. “It’s called an immersive training program. But by immersive, they really mean drowning,” he said, lowering his voice the way many of us do when we speak of cancer itself. “Have a life outside the hospital,” the doctor warned him. “You’ll need it, or you’ll get swallowed.”

“But it was impossible not to be swallowed,” Mukherjee writes. At the end of every evening he found himself stunned and speechless in the neon floodlights of the hospital parking lot, compulsively trying to reconstruct the day’s decisions and prescriptions, almost as consumed as his patients by the dreadful rounds of chemotherapy and the tongue-twisting names of the drugs, “Cyclophosphamide, cytarabine, prednisone, asparaginase. . . .”

Eventually he started this book so as not to drown.

The review in the New Statesman has a short recap of the early history of cancer:

[T]here are mummified remains dating from the 10th century that were found in the Atacama Desert, where aridity has preserved tumour as well as bone, and there is inferential proof of the existence of cancer in human populations going back to the Neolithic age. As for treating “bulging tumours of the breast”, we have a papyrus, dated to 2625BC, in which the Egyptian polymath Imhotep describes them with unsurpassed forensic accuracy, while offering, under the heading “Therapy”, the bleak prognosis: “There is none.” Herodotus begs to differ; in his Histories, he retails a characteristic anecdote concerning the Persian queen Atossa (550-475BC), whose Greek slave Democedes performs on her the first recorded mastectomy.

It was Hippocrates in the 5th century BC who named the cancerous tumour, with its defining network of blood vessels, karkinos, or “the crab”. By the time we reach the physician Galen in the 2nd century AD, the malady has become incorporated into his system of humours and resides in the most gloopily malevolent and systemically prevalent of them all, the dreaded “black bile”.

NPR sets out to look for a definition of cancer, and runs aground in the branching streams of ongoing research:

Oncologist Siddhartha Mukherjee was treating one of his patients, a woman with advanced abdominal cancer who had relapsed multiple times, when she asked him what seemed like a simple question.

“She said, ‘I’m willing to go on, but before I go on, I need to know what it is I’m battling,’ ” Mukherjee tells NPR’s Terry Gross.

But, as Mukherjee explains, describing his patient’s illness wasn’t so simple. Defining cancer, he says, is something doctors and scientists have been struggling to do since the disease’s first documented appearance thousands of years ago.

“Cancer is not just a dividing cell,” he says. “It’s a complex disease: It invades, it metastasizes, it evades the immune system. So there are many, many other stages of [defining] cancer which are still in their infancy.”

“If there’s a seminal discovery in oncology in the last 20 years, it’s that idea that cancer genes are often mutated versions of normal genes,” he says. “And the arrival of that moment really sent a chill down the spine of cancer biologists. Because here we were hoping that cancer would turn out to be some kind of exogenous event — a virus or something that could then be removed from our environment and our bodies and we could be rid of it — but [it turns out] that cancer genes are sitting inside of each and every one of our chromosomes, waiting to be corrupted or activated.”

The review in the Guardian goes on to say:

But as Mukherjee’s narrative unearths his central character, and our understanding of cancer accumulates depth and complexity, the notion of a war becomes ever more threadbare. … The practitioners of surgery, radiation and chemotherapy had proceeded to treat cancer without understanding its fundamental mechanisms.

In 1986, in The New England Journal of Medicine, John Bailar and Elaine Smith published a cold assessment of comparative trends in cancer mortality over the years. This revealed what they called a “qualified failure”. Between 1962 and 1985, though duration of survival had improved in certain areas, the war on cancer had not only failed to show overall progress, but deaths from cancer had actually increased by 8.7%. Even accounting for the postwar boom in smoking-related lung cancer, Mukherjee writes, this “shook the world of oncology by its roots”.

It is from here, as he reaches for the final act in his historical drama, that it becomes clear that Mukherjee is doing more than providing an account of medical developments, scientific discovery and human suffering. The underlying structural dynamic of his book turns out to be the riddle of progress itself, the application of reason and science to chaos and disease.

By the end of the 1990s, the development of Gleevec as a genetics-based drug treatment for chronic myeloid leukaemia had, as one researcher put it, proved a principle: “It demonstrates that highly specific, non-toxic therapy is possible.”

The cellular composition of cancer is Mukherjee’s own field, but he is under no illusions that the new era will leave history behind, or that gene-based therapies will lead us out of the cancer age.

The idea that cancer cells are copies of who we are is, Mukherjee emphasises, not a metaphor. “We can rid ourselves of cancer,” he concludes, “only as much as we can rid ourselves of the processes in our physiology that depend on growth – ageing, regeneration, healing, reproduction.”

And so his intensely vivid and precise descriptions of biological processes accumulate into a character, fully developed and eerily familiar. The notion of “popular science” doesn’t come close to describing this achievement. It is literature.

Every review was positive, and if the book were half as good as half the reviewers say it is, then it should be a really good read.

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