A Biography of Cancer

A Book Review of The Emperor of All Maladies By Siddhartha Mukherjee

I was recommended to read Mukherjee’s work several times, been praised for its high-quality writing, and the faithful description of science. I’ve had his “The Gene” book on my shelf for years, but I kept delaying it. But I was unaware he had a book on cancer. I’ve always wanted to know more about the topic, so I dived in right away.

Not only was I excited about his good reputation as a writer, but he is also a cancer physician and researcher, so I was confident in the scientific accuracy of the book. Despite his background, however, the book isn’t a scientific account of what cancer is. As the title implies, it is meant as a biography of cancer. The whole tone of the book is to know cancer in a more holistic, contextualized form. I found it somewhat odd at first, but it was beautifully done, and in large part what makes this book so great.

The start of the book is about cancer’s history. The first case of it was recognized in Egypt in 1600 BC, with Hippocrates being the one who first described it in more detail. But it was Galen in the 2nd century CE that gave its etymology — “oncos”, meaning swelling or lump. Since then, cancer it was conceptualized within the humoral theory that shaped medicine for almost two millennia, with cancer supposedly being caused by the imbalance of black bile.

Nothing changed much for cancer until the 19th century, when surgeons, now finally equipped with antibiotics and effective painkillers for the first time in history, started operating on cancer tumours. In the 20th century, chemotherapy and other more modern treatments appeared. Each with its own history, paradigms, developments, and mistakes. This was a major part of the book since it is mostly where our knowledge and therapies of cancer originated.

This part is also where it eventually gets into a more scientific description of cancer. Cancer is a collection of diseases, and hence difficult if not impossible to treat all of them with a single therapy. Yet, they all share similarities. According to one paper mentioned in the book, there are six core features of cancer: 1) self-sufficiency by activation of oncogenes, 2) insensitivity to antigrowth signals, 3) evading programmed cell death (apoptosis), 4) limitless replicability (cells become immortal), 5) tumour angiogenesis — acquiring their own blood supply, and 6) tissue migration (metastasis). Yet, these 6 factors are caused by endless pathways, with mutations of hundreds of genes.

This story, however, isn’t just a timeline of facts or events. They are told through people. The doctors that first recognized cancer, the patients getting the diagnosis, the surgeons’ constant search for better surgeries, the endless new drugs for chemotherapy, and everything in between. The general trend of this entire journey is of both hope and disappointment. The hope every time a new therapy is discovered, and yet the disappointment of how little it changes the overall picture.

There is progress but is antagonistically slow. Most major forms of cancer have a decreased mortality of about 1% per year.

If there is one thing that you will get out of the book, it is the incredible nuance of both cancer and medicine in general. The endless conflicting theories, the failed trials, the ethical dilemmas, the politics of science, and the complexity of research methodology.

It is a painful reminder of how limited we are. How little we know, and the embarrassing amount of things we have gotten wrong. But it also illustrates the best of mankind. The empathy of doctors, the dedication of researchers, and the strength of the patients.

The book isn’t perfect. It was too long, reaching almost 600 pages, and at times the pace was too slow. But in part, that’s because of the detail the author gives to things that would often be omitted. Not only what led to a particular cure, but the context in which that cure was discovered. It makes justice to all the people who dedicated their lives to one of the most difficult battles against nature.

For anyone wanting to know about cancer, especially beyond its scientific technicalities, I highly recommend the book. You will not only finish it with increased knowledge about cancer’s history, biology and therapies, but also a deep appreciation for science, and the incredible work that has led us to where we are now, despite all the limitations.

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Tiago V.F.