Her Fine Eyes

I've delayed writing a review of The Emperor of All Maladies because the scope of the book is so sweeping I knew that I couldn't do it justice. So I'll just jot a few notes here.

I believe all oncologists and cancer surgeons should read this book, to understand their place in the history of discoveries (and incidentally of suffering) surrounding this ancient disease. If I were a cancer researcher, this book would be a combination Bible and road map for me--albeit a map that shows only how we got where we are, and not necessarily where we go from here. In fact, I wish a book just like it were written in every medical specialty. Someone needs to write the biography of obstetrics-gynecology, the biography of hematology, the biography of orthopedics, etc.

Suffice it to say, this is how I like my non-fiction. Mukherjee presents a rigorous, thorough "biography" of cancer from Egypt in 1600 BCE (the first recorded cancer, a breast cancer) to the present day. He delves into every aspect of the disease--historical, political, social, clinical, scientific, cultural--but he does it all fluidly, keeping a fairly straight chronology of the disease and science through time.

I learned so much. Which is to say, in the course of the book I came to realize how little I know--how little we as human beings know--about cancer. It's hard not to feel a bit hopeless at the task that faces us. Every cancer is unique in its genetics; in each case we have to know which of the many switches in the cell's DNA is the accelerator that's stuck, and which is the brake that's missing? And every cancer is unique in how it spreads in the body. For instance, I had always assumed, as many early researchers apparently did (hence the popularity of ever more disfiguring radical mastectomies in the 1970s), that breast cancer spreads somewhat radially before it leaps to lymph nodes. I used to proclaim, "If I get breast cancer, I'll choose a mastectomy just to be safe." I was surprised at how fundamentally impaired that logic is. Lumpectomies finally make sense to me in Mukherjee's hands: if a cancer is the type that stays relatively contained, a lumpectomy does the job of removing it. If a cancer is the type that spreads through the lymphatic system, a mastectomy--no matter how radical--might not help.

I learned about how the "War on Cancer" legislated by Richard Nixon was doomed, given that when it was launched in the early 70s, the science of cancer was still in its infancy. The mechanisms of a healthy cell becoming malignant, the genetics, and the methods of metastasis were as yet undiscovered. The goal of eradicating cancer was based on a lack of understanding of the scope of the problem: there is no single cure, the way penicillin was the cure for infection--each cancer must be understood on its own, and the treatment tailored to it.

I was unaware of just how much the early history of chemotherapy was characterized by a sort of trial-and-error science. With advances in genetics, some recent drugs have been developed by predicting the effect they'll have on the biology of the tumor, but many of the initial drugs came from a "flood it with poison and see if it works" methodology (first in the petri dish and then in the human body).

The evidence against smoking. This was one of the most riveting parts of the book for me: the scientific, political, and cultural connections drawn through the decades between cigarettes and cancer. He does a good job of discussing the propaganda campaigns of the tobacco companies, the lawsuits, and the obfuscation of what should have been overwhelming health data. While I knew that my mother's generation smoked more than mine did, I had no idea that in 1953 the average American smoked ten cigarettes a day. Every single pre-teen needs to be taught the science and statistics behind cigarette-induced cancer in the powerful way that Mukherjee describes them. Cancer rates of all kinds (not just cancer of the lungs) along with heart disease are so unequivocally tied to cigarette use, it's incredible to me that anyone still smokes. Mukherjee presents data that shows the education of young people is beginning to fail again, as the number of teen smokers has climbed in the last decade. With increased smoking in this generation, the statistical gains in health will diminish again to pre-1970s levels.

A lot of the book focuses on Dr. Sidney Farber, an awkward, formal man who made the political war on cancer possible, along with the wealthy socialite and medical philanthropist Mary Lasker, through their high-visibility "Jimmy Fund." I wasn't sure to what extent Farber was overrepresented in the book; Mukherjee received his training at the Dana-Farber Cancer Institute in Boston, and it's there that he conceived of the idea of a biography about cancer. (The book seems to have been a catharsis for him--a way of relieving the daily strain of such an emotionally difficult career.) Certainly Farber was an important figure in the popularization of the cause, and made advances in acute lymphoblastic leukemia, but a lot of words are devoted to him, and relatively fewer to more recent researchers who have figured out pathbreaking genetic sequences and other molecular details (Harold Varmus, Bert Vogelstein, and others)--people who have changed the level of sophistication of our attack on cancer, who will make non "trial-and-error" successes possible. 

In sum. Remember how disappointed I was with the scientific flimsiness of Susan Cain's Quiet: The Power of Introverts, and the lack of thoroughness and ambition of Caitlin Doughty's Smoke Gets in Your Eyes? Well, Mukherjee's Emperor of All Maladies is the standard-bearer for adult non-fiction for me now.