The Emperor of All Maladies: a Biography of Cancer
By Siddhartha Mukherjee
The terrible omnipresence of cancer.
"I feel it in my fingers/I feel it in my toes/Love is all around me/And so the feeling grows . . ." So have crooned a succession of pop stars, from the Troggs, who first coined the expression, to Bill Nighy and Wet Wet Wet. But from where I'm sitting a more plausible candidate for omnipresence would be cancer. Let's make the substitution and see how it sounds: "I feel it in my fingers/I feel it in my toes/Cancer is all around me/And so the feeling grows . . ." Ye-es, much better, I'm sure you'll agree.
Both of my parents died of cancer; my wife is receiving radiotherapy for breast cancer; the sister of one of my closest friends is in a hospice dying of lung cancer; I was on the phone recently to another friend whose breast cancer - treated a decade ago with a mastectomy and chemotherapy - has recurred and metastasised into her bones; another good friend is suffering from throat cancer; indeed, cancer is so much all around me that two people I know well are being treated for leukaemia in the same ward of the same hospital.
I don't imagine that I'm exceptional in this regard - cancer really is all around. Whether it's a function of an increasingly carcinogenic environment - and lifestyle - or merely our ageing population, the incidence of cancer has now reached one in five of the population. Some epidemiologists believe that in years to come half of us may well die from the disease that the oncologist author Siddhartha Mukherjee hails as the "emperor of maladies". Yet, despite this ubiquity, the available cancer literature has been notable for its specificity. From Crazy Sexy Cancer Tips to Because . . . Someone I Love Has Cancer: Kids' Activity Book and from Prostate Cancer for Dummies to Cancer Etiquette, this is a subject that readers seem to encounter only on a need-to-know basis - until now, because Mukherjee's book lifts cancer bodily from the self-help section of the bookshop, dissects it and then apportions it to several other genres.
The Emperor of All Maladies styles itself as “a biography" of cancer, but while Mukherjee does indeed survey the historical and even archaeological evidence, this is remarkably sparse. Yes, there 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".
All of this background Mukherjee dutifully records, but it is the era of modern medicine that thrills him most (he, too, is a physician). He dates the genesis of the modern search for cancer therapies to 1845, when the German researcher Rudolf Virchow renamed what was previously adjudged a "suppuration of the blood" as weißes blut, or the more academic-sounding "leukaemia". It is here that the purview of The Emperor of All Maladies becomes sufficiently magnified to encounter the cellular ontogeny of cancer, and here also that the narrative starts to feel like a thriller more than
In fact, Mukherjee has already primed us for this genre-bending by introducing two other strands to his story: first, the tale of one of his own cancer patients, Carla Reed, a young mother struck down by the sudden onset of leukaemia; and second, the equally dramatic story of Sidney Farber, who first administered cytogenic (cell-killing) drugs to leukaemia patients in the 1940s at Children's Hospital Boston, becoming the founding father of modern chemotherapy. In the rest of the book, Mukherjee moves back and forth between timelines, ramping up the tension as the reader riffles through 400-odd pages of detailed explanations of advances in cancer therapeutics, molecular biochemistry and genetics, desperate to find out whether a cure is discovered in time to save Carla.
This isn't altogether fair, but although in the United States The Emperor of All Maladies received a National Book Award and fulsome encomiums for its literary merit, I suspect British readers may, like me, find the introduction of scores of American lab rats with notable characteristics - "Rous was bulldoggish, persuasive and inflexible", "restless and imaginative Tamer" - more than a little wearing. Then there is the author's dogged insistence that America's "war on cancer", inaugurated by Sidney Farber, is, was and always will be where the action is. It's strange, because Mukherjee studied in the UK, and he writes particularly well about the pioneering 1950 study on smoking and cancer conducted by Richard Doll and Austin Bradford Hill, which not only established a link between the two factors, but also inaugurated a wholly new approach to epidemiological statistics.
Another feather in British - or at least, Scottish - medicine's cap was the launch of the hospice movement, which Mukherjee rightly identifies as a timely corrective to the "heroic" excesses of chemotherapy in the 1980s and early 1990s, when patients were callously sliced, diced, pickled and irradiated until they toppled into the grave. Overall, though, he is a peerless guide to the depredations of and battles with the demon crab, and seems to have retained a healthy scepticism about the effects of professional closure within the medical industry.
In his acknowledgements, the author cites Richard Rhodes's book The Making of the Atomic Bomb, and The Emperor of All Maladies is an equally accomplished example of popular science writing. Mukherjee never condescends, yet he manages to write lucidly and tellingly about complex experimental, technological and theoretical matters. This is very much a narrative of hard science, but Mukherjee has the grace to admit that, despite all the advances, "much about this battle [with cancer] will remain the same: the relentlessness, the inventiveness, the resilience, the queasy pivoting between defeatism and hope, the hypnotic drive for universal solutions, the disappointment of defeat, the arrogance and the hubris".
I feel it in my fingers, I feel it in my toes - that I've been waiting a while to read a large-scale book about cancer - and this one, though it hasn't cured my desire, has managed quite effectively to palliate it. That's probably just as well, because, given my life expectancy as a smoker of 35 years' standing, I am unlikely to live long enough for the next one to come along. l
The Emperor of All Maladies: a Biography of Cancer
Fourth Estate, 592pp, £25