The Emperor of all Maladies: A Biography of Cancer
Few books can combine the eminent readability of a pulp fiction thriller with the penetrating insight of a biography, the precision of biology, the encompassing breadth of history, and the compassion of a cancer clinician. Like a master alchemist, Siddhartha Mukherjee combines these to produce a work of distilled magnificence – The Emperor of All Maladies, a biography of cancer.
I was a somewhat reluctant reader, wondering if a topic as macabre and frightening as cancer would make a good read. I wouldn’t, for instance, find a biography of car crashes or parachute failures to be especially interesting. The difference is that Mukherjee is able to identify an implacable, ever-resourceful protagonist, an anti-hero, and then recount how we’ve been engaged in a 5,000-year struggle to understand and establish supremacy over our own bodies. From Egyptian hieroglyphics circa 1600 BC (describing a breast cancer and the chilling prognosis: “None”), to the almost tragically comedic “insights” of ancient Greece, from nineteenth century recipients of crude radiation and chemotherapy, to the many false leads of the first half of the twentieth century, to the past 20 years of comprehension and progress.
From a strategy perspective, what I found fascinating was the contrast between the top-down approach to curing cancer vs. the bottom-up approach, which focused on the internal goings-on of the cell. In the fight against cancer, we see that a blanket spending of billions of dollars had almost no impact on long-term survivability (between 1971 – 1990), but that the science (and prognosis) dramatically improved when researchers started from the ground up, exploring at a cellular level the link between cancer and genes. Many companies create strategy in the Boardroom with limited understanding of the appropriateness of the strategies given conditions “on the ground.” Conversely, companies that patiently inform their strategies with careful analysis are better prepared, with a road map for success.
But the soul of The Emperor of All Maladies is the author’s recognition that all of the progress and discovery and development come at the cost of human suffering, that the biography of cancer is composed of the mini-biographies of every patient. “A patient, long before he becomes the subject of medical scrutiny, is, at first, simply a storyteller, a narrator of suffering – a traveler who has visited the kingdom of ill.”
Mukherjee doesn’t promise a cure, and alternates between guarded optimism and resignation. For every patient who sees sustainable remission, there are others with seemingly identical conditions who fail to respond, for whom palliative care is the best prescription. The reality is that Cancer may always be with us -the Greek word onkos means “mass” or “burden.” As Mukherjee writes, “Cancer is indeed the load built into our genome, the leaden counterweight to our aspirations for immortality.”
But onkos comes from the ancient Indo-European nek, meaning to carry the burden: the spirit “so inextricably human, to outwit, to outlive and survive.” Mukherjee has now seen many patients voyage into the night. “But surely,” he writes, “it was the most sublime moment of my clinical life to have watched that voyage in reverse, to encounter men and women returning from that strange country— to see them so very close, clambering back.”
While there isn’t yet (and may never be) a happy ending in our fight against cancer, the past 30 years have seen improvements that dwarf what we’d seen in the previous 5,000 years. We haven’t beaten cancer, but we’re on more equal footing everyday, and it’s now as worried about us as we are about it.