Emperor of All Maladies (Mukherjee)

The Emperor of All Maladies: A Biography of Cancer
Siddhartha Mukherjee, 2010
Simon & Schuster
571 pp.
ISBN-13: 9781439170915


Summary
Winner, 2011 Pulitzer Prize

The Emperor of All Maladies is a magnificent, profoundly humane “biography” of cancer—from its first documented appearances thousands of years ago through the epic battles in the twentieth century to cure, control, and conquer it to a radical new understanding of its essence.

Physician, researcher, and award-winning science writer, Siddhartha Mukherjee examines cancer with a cellular biologist’s precision, a historian’s perspective, and a biographer’s passion. The result is an astonishingly lucid and eloquent chronicle of a disease humans have lived with—and perished from—for more than five thousand years.

The story of cancer is a story of human ingenuity, resilience, and perseverance, but also of hubris, paternalism, and misperception. Mukherjee recounts centuries of discoveries, setbacks, victories, and deaths, told through the eyes of his predecessors and peers, training their wits against an infinitely resourceful adversary that, just three decades ago, was thought to be easily vanquished in an all-out “war against cancer.” The book reads like a literary thriller with cancer as the protagonist.

From the Persian Queen Atossa, whose Greek slave may have cut off her diseased breast, to the nineteenth-century recipients of primitive radiation and chemotherapy to Mukherjee’s own leukemia patient, Carla, The Emperor of All Maladies is about the people who have soldiered through fiercely demanding regimens in order to survive—and to increase our understanding of this iconic disease.

Riveting, urgent, and surprising, The Emperor of All Maladies provides a fascinating glimpse into the future of cancer treatments. It is an illuminating book that provides hope and clarity to those seeking to demystify cancer. (From the publisher.)

Author Bio
• Birth—1970
• Where—New Dehli, India
• Education—B.A., Stanford; Ph. D, Oxford; M.D., Harvard
• Awards—Pulitzer Prize
• Currently—teaches at Columbia Medical School in  New York City, New York
 

Siddhartha Mukherjee (born 1970) is an Indian-born American doctor and non-fiction writer. He is the author of the Pulitizer Prize winner The Emperor of All Maladies: A Biography of Cancer (2010). In 2016 he published The Gene: An Intimate History.

Mukherjee was born in New Delhi, India. He went to school at St. Columba's School. He majored in biology at Stanford University, then won a Rhodes scholarship to Oxford University where he earned a Ph.D. in immunology. After graduation, he attended Harvard Medical School to train as an internist and won an oncology fellowship at Massachusetts General Hospital.

He is currently serving as Assistant Professor of Medicine at Columbia University in New York City. He is also a staff cancer physician at Columbia University Medical Center.[3] He lives in New York and is married to the MacArthur award-winning artist Sarah Sze. They have two daughters.

HIs 2010 higly-regarded book, The Emperor of All Maladies: A Biography of Cancer, details the evolution of diagnosis and treatment of human cancers from ancient Egypt to the latest developments in chemotherapy and targeted therapy. In addition to winning the 2011 Pulitzer Prize, it was listed in "The 10 Best Books of 2010" by the  and the "Top 10 Nonfiction Books by Time magazine. In 2016 Mukherjee published The Gene: An Intimate History, which quickly reached the top of the New York Times Bestseller list. (Adapted from Wikipedia.)

Book Reviews
An informative, well-researched study....The Emperor of All Maladies is at its most honest in describing the push-pull dynamics of scientific progress.
Janet Maslin - New York Times


Mukherjee has undertaken one of the most extraordinary stories in medicine: a history of cancer.... He frames it as a biography, "an attempt to enter the mind of this immortal illness, to understand its personality, to demystify its behavior." It is an epic story that he seems compelled to tell, the way a passionate young priest might attempt a biography of Satan.
Jonathan Weiner - New York Times


It’s time to welcome a new star in the constellation of great writer-doctors. With this fat, enthralling, juicy, scholarly, wonderfully written history of cancer, Siddhartha Mukherjee vaults into that exalted company, inviting comparisons to...Lewis Thomas and...Stephen Jay Gould.
Washington Post


It’s hard to think of many books for a general audience that have rendered any area of modern science and technology with such intelligence, accessibility, and compassion. The Emperor of All Maladies is an extraordinary achievement.
The New Yorker


Mukherjee's debut book is a sweeping epic of obsession, brilliant researchers, dramatic new treatments, euphoric success and tragic failure, and the relentless battle by scientists and patients alike against an equally relentless, wily, and elusive enemy. From the first chemotherapy developed from textile dyes to the possibilities emerging from our understanding of cancer cells, Mukherjee shapes a massive amount of history into a coherent story with a roller-coaster trajectory: the discovery of a new treatment--surgery, radiation, chemotherapy--followed by the notion that if a little is good, more must be better, ending in disfiguring radical mastectomy and multidrug chemo so toxic the treatment ended up being almost worse than the disease. The first part of the book is driven by the obsession of Sidney Farber and philanthropist Mary Lasker to find a unitary cure for all cancers. (Farber developed the first successful chemotherapy for childhood leukemia.) The last and most exciting part is driven by the race of brilliant, maverick scientists to understand how cells become cancerous. Each new discovery was small, but as Mukherjee, a Columbia professor of medicine, writes, "Incremental advances can add up to transformative changes." Mukherjee's formidable intelligence and compassion produce a stunning account of the effort to disrobe the "emperor of maladies."
Publishers Weekly


(Audio version.) Taking a strictly Western approach to the study and treatment of cancer, clinical oncologist Mukherjee presents a comprehensive, fascinating, and informative view of the subject that is part historical treatise, part biography, part memoir, part case study, and part science textbook. Two-time Audie Award winner Stephen Hoye does a great job of conveying all of the nuances of the narrative, which can jump around at times and includes a large number of footnotes. This highly accessible and quality audio production will greatly satisfy audiences liking titles that similarly attempt to humanize otherwise clinical topics, such as Seth Mnookin's The Panic Virus, Mary Roach's Stiff, and Atul Gawande's Complications. —Nicole A. Cooke, Montclair State Univ. Lib., NJ
Library Journal


(Starred review.) Apparently researching, treating, and teaching about cancer isn’t enough of a challenge for Columbia University cancer specialist Mukherjee. He was also moved to write a biography of a disease whose name, for millennia, could not be uttered. The eminently readable result is a weighty tale of an enigma that has remained outside the grasp of both the people who endeavored to know it and those who would prefer never to have become acquainted with it. —Donna Chavez
Booklist

Discussion Questions
1. Cancer is often described as a "modern" disease—yet its first description dates from 2500 B.C. In what sense, then, is cancer a disease of modern times? How does knowing its ancient history affect your notion of cancer?

2. Mukherjee frames the book around the story of his patient, Carla Reed, a teacher who is diagnosed with leukemia. What did you find interesting or important about Carla's experience? How do you think she shaped the author's life and thoughts?

3. Mukherjee writes how in the early 1950s The New York Times refused to print the word "cancer" (or "breast"). Compare this to how we view cancer today. Is there any difference in the way you discuss cancer as a political or news topic and how you discuss a cancer diagnosis among family and friends?

4. Looked at one way, Sidney Farber's early clinical trials with antifolates in 1947 and 1948 were a failure, with all of his young leukemia patients eventually dying of the disease. But with the results of these trials, Mukherjee writes, Farber "saw a door open—briefly, seductively" (p. 36). How so? Why do Farber's trials mark a turning point in the history of cancer research?

5. "The stories of my patients consumed me, and the decisions that I made haunted me," Mukherjee says about working in a cancer clinic (p. 5). But in the 1970s, during the height of aggressive combination chemotherapy trials, Mukherjee paints a different picture of doctor-patient interaction: "The language of suffering had parted, with the 'smiling oncologist' on one side and his patients on the other." How have the relationships between doctors and patients evolved along with cancer treatments? What could be done to restore some of the lapses in this relationship?

6. "'Li was accused of experimenting on people,' Freireich said. 'But of course all of us were experimenting… To not experiment would mean to follow the old rules—to do absolutely nothing.'" Review the case of Min Chiu Li (pp. 135-138), and explain Emil Freireich's quote. Do you think Li's actions were ethical? How can doctors and scientists draw the line between reckless, unproven treatment and necessary experimentation for drug development?

7. How did Mary Lasker borrow from the worlds of business, advertising and even the military to build a nationwide effort to combat cancer? How might Lasker's vision be invoked today to generate funding and national attention for breast or ovarian cancer?

8. So many of the scientific breakthroughs that impacted cancer research, such as Wilhelm RÖntgen's discovery of the X-Ray in 1895, occurred by accident. What other "chance" discoveries appear in the text?

9. Numerous advances in cancer research would have been impossible without patients willing to submit themselves to grueling experimental trials—experiences from which they did not benefit, but future cancer patients might. How would you counsel a friend or relative about submitting themselves to such experiments?

10. How is the early history of chemotherapy linked to the histories of colonialism, the Industrial Revolution, and World War Two?

11. Was the War on Cancer a failure? Why or why not?

12. How did the tobacco industry react to studies in the 1950s about the link between cigarettes and lung cancer? How did the industry's reaction differ to that of the general public? Do you think cigarette companies should be legally liable for cancer and other health problems likely caused by smoking?

13. The 1980 Canadian mammography trial (see pp. 298-300) was possibly flawed because technicians disproportionately steered women with suspected breast cancer to get mammograms, likely out of compassion. Put yourself in the technicians' shoes. Would you have allocated your friend to the mammogram group? If so, how can trials ever be randomized? Should a trial with a promising new drug be randomized—even if it means forcing some patients to be in the non-treatment group? What if a new treatment emerges for a deadly form of cancer? Should half the enrollees in the trial be forced to take sugar-pills to document the efficacy of the treatment?

14. On page 316, Mukherjee argues that "the trajectories of AIDS and cancer were destined to crisscross and intersect at many levels." Do you agree with Mukherjee's comparison? What did Susan Sontag mean when she said AIDS and cancer had both become "not just a biological disease but something much larger—a social and political category replete with its own punitive metaphors?"

15. Review the case of Nelene Fox (pp. 322-324), whose HMO, Health Net, refused in 1991 to pay for an expensive bone marrow transplant to treat her diagnosis of advances breast cancer, citing the procedure as "investigational." In your view, was it appropriate for Health Net to refuse reimbursement? Should patients pay for expensive experimental treatments out of their own pocket? What if these experimental treatments turn out not to extend survival—as with Fox's transplant?

16. The author says that he was motivated to write this book after a patient asked him, "What is cancer?" Mukherjee could not think of a book that would answer her question. So he wrote it. Does "knowing your enemy"—knowing cancer—bring some kind of comfort?

17. On page 459, Mukherjee writes, "As the fraction of those affected by cancer creeps inexorably in some nations from one in four to one in three to one in two, cancer, will indeed, be the normal—an inevitability." Mukherjee makes this assessment despite the approval of oncogene-targeting drugs like Herceptin, which have given new hope to cancer patients, as well as promising efforts to sequence the cancer genome. At the end of The Emperor of All Maladies, do you come away with optimism about science's efforts to combat cancer? Why or why not?

18. In the final chapter of the book, Mukherjee creates a fictional journey for Queen Atossa through time to demonstrate how cancer treatment has changed over the centuries. How might you have summarized this book? What image, or metaphor, emerges most powerfully at the end of this book?

19. Germaine Berne's story, which ends the book, is not superficially a story of hope, since she ultimately dies from relapsed cancer. Yet Mukherjee portrays her as a symbol of our war on cancer. In what sense does Germaine epitomize the battle against cancer? How is her story a story of hope?

20. Mukherjee calls this book a "biography." Can a "biography" be written of an illness? How might such a biography differ from the traditional biography of an individual? Are there other diseases that demand biographies, or is this project unique to cancer?

21. In what sense does history "repeat itself" in cancer research? In science, where new discoveries keep altering the landscape, what is the worth of reliving the past?
(Questions issued by publisher.)

top of page (summary)