Cancer is not so much a disease as it is a kind of existence
When I picked up The Emperor of All Maladies, I was seeking answers to some very specific questions – what exactly are the physical changes that arise when one has cancer; what is the difference in nature of the different types of cancer, when stripped away from the nature of the affected organ; and how close are we from its cure.
Mukherjee, an oncologist by profession, started toying with the idea for the book around 2004. Six years later, he shared the final drafts of this immensely well-researched book with the publisher. The book would go on to win the Pulitzer Prize.
Admittedly, cancer is not so much a disease as it is a kind of existence. Mukherjee mentions in the book how the clutches of cancer inure one to it, to the extent that a life outside it is not simply difficult to imagine, it sometimes becomes impossible to imagine. This is most vividly brought to the reader’s attention when Mukherjee quotes a cancer patient as saying that living with her disease “is the new normal”.
There are a few foundational reasons for this. I think the most important reason is that very few diseases in human history have remained not simply unexplained, but also without any preventive, palliative or curative solutions for so long – one of the first mentions of cancer, now believed to be that of breast cancer, can be found in the writings of Imhotep in Ancient Egypt nearly five millennia ago.
This long time interval has cloaked the disease with a psychological armor of invincibility, surrounded by an air almost of reverence and, finally, subjugation.
Mukherjee leaves no stone unturned as he charts out this history of cancer. Chapter by chapter, in a brilliant exposition, he carries the reader through the five distinct modern approaches to the cure of cancer, most of them having emerged after the late nineteenth century.
Prior to the nineteenth century, surgery of the afflicted organ was often chosen as one potential cure of cancer. It is only with hindsight that we are able to see how inappropriate this approach was.
Take the example of breast cancer. Not only did mastectomies cause immense pain in the pre-anesthesia times, they also led to severe physical disfigurement. To top it all, the women who had to undergo this harrowing emotional and physical experience, took it in stride as something they were morally obligated to bear. Mukherjee mentions the words of a pre-nineteenth century physician who said he had been so “loathe to disfigure [a patient]”; and of a woman who gave a short speech thanking the doctor after her mastectomy.
As we enter the second half of the nineteenth century, this surgery takes a more radical turn and even larger parts of the human body, especially in breast cancers, are beginning to be excised. As we realise now, this was a blind race and the surgeons were shooting arrows in the dark, incorrectly correlating the volume of organ removed with better chances of cure (this logic holds no water in cancers that have metastasised; and where it hasn’t, even a simple local surgery would have sufficed).
The second stage that followed was the use of radiation to kill off tumor cells.
The third was chemotherapy, which involved the consumption of pharmaceutical drugs by patients. These drugs were not targeted, thereby harming the normal cells as well along with the cancer cells.
The fourth was adjuvant chemotherapy. This was a more rigorous version of chemotherapy that was continued even after all visible signs of cancer were gone – this was to prevent cancer’s relapse (i.e. its return) which often, though not necessarily, happened due to the cancer cells’ ability to metastasise (move to other parts of the body that were not being treated for cancer).
And finally, advancements in genetic and molecular engineering gave rise to targeted therapy, which could kill cancer cells with specificity while not harming the normal cells.
In a parallel arc, he also covers some crucial political, legal and socio-economic developments in the story of cancer, which changed how the disease, and its patients, were perceived; how it led to new preventive strategies (for example, the landmark ruling to label warnings on cigarette packets) and how it precipitated research for its cure.
But, at the same time, it seems that Mukherjee failed to gauge the relevance of certain strands of the scientific and humanistic arcs of cancer, for a reader. In such sections of the book, he becomes a chronicler of history, giving the impression that he is almost obligated to present details on account of propriety.
Most frustratingly, so many scientists, researchers and activists are mentioned by name, that one sometimes misses the woods for the trees. Then again, Mukherjee doesn’t necessarily want us to remember each of them by name, but this profusion inhibits the reader’s ability to keep a track of even the most important characters of the story.
The second issue I had with the book was the slightly excessive focus given to the social and political activism that would understandably be very intrinsically linked with the historical developments of a disease with such a nature as cancer and though I would personally have preferred a book that covered only the scientific principles at work, the political, economic, legal and social biography that was covered may be useful for someone looking for a more comprehensive historical perspective of this dreaded disease. Indeed, I am willing to overlook this dissonance as more on account of my own expectations from the book, than as an indication of any issue with the book’s narrative.
Thankfully, Mukherjee spends the last chapter giving a condensed version of the developments in the search for a cure of cancer and these last few pages manage to contextualise the rest of the pages – thus evoking relief and dismay in equal measure, and each on two counts.