The Emperor of All Maladies

Siddartha Mukherjee

ISBN 978-1439-107959

Published by Scribner in 2010

In short: An incredibly well done "biography" of a disease that impacts us all uniquely. Mukherjee covers an astonishing breadth of subject matter from Egyptian Imhotep's teachings of 2625 BC indicating, "Therapy: There is none." to the latest advances and theory on cancer. This is the story of ambitious experiment and discovery that is the story of cancer research. And gratitude is paid to the many patients whose lives and deaths added to our current knowledge of this disease.

Cancer has had a profound impact on my life mainly due to significant family history and loss of loved ones to terminal cases. My direct exposure to cancer was well before I had completed any formal training in EMS. My role then was as the son of a victim; a contributor of hope, unskilled care and comfort. Memories of this time burn in my heart with incredible distraction and will be forever unresolved. The wasting of a human being as a result of this disease is something that no one should have to endure or observe. I suppose that is why I approached The Emperor of All Maladies with both trepidation and intense interest.

Mukherjee is a rare author. Many have taken a biography and made a page turner of it. To do so with a popular personality is routine; take a black glossy dust jacket, add a portrait of the subject, splash the title on with gold lettering, and, finally, fill the pages with reflection and anecdote. But in The Emperor of All Maladies, Mukherjee has done it with a disease that can't speak, has countless occurences of the same story, and takes a very poor picture. His subject also benefits from no sympathy or endearment. This is, however, a remarkable story.

Based on the publisher's interview with the author and the introduction of the book, the motivation for it was his own patients. One of them asked him "Where are we in the war on cancer?" Humbled by his lack of a ready answer, he began researching the book. In another interview with the author he notes that he started the work as a history, but realized that it really was a biography: a biography of a disease and the multitudes that have been afflicted by it and worked against it.

There is a constant undercurrent in the book that stresses the importance of cancer patients in our attempts to understand the disease. Even when that patient is an ancient Peruvian mummy showing signs of malignant cancer in her bones the reverence paid is clear. The history of cancer researchers such as Sidney Farber is retold without apology for generally toxic treatment strategies more focused on cure than understanding the disease. In fact, this imbalance between trial and error and intentional design is another common theme on these pages. The other is the dichotomy among surgeons and chemotherapists who often worked insularly without considering the benefit of potential combined treatment which is so commonplace today. Palliative care is given as much credence in this work as surgical, pharmacological and radiological care. Finally, after the long historical road has been traveled, prevention is presented as the best cure.

Of all the patients we encounter in EMS, I find cancer patients some of the most challenging. These are full-time patients; they have seen it all and felt pain way beyond "severe." I find them generally eerily comfortable with mortality and stoic in their needs. I feel inadequate since resolution of their complaints are limited generally to basic palliative care.

The description of various types of cancers and mechanisms of migration found in the book are helpful for visualizing what patients are confronted with. The in-depth coverage of the diverse approaches to cancer research over history is instructive on several counts. Despite a heavy focus on data-driven care and quality improvement, sometimes there simply is no data or no known solution given the data. Trial and error will be required. Sometimes solutions come from completely unexpected sources; like early chemotherapy being derived from an errant mustard gas deployment during WWII.

Coverage of the political and social aspects of cancer research over time are incredibly interesting and instructive. The roles of certain non-medical participants in the nascent field instill faith in humanity and the revolutionary power embodied in one person. The leverage of the burgeoning entertainment industry by the early Jimmy Fund demonstrates that not all big ships turn slowly.

I have high standards for historical writing, and consider Mukherjee a master of this genre. it may be that the subject is close to home, but I suspect it will be close to home for any reader. If you are going to read a book about an awful subject, it better be well written, informative and engaging. And this is.