The Emperor of All Maladies.

Siddhartha Mukherjee, an Indian-born American oncologist who trained at the Dana-Farber Cancer Institute in Boston, won the Pulitzer Prize for Non-Fiction for his 2010 tome The Emperor of All Maladies: A Biography of Cancer, his first book and an enormous undertaking – an exhaustive attempt to chronicle the history of the disease itself and the ongoing scientific fight to cure it. Interspersed with anecdotes from his own oncology work, including several patients he treated – some who survived the disease, and many who did not – Emperor covers a truly incredible amount of ground, often with more detail than I needed to understand the story, and presents a sobering picture of how endless the efforts to treat and cure cancer will be, given the disease’s nature and ability to defeat our best weapons against it.

Mukherjee goes back to ancient Egypt and Greece to give us the earliest known examples of the disease’s appearance and explain how it got its name – it’s from the Latin word meaning ‘crab,’ and the word carcinoma comes from the Greek word for the same – but the bulk of the history in this book starts in the mid-19th century with the first real identification of a specific cancer, leukemia. The story wends its way through the late part of that century with the advent of radical mastectomies to remove breast cancer, disfiguring surgeries that would remove many muscles beyond the breasts and that were the brainchild of the coke-addicted surgeon William Halsted, who also conceived the modern residency program for new doctors that forces them to operate without sleep. We get the discovery that radiation causes cancer, and the related discovery that it might treat cancer as well, as would certain drugs that we now put under the umbrella of chemotherapy. Mukherjee takes the science thread all the way through what were, at the time, the latest developments in oncology treatment and research, including the ongoing identification of oncogenes (genes that, when switched ‘on,’ can produce cancer), proto-oncogenes (genes that become oncogenes with mutations), and anti-oncogenes (tumor-suppressing genes); and therapies that target specific cancer subtypes based on their genotypes – such as Herceptin, which has proven exceptionally effective against breast and other cancers cancer with the HER2 oncogene.

The science bits – my favorite, of course – are interspersed with much of the story of the American public policy fight over cancer, which led to a so-called “War on Cancer,” the passage of the 1971 National Cancer Act to boost the National Cancer Institute, and many breathless pronouncements that we were mere years away from finding a cure. The narrative lags at several points here – the origin story of the Jimmy Fund’s “Jimmy,” real name Einar Gustafson, is the big exception – although it serves as a reminder of how credulous the world was, including early researchers into oncology, about our ability to ‘beat’ or cure cancer. Cancer is not just one disease; it is many, probably hundreds, of diseases that all share the common characteristic of abnormal cell growth, but that can differ substantially by their origin in the body, and even for a specific source or organ can come in vastly diverse forms that require different, targeted treatments. The above-mentioned Herceptin works on HER2+ cancers, mostly breast cancer but sometimes appearing in gastric or ovarian cancers; it will be ineffective against HER2-negative cancers. Someone with ‘breast cancer’ can have any of several forms of the disease – each of which will respond in totally different ways to treatments. This is good news and bad news; the more we know about specific forms of cancer, the better that scientists can come up with targeted treatments to attack them, but there are also far more forms of cancer than we’d ever realized in the history of our fight against the disease. The single ‘cure for cancer’ is probably a chimera, because cancer is not just one thing, but a common attribute of many diseases, and stopping that attribute – rampant cell division – would kill regular cells too.

The Emperor of All Maladies is kind of a depressing read, between the awful outcomes for some of the patients described, but also because the outlook for the future of the disease is not that great. Yes, the medical world continues to search for and find treatments for specific cancers, some of which are the most effective drugs in the history of oncology, but it’s also clear that if your specific cancer isn’t one of those, the medical response is the same drug cocktail approach that has been the norm for decades – better than it was, and with the benefit of drugs to help combat nausea, but still an ordeal for the patient with modest success rates. And finding Herceptin-like advances for all cancers will take many years and billions of dollars that may not be available without a massive public investment. Dr. Mukerjee has put together a remarkable work of research and insight, written with great feeling for the individual patients fighting their cancers, but I left this book feeling worse about the war on cancer than I ever had before.

Next up: Dan Simmons’ The Fall of Hyperion.