The DO Book Club, Oct. 2021: The Emperor of All Maladies: A Biography of Cancer

Welcome back to The DO Book Club!

For October, Kevin Seely, OMS II, read The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee, MD.

If you’ve read this one, please share your thoughts in the comments below. And if you’d like to write a book review for a future month, please email rraymond@osteopathic.org.

Plot summary

Although despair and hope are diametrically opposed, readers of this Pulitzer Prize-winning book are somehow left feeling both. Siddhartha Mukherjee, MD , an oncologist, researcher, and award-winning science writer, investigates cancer with precision, perspective and passion, yielding an incredibly clear and expressive account of a condition that humans have lived with and died from for more than 5,000 years.

Through years of dedicated study, research and detailed history collection, Dr. Mukherjee produced a comprehensive literary biography of cancer that gratifies both the cerebral and emotional mind. From the first documented cancer diagnosis to modern-day therapeutics, with many deaths and cures in between, each page takes the reader deeper into the world of cancer, revealing its relentless ubiquity in medicine and humankind.

Published in 2010, the book tells the story of centuries of discoveries, losses, successes and deaths through the perspective of Dr. Mukherjee’s predecessors, peers and patients who have tested their will and wits against an infinitely resourceful disease. In 571 pages, the reader learns of cancer’s place in history next to seminal discoveries such as Dr. Joseph Lister’s sterile technique and the surgical prowess of William Stewart Halstead, MD.

Most notably, we learn of Sidney Farber, MD, “The Father of Modern Chemotherapy,” and his substantial contributions to early cancer treatment, including his monumental, albeit controversial, 1948 study on the first-ever genuine remissions of childhood leukemia after the injection of anti-folate. This study marked the impetus of chemotherapeutics and a new school of thought about cancer and its properties.

The book is divided into six sections that examine the formative events that have shaped cancer screening, diagnosis, treatment and prevention. In part I, the author mentions the first description of leukemia as “a suppuration of blood” by Dr. John Bennett and subsequent renaming to “leukemia” by Dr. Rudolf Virchow in 1847. Indeed, the progression of the nomenclature surrounding cancer provides a fitting starting place for the story of cancer.

Recognized as a natural progression of Dr. Rudolf Virchow’s tenets (First, the human body, like all other living organisms, is made up of cells, and second, cells arise from other cells), and with the differentiation of hyperplasia and hypertrophy, the recognition of cancer as “new growth” or neoplasia was groundbreaking in our understanding of cancer pathology. As the nomenclature progressed, so did our approach to treatment.

With naming and classification and subclassifications also came the development of surgery and anesthesia, as well as the concept of the radical removal of the tumor. In later sections, several milestones in the advancement of cancer treatment are recounted, including combination chemotherapy and targeted molecular therapies.

The reader is also guided through the history of cancer research, including the discovery of cancer-causing viruses and the two-hit hypothesis, which involves activated proto-oncogenes and inactivated tumor suppressor genes and a combination of genetic and environmental influences.

In the final section, we read of post-human genome project breakthroughs as science and medicine arrived at the understanding of cancer as a genetic disease. These achievements notwithstanding, it becomes clear that there are still mountains to climb in our efforts to suppress the ever-present grasp of cancer’s growth.

An oncologist by training, Dr. Mukherjee wrote this book not only to provide a history of cancer but also to share details on his early days as an oncology fellow. His personal accounts of treating patients offer a thought-provoking, humanistic perspective. As such, this book will likely appeal considerably to the aspiring physician, medical professionals and those whose lives have been directly affected by cancer.

Cancer and osteopathic medicine

“To find health should be the objective of any doctor. Anyone can find disease.” -A.T. Still, DO, MD

Part 4 is titled “Prevention Is the Cure,” in which the development of the Papanicolaou test and mammography as effective screening strategies for uterine cervix and breast cancers is reviewed. Smoking cessation is also introduced as effective primary prevention of lung cancer.

Later, as various carcinogens were identified and classified, such as H. Pylori and human papillomavirus, vaccination and avoiding exposure to carcinogens became essential prevention measures. As medicine’s understanding of carcinogenesis developed, so too did a mechanistic understanding of the processes by which normal cells become cancer cells, and ideas unfolded about how we might intervene in these processes.

That the body is capable of self-regulation and self-healing is a core osteopathic tenet. Osteopathic medicine also focuses on promoting health and prevention as the ultimate strategies in the fight against disease.

“Structure and function are reciprocally interrelated.”

This osteopathic tenet was powerfully depicted in the case of one of Dr. Mukherjee’s patients, Carla, who developed acute lymphoblastic leukemia. Of Carla he wrote, “Although superficially amorphous, bone marrow is a highly organized tissue that generates blood in adults. In Carla’s marrow, this organization had been fully destroyed. Sheet upon sheet of malignant blasts packed the marrow space, obliterating all anatomy and architecture, leaving no space for any production of blood.”

This potent description gives tangible significance to the osteopathic tenet defining the relationship between structure and function, implying that cancer’s destructive intrusion ultimately suffocates proper function until life is no longer possible. This account reinforced this principle’s significance for me as an osteopathic medical student striving to become a physician who considers the whole person.

Notable quotes

“Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.” -Susan Sontag, Prologue

“The secret to battling cancer, then, is to find means to prevent these mutations from occurring in susceptible cells or to find means to eliminate the mutated cells without compromising normal growth. The conciseness of that statement belies the enormity of the task. Malignant growth and normal growth are so genetically intertwined that unbraiding the two might be one of the most significant scientific challenges faced by our species.” -Page 6

Takeaways

The reader cannot help but feel sadness in reading the accounts of cancer patients throughout history, especially if they have had personal experiences with cancer. On the other hand, this book paints a picture of a world that does not yet exist but is conceivable and perhaps even possible—a world in which cancer is entirely curable in all its forms, or one in which it does not exist at all.

The Emperor of All Maladies is a book for anyone seeking to clarify or better understand cancer as not one single disease but a category of diseases with deep complexities. Its central message is that cancer begins and ends with human beings. As we carry on in our aggressive campaign to prevent and cure this malady, the book asserts that we must remember those patients, doctors and researchers who came before us and always remain humanistic and compassionate in our care.

November’s books

For November, The DO’s books column will review Station Eleven by Emily St. John Mandel, Mortal Lessons: Notes on the Art of Surgery by Richard Selzer, MD, and Physician Leadership by Karen J. Nichols, DO. We encourage all who are interested to read along (this book club can be followed at any pace)! If you are unable to get out to a local library or bookstore, we recommend checking out eBook options.

As a reminder, if you read The Emperor of All Maladies or any previous Book Club selection and want your reflections to be shared in future posts, or want to write your own book review for a future month, please leave a comment below or email rraymond@osteopathic.org.

Happy reading!

Related reading:

The DO Book Club, Sept. 2021: The House of God

The DO Book Club, Aug. 2021: The Undying