The Emperor of All Maladies

As I explained earlier this week, I've been feeling overwhelmed and more than a little anxious lately.

Everyone has coping skills that help them manage the stresses of daily life. Psychologists rate coping skills along a continuum from pathological to mature. I have a variety of defense mechanisms that I fall back on in a Chinese menu kind of way: one from column A, one from column B and another from column C.

When I'm behaving maturely, I tend to use humor to help me manage while, at the same time, I suppress the uncomfortable thoughts and feelings. When the stress increases, I fall back on less mature mechanisms like intellectualization and magical thinking.

This month, I did not pass "go"; I went straight to those neurotic coping skills.

Since I was anxious about having to face yet another Mohs surgery for skin cancer, I fell back on my immature defense mechanisms. First, I upped my exercise routine from five nights a week to seven (thereby magically "undoing" the unhealthy situation by acting in a more healthy manner).

But because on the face (no pun intended) it was cancer that was frightening me, I intellectualized that a book would give me more information on the subject, theoretically increasing my sense of competence and control (while at the same time permitting me to suppress my fears related to my mother's steady deterioration).

Last November, I first heard about such a book during an interview on NPR's Fresh Air. Since that time, the book won the 2011 Pulitzer Prize for general non-fiction. The title is The Emperor of All Maladies: A Biography of Cancer, and the author is Dr. Siddhartha Mukherjee, an assistant professor of medicine at Columbia University.


I remembered the interview clearly and especially a segment in which Dr. Mukherjee was asked to describe what causes a cell to become cancerous. I went back to find that broadcast of Fresh Air, in which he said:

In cells, there are genes that are present whose normal function is to regulate the growth, the metabolism and the cell division of cells. And corruptions of these genes, mutations of these genes, essentially activate or inactivate critical processes that act like accelerators and brakes. So to rephrase this, you can imagine the cell as a molecular machine, and cell division is one of the activities it performs. And there are accelerators and brakes on cell division ...

By mutating genes, if you jam the accelerators or if you mess up the brakes, then the cell doesn't know how to stop dividing and it begins to divide incessantly. And part of that division also creates even more mutations. Sometimes there are genes that can be mutated which can accelerate the mutations of other genes, and this process goes on and on until you have a cell which is now capable of infinite cell division and does not know when to stop dividing. And that's what unleashes a cancer cell. But that said, I think that's just the beginning of an understanding ... there are many, many other features of cancer which are still in their infancy in terms of our understanding.

Two weeks into it, I'm a little more than halfway through the book, which is astonishing to me. I'm accustomed to reading most books--both novels and non-fiction--in a couple of days. However, my desire to understand this subject matter has me taking detours via the Internet to buttress my small store of high school science knowledge.

As an example, I remembered there were three kinds of cells (red, white and platelets), but couldn't for the life of me remember what platelets do (assist in the clotting of blood). And I absolutely did not remember where blood cells are manufactured (in the bone marrow). And I swear to God when I went through school, we were never taught that our immune systems have three major types of lymphocytes that fight infection: T cells (thymus), B cells (bone) and NK cells (natural killer).

Dr. Mukherjee is very thorough in his approach. He describes the history of the study of cancer from its earliest beginnings: a papyrus in which an Egyptian physician who lived around 2625 BC describes a case "having bulging masses on [the] breast that ... have spread over his breast." Under therapy, Imhotep says only "there is none."

The good doctor Mukherjee has a tendency to devolve into what I would describe as "purple prose" through his use of metaphors and similes. I laughed out loud at this sentence: "But Cole now wondered whether Halsted had tried to cleanse the Augean stables of cancer with all the right intentions, but with the wrong tools."

I am, however, struck by his humanity in recounting the story of cancer. He openly addresses the arrogance of physicians who refused to consider any theories of cancer which did not fit their own world views. In the early-1970s when an oncologist at the National Cancer Institute (NCI) proposed a treatment regimen of surgery followed by chemotherapy, no American surgeons or chemotherapists could be located who would agree to such a protocol. As the result of all that hubris, the NCI was forced to sponsor that first clinical trial at the Istituto Tumori in Milan, Italy where "Bonadonna and Veronesi, the only surgeon-chemotherapist pair seemingly on talking terms with each other" agreed to accept an award for the NCI trial. The results of that trial shook "the terra firma" of cancer research. The combined treatment "prevented breast cancer relapses in about one in every six treated women," a stunning victory at that time.

I also sensed Dr. Mukherjee's outrage was genuine when he talked about the medical profession's failure to focus on symptom relief and comfort of the patients who were dying under their care. "The movement to restore sanity and sanctity to the end-of-life care of cancer patients emerged, predictably, not from cure-obsessed America but from Europe."

It is staggering to me to realize how far cancer treatment has come over the last forty years. Just this week, I read a newspaper article about an experimental drug that has killed a "rare, stubborn form of cancer called acute promyelocytic leukemia ... Tamibarotene ... is a retinoid drug that induces [immature] cancer cells to differentiate into mature cells and eventually die."

Bottom line, I'm feeling more optimistic and want to recommend this book to anyone dealing with (or simply interested in) the subject of cancer.