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The enemy within

In his sweeping, humane chronicle of the war against cancer, an oncologist blends equal parts history, thriller, and memoir

By Jacob Appel
Globe Correspondent / November 21, 2010

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When breast cancer survivor Fanny Rosenow contacted The New York Times in the early 1950s hoping to advertise a support group for women with breast cancer, an editor informed her that the newspaper could not publish the words “breast’’ or “cancer’’ in its pages, and instead suggested announcing “a meeting about diseases of the chest wall.’’

That was an era when tobacco booths at the American Medical Association’s annual convention distributed free cigarettes to physicians and when many leading oncology researchers suspected what a 1962 Life magazine cover warned openly: “Cancer may be infectious.’’ It was also an era when the diagnosis of malignancy was, for the vast majority of those afflicted, a death sentence. Three decades later, inspired by the activists of the AIDS organization ACT UP, the politically empowered women of the Breast Cancer Action project stormed the California campus of Genentech in a successful bid to garner early access to a novel therapy, Herceptin.

At the same time, pioneering biologists like Robert Weinberg, Thad Dryja, and Steve Friend systematically unraveled the chromosomal mechanisms underlying carcinogenesis. Still, for the vast majority of those beset today with many solid tumors — lung cancers, pancreatic cancers, glioblastomas — a diagnosis remains a death sentence. The story of how we have come so far in the struggle against cancer, and why we have so much further to go, is the subject of oncologist Siddhartha Mukherjee’s “The Emperor of Maladies,’’ a meticulously researched panoramic history and deeply moving personal memoir.

Although Mukherjee describes his work as a “biography’’ of cancer, a fairer assessment is that he has written the definitive history of cancer’s enemies. Among the most notable of these were socialite-turned-crusader Mary Woodard Lasker, who once told a reporter, “I am opposed to . . . cancer the way one is opposed to sin,’’ and the indefatigable Sidney Farber, the Boston doctor whose one-man crusade nearly did for chemotherapy what Alexander Fleming’s penicillin did for antibiotics — and whose name would grace one of the nation’s preeminent cancer institutes. Yet at the core of Mukherjee’s saga are the research scientists and ward clinicians who devoted years to isolating the complex mechanisms by which environmental mutagens transform healthy tissue into one of humanity’s most feared scourges.

What makes Mukherjee’s narrative so remarkable is that he imbues decades of painstaking laboratory investigation with the suspense of a mystery novel and urgency of a thriller. His grass-roots account of the quest for potential treatments such as proto-oncogenes and tumor-suppressor genes, as seen through the eyes of the biologists in the trenches, rivals the best of Agatha Christie and Robert Louis Stevenson. Mukherjee is able to accomplish this because he possesses a striking gift for carving some of science’s most abstruse concepts into forms as easily understood and reconfigured as a child’s wooden blocks. The masterful analogies in this volume should earn Mukherjee a rightful place alongside Carl Sagan, Stephen Jay Gould, and Stephen Hawking in the pantheon of our epoch’s great explicators.

Much of “The Emperor of All Maladies’’ is threaded with a complex argument about the longstanding conflict between human beings and deranged cells. In the decade following World War II, zealots like Lasker sought to create a “Manhattan Project’’ for cancer that would tackle the disease with centralized planning and a relentless wave of resources. In contrast, Vannevar Bush, an electrical engineer who rose to become President Truman’s chief science adviser, favored a system of diffuse basic research over “programmatic’’ science dedicated solely toward precise, practical ends. DNA pioneer James Watson, among the best known of the anti-Laskerites, argued that the success of the Manhattan Project, and later the moon landing, rested upon a previous generation’s collected body of theoretical insights and empirical research of the sort not yet available to cancer’s foes. These two competing visions of the anticancer struggle finally joined in battle over the content of the National Cancer Act of 1971, ultimately a Pyrrhic victory for the Laskerites that ensured Richard Nixon’s “war’’ on cancer would be little more than a muted salvo.

That was 1971. The punch line of Mukherjee’s narrative is that today we do possess the knowledge upon which to ground a Manhattan Project against cancer. He quotes the arch-contrarian Watson himself, who in 2009 declared, “Beating cancer now is a realistic ambition because, at long last, we largely know its true genetic and chemical characteristics.’’ Mukherjee makes a compelling case for this central message: That the time for an all-out war on cancer has finally arrived. To what extent policymakers are listening is a question that he leaves for future volumes.

A refreshing aspect of Mukherjee’s history is his rare willingness to confront head-on the ways in which the medical intransigence and surgical hubris of his fellow physicians contributed to many of the worst excesses of the anticancer fight. These include well-known missteps, such as William Halsted’s much-replicated radical mastectomies, disfiguring (and unnecessary) operations whose “success’’ was measured in the number of ribs and collar bones removed. But Mukherjee also exposes the epidemic hostility of breast surgeons toward breast oncologists that prevented meaningful research on less invasive therapies, such as lumpectomies, for half a century.

As much as “The Emperor of All Maladies’’ is riveting history, it is also touching memoir. Mukherjee sutures together his accounts of promising clinical trials and petri dish setbacks with indelible portraits of the patients whom he encountered during his professional training in oncology: Carla, a schoolteacher with leukemia; Len, an athlete stricken with lymphoma. “Medicine,’’ Mukherjee writes, “begins with storytelling. Patients tell stories to describe illness; doctors tell stories to understand it.’’ Mukherjee’s stories prove heart-wrenching because he so clearly possesses the rare breed of compassion that — even in this age of sanitized and impersonal medicine — the best of caregivers still feel for their charges. If we make no further progress in the struggle against cancer, if we launch no Manhattan Project, the odds are that, on average, more than one in three readers of this review will eventually develop the disease. In exploring Mukherjee’s tour de force, these readers will meet the model of a physician most of us would want at our bedsides should that fateful moment ever arrive.

Jacob M. Appel practices medicine at Mount Sinai Hospital in New York City. He can be reached at jacobmappel@gmail.com.

THE EMPEROR OF ALL MALADIES: A Biography of Cancer By Siddhartha Mukherjee

Scribner, 571 pp., illustrated, $30