The Doctor Knows Best

A sweeping history of cancer the eureka moments,the false starts and those who have battled the bad cell.

In The Emperor of All Maladies,cancer physician Siddhartha Mukherjee sets out not only to write a sweeping history of cancer but also to capture our imagination while doing so. He does this by identifying and bringing to life through some vivid vignettes those who have played a role in helping us move closer to an understanding of cancer and what is needed to treat people diagnosed with it. The circumstances that have led to discoveries have often been serendipitous,and the cast includes a wide range of characters: doctors,scientists,socially prominent people,activists,cancer survivors,patients and their families. It is these stories that fascinate and make it difficult to put this volume down.

The tale begins in the 1940s with Sidney Farber,a pathologist specialising in the study of childrens diseases in Boston and a pioneer of chemotherapy,and his young leukaemia patient,Robert Sandler,to whom the book is dedicated. It goes back to William Stewart Halsted and his radical surgeries for breast cancer in the late 19th century,as it was believed that cancer was a local occurrence and the more you removed of the organ affected the better. In the early 20th century,radiation using X-rays entered the cancer armamentarium. By the 1950s,it was paired with chemotherapy as the wisdom now was that cancer was a systemic disease that had to be treated with therapeutic drugs. By the 1980s,more and more toxic combinations of drugs were given to patients as survivorship figures slowly began to rise. What followed thereafter was more of the same with bone marrow transplants promising a cure even as they threatened to push people over the brink.

What is remarkable about this account are the many false starts,the successful campaigns conducted to bring cancer to public and national attention in the US,and the eureka moments which were often the result of the dogged determination of a few who were willing to persist and take their chances.

However,the period between 1983 and 1993 was the golden decade for researchers as the discovery of oncogenes and tumour-suppressor genes and the pathways they use for cell proliferation situated the genesis of cancer firmly in the human cell. It was now possible to think of treatments which were tailor-made to offset specific genetic mutations.

For those looking for hints to a simple cure for cancer,this book has no answers. However,it reminds us that discoveries in science have shown the capacity to change the course of illnesses and our ability to combat them. Cancer has certainly come a long way since 2500 BC when it was first recognised by the Egyptian physician Imhotep as an illness for which there is no treatment or from the time of Hippocrates who gave cancer its name,karkinos. Today,more and more people are being cured of cancer and living longer with their disease than in any other time in history. Hope lies in the passion of people who have never allowed challenges to deter them as well as in the attempt to create a colossal atlas of cancer which will be a compendium of every gene mutated in the most common types of cancer. Mukherjee has brought both these aspects to our attention in this remarkable book.

In the final chapter in his book,he highlights the steady advances that have been made over the years in the treatment of cancer and which have resulted in more and more people living longer and more fruitful lives. He invites us to travel back and forth across time with the Persian Queen Atossa who was diagnosed with breast cancer in 500 BC and underwent the most primitive form of mastectomy performed by her own slave. By the time she arrives in the mid-1990s,Mukherjee says,the management of her breast cancer would involve treating a mutation in her genome and checking to see whether her daughters too have the mutation so that steps could be taken to ensure that cancer never enters their lives.

However,as Mukherjee rightly warns,while this is good news for breast cancer and a few other cancers such as chronic myelogenous leukemia and Hodgkins disease,the prognosis for those diagnosed with many other types of cancer has hardly changed by more than a few months over 2,500 years.