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By Diane Cole

The Specter of the Big "C"
A modern look at an age-old malady

The Emperor of All Maladies: A Biography of Cancer
By Siddhartha Mukherjee
Scribner. 571 pp. ISBN: 9781439107959

In a nightmare rewrite of a beloved Sesame Street ditty, the irrepressible Cookie Monster—renamed Chemo Monster—would fatalistically croon, "C is for Cancer," moan "Why me?" and warily eye his oncologist-prescribed chemical-cookie regimen before blurting out what's really on his mind: will this un-yummy treat and its side effects lead to Catastrophe, or to Cure?

Alas, so pesky and persistent is the multifarious disease we call cancer, that not even oncologists know whether there'll be a cure. Indeed, the theme that runs throughout Siddhartha Mukherjee's The Emperor of All Maladies: A Biography of Cancer is just how elusive cancer remains for those forced to contend with it—whether as patients, survivors, family members, medical researchers, physicians, or psychotherapists. Mukherjee, in addition to being a remarkably assured first-time author, is an oncologist at New York's Columbia University Medical Center. He began this book to avoid his own burnout from 24/7 immersion in the physical and emotional devastations that fatal diagnoses can cause, and that form part of even the most successful treatments. "The stories of my patients consumed me, and the decisions that I made haunted me," he writes.

Only by viewing cancer from the larger perspective of history's timeline could he begin to see his work, and his patients' struggles, as part of a larger story of suffering and healing, to which they could contribute by working together. By contextualizing the disease, he could begin to answer, in his own mind, the questions he routinely heard from his patients: "Where are we in the 'war' on cancer? How did we get here? Is there an end? Can this war even be won?"

The result of Mukherjee's quest is a magisterial work of compelling urgency. He intertwines a profound examination of cancer's power to damage our bodies and souls with a history of the human resilience and scientific determination that have fought this defiant and mystifying ailment over the past millennia (evidence of malignancies have been discovered in human fossils thousands of years old). He does so by interspersing the stories of his patients' encounters with cancer and accessible explanations of the long journey that medicine itself has taken, from the excruciatingly painful, hit-or-miss treatments of the past to today's more sophisticated, focused approaches.

The variable pace and distance of that journey is exemplified in breast cancer's treatment through the ages. An Egyptian medical text from 2500 B.C. describes "a bulging tumor in [the] breast . . . like touching a ball of wrappings," but provides no hope for any treatment at all. So perhaps it should be seen as progress that in 500 B.C., Queen Atossa of Persia, suffering from a breast tumor oozing blood, could pursue some form of treatment: having her slave slice off the breast. As primitive as that sounds, Mukherjee reminds us that ever-more aggressive treatments were routinely performed on women into the 20th century, in the belief that the more tissue and muscle and bone that could be cut away, the less chance there'd be of recurrence. While Mukherjee focuses most of his narrative on the revolutionary scientific and medical discoveries that have transformed cancer treatment in the past century, neither he nor his readers can escape wondering how future generations will regard our "highly refined," modern-day approaches.

Throughout, Mukherjee presents an uncommonly clear portrait of cancer's ambiguities. First of all, how does one even define cancer? Contrary to the notion—originating in ancient times and still at play in popular usage—that it's a single disease with one cause and therefore one cure, scientists have come to know that the term actually encompasses a broad spectrum of diseases, each of which manifests different symptoms, requires different treatments, and leads to different prognoses. That's a crucial distinction because—as Mukherjee's historical chronicle painfully demonstrates—the bias toward the unitary theory of cancer was so strong, well into the 20th century, that it kept researchers and clinicians from considering other paradigms to explain the distinct expressions of cancer, which can be so unlike and like at once.

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