Open Book

The Specter of the Big “C”

A Modern Look at an Age-Old Malady

Magazine Issue
March/April 2011
Bookmarks March/April 2011

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.

Ultimately, the key to unlocking some of cancer’s basic mysteries has come out of a better understanding of its complexity. Only in recent years have scientists mapped the key components that the different forms and facets of cancer share: a variety of physiological mechanisms at the cellular level (simplistically put, disabled on/off switches and stop-and-go traffic signals), which allow abnormal cells to proliferate, spread, and infiltrate the body. Similarly, it’s only at the cellular level that all cancers can be said to possess a universal “cause” (“starting point” would be a better way to put it), in the form of an initial genetic mutation. As for what sets that initial process in motion: here, too, every form of cancer possesses its own set of suspects—a complex mix of genetics, environmental factors, lifestyle habits, pure chance, and other factors—that predispose or raise the risk of onset.

The practical applications of these insights have meant monumental clinical progress. The more specifics we know about the conditions under which normal cells turn cancerous, Mukherjee emphasizes, the better equipped physicians will become at targeting those aberrant cells and their fatally errant mechanisms. This explains why, today, each patient receives slightly different regimens or dosages of radiation or chemo. In sum, the days of the cookie-cutter approach—of using one type of radical surgery or radiation dosage for all patients—is past. “Viewing [cancer] as a single disease that will yield to a single approach is no more logical than viewing neuropsychiatric disease as a single entity that will respond to one strategy,” wrote National Cancer Institute director Richard Klausner in 1997.

In retrospect, Klausner’s statement seems obvious; but as Mukherjee demonstrates, that change of mindset took centuries. Even with today’s hard-won advances, cancer remains an enigmatic realm, where medical conundrums (how and why did the nasty tumor cells surgically excised and irradiated at Point A still manage to pop up in an even more virulent form in Points B and C?) are oncologists’ daily diets. Patients anxiously seek answers to questions whose resolution too often can only be guessed at. Is the remission real? or is it the calm before a metastasis? Are the benefits of the preventive treatment worth the risks of the side effects? Will I be better off going with an experimental regimen? or with a more traditional treatment? Such is the unstable roller-coaster land of dread, hope, and anxiety into which a cancer diagnosis can cast anyone, whether ourselves or those we care for, or care about.

Who isn’t included in this group? Statistically speaking (statistics being the lingo on which most oncologists rely, explains Mukherjee), the odds in favor of the prevention, cure (especially for young people), and ever-longer survival rates for just about every type of cancer appear to be improving. Paradoxically, however, precisely because of our longer life spans and lower mortality rates from other causes, statistics also favor more of us being diagnosed with cancer. Indeed, epidemiological surveys predict that approximately 40 percent of all American men and women born today will be diagnosed with some form of cancer.

Mukherjee makes sense of these statistics, among cancer’s many complexities, by structuring his narrative like a medical thriller that plays out through the millennia. The intractable enemy is cancer; the heroes are the scientists and doctors who hunt it down; the people in need of rescue are all of us. The story is ongoing and ultimately inconclusive.

“Perhaps cancer, the scrappy, fecund, invasive, adaptable twin to our own scrappy, fecund, invasive, adaptable cells and genes, is impossible to disconnect from our bodies,” the author muses near the book’s conclusion. “Perhaps cancer defines the inherent outer limit of our survival. As our cells divide and our bodies age, and as mutations accumulate inexorably upon mutations, cancer might well be the final terminus in our development as organisms.”

Which takes us back to what “The Big C” also stands for: our Cells—and, of course, learning to Cope.

Diane Cole

Diane Cole is the author of the memoir After Great Pain: A New Life Emerges and writes for The Wall Street Journal and many other publications.