It may not be a new book anymore, and I actually read it a few months ago, but I would like to share my thoughts on Siddhartha Mukherjee’s The Emperor of All Maladies. Dr. Mukherjee subtitled his book, “A Biography of Cancer.” Much has been made in other reviews about the significance of this subtitle, and what it means to the approach he took to his topic – the history of cancer therapy.
I am fascinated by the history of medicine. When I teach residents about current sarcoma therapy, I always teach them the history of how we got to where we are. Dr. Mukherjee took this approach to its logical extreme, beginning with the first known record of the disease in ancient Egypt all the way to the present.
The main theme coursing its way through the book is the evolution of our therapies from radical to targeted. Mukherjee starts with the 4th century BC Persian Queen Atossa, who commanded her servant to cut her breast from her body, and traces the evolution of surgery up through Halsted’s radical mastectomies in the early part of the 20th century and then to our current practice of lumpectomy, showing along the way how medicine is shaped by the personalities of those who set the standards of care.
Dr. Mukherjee gives chemotherapy a similar treatment, tracing the evolution of systemic therapies from the use of single chemotherapy drugs (beginning with nitrogen mustard-derivatives and anti-folates), through high dose chemotherapy with stem cell support, and back to the current vogue of molecularly targeted therapies.
Reading the novel as a oncologist who treats children, I was, of course, thrilled with the center stage given to pediatric oncology, especially the focus on childhood acute lymphoblastic leukemia as the first example of the successful use of chemotherapy to cure cancer. Given the importance cooperative groups have played in the development and dissemination of cancer therapies over the past 40 years, I was a bit disappointed at how little attention was paid to the role of these organizations in advancing cancer treatment. Reading this book, you would get the impression that most important clinical trials were run by small groups of physicians at their own hospitals. The staggering successes seen in pediatric oncology over the past 30 years have come about almost entirely as a result of pediatric oncologists working together across the country to perform the kind of trials that would otherwise be impossible.
My other problem with the book is a common problem among medical oncologists – a marginalization of the successes of pediatric oncology. In his effort to support the thesis that radical treatments (radical surgery, high dose chemotherapy…) are of little value, and that the future of cancer treatment is molecularly targeted therapies, Mukherjee substantially downplays diseases where high dose chemotherapy has been shown to make a difference. Randomized trials have demonstrated superior survival for children with neuroblastoma if they have high dose chemotherapy with stem cell support compared with standard chemotherapy. Neuroblastoma is the most common solid tumor of childhood, so this is not an insignificant finding. High dose chemotherapy clearly improves the survival of both children and adults with relapsed leukemia. Sure these diseases are not as common as breast cancer, but they serve as stark examples of how in some cases, the radical treatments Mukherjee deplores clearly improve survival.
Certainly childhood cancer is biologically distinct from the common adult tumors (breast, prostate, lung, colon), and what works for kids may not work for adults. But the paradigm pioneered by pediatric oncology – the cooperative group – is responsible for some of what Mukherjee proposes are the most important advances in adult cancer (such as the National Surgical Adjuvant Breast and Bowel Project). As I have said before, I think the medical oncology world has a lot to learn from the advances made in treating and curing cancer in children, and I wish that high profile works like this one did more to emphasize that point.
Nevertheless, I really enjoyed this book. It makes the history of medicine an easy read, and its focus on the personalities of some of the giants in our field was truly fascinating. If you have even a passing interest in oncology (and if you’re reading my blog, you must), you’ll enjoy this book.