Tuesday, February 22, 2011

The Emperor's New Book


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.

Related Posts:

11 comments:

Christy Griffith said...

I am about 200 pages into this book...I agree it's a most-interesting read. Mom to a bilateral anaplastic WT survivor gets excited when she sees words like "doxorubicin" and "actinomycin-D" used in a context she can understand.

-Christy
www.evegriffith.blogspot.com
www.reddye48.blogspot.com

Lorin Decker Buck said...

David,

I'm only 130 pages into "Emperor," but then I'm trying to memorize it as I go. ;-) Seriously, the story is giving me a much deeper appreciation for how tricky cancer is to manage -- much less cure -- and why development of effective treatments is such a slow process. So in a big way it's helping me understand what happened to David, and in a small way it's helping me accept that he couldn't be cured. But in many ways, it's frustrating me to see how hard it is to conquer this "emperor."

It's been neat to see so many familiar names in the book -- doctors for whom buildings at Hopkins have been named. :-)

Lori
www.the5bucks.com

DIY Health said...

This is really interesting. My mum died of cancer and I can't imagine what will she endure if she died during those periods when there were no anesthesia's, chemo therapies and pain relievers.

viagra online said...

So the guy who invented modern surgery was just an addict!

Harivansh Rai said...

It is a book which brings you the history, the present and the future of CANCER.
The book moves around the earliest discoveries of this disease, its symptoms and cures and then moves into the present day explaining how the ttreatments matured into what they are today. It also touches the political aspects related to the ethicity of the treatments.
It finaly ends by explaining all that we know today of this deadly disease and telling us of the possible journeys which medical sceince is taking towards finding a cure for this.

Genmedicare said...

Kamagra (Sildenafil) is an ingredient which is present in Viagra. It is an FDA approved the oral medication for the treatment of erectile dysfunction (ED). Viagra is the brand name of the medicine which is being invented by Pfizer. Kamagra assists in the relaxation of blood vessels and improves the flow of blood towards the pen*s for achieving hard and also long lasting erection. We also have in stock (kamagra 100mg,Buy kamagra 100mg,Cheap Kamagra 100mg,Kamagra 100mg Tablets,Kamagra,kamagra tablets how to use,kamagra sildenafil 100mg,Kamagra Gold,kamagra gold 100,kamagra 100 gold,Kamagra Effervescent,Kamagra oral jelly review,buy kamagra oral jelly,kamagra jelly,buy kamagra jelly online,kamagra 100mg oral jelly,kamagra 100mg oral jelly how to use,kamagra 100 mg oral jelly,kamagra oral jelly 100mg,kamagra chewable,kamagra 100 chewable tablet,kamagra soft tablets,kamagra soft tabs,best place to buy Kamagra online,Super Kamagra 100mg) which is used to treat the same indications.

Merry jack said...

The Vidalista (Tadalafil, also known by the Brand Name Cialis), which is one of the most prescribed drugs, that are meant for the treatment of erectile dysfunction. In contrast to other oral medications which have been prescribed for ED, the effect of Tadalafil may last for up to 36 hours, and this is a reason why it is also called as the weekend pill. We also have in stock (Vidalista,Vidalista 40,Vidalista 40 reviews,Tadalafil 80 mg,Tadalafil chewable,Tadalafil sublingual) which is used to treat the same indications.

Fildena 100 said...

The Sildenafil Citrate composed Fildena pills works extremely well in the presence of complete sexual arousal. The medicine also helps in avoiding repeated failure of penile for providing a spontaneous erection. Actively composed of Sildenafil Citrate, this ED pill is an ideal choice for men with some of the severe erectile dysfunction conditions.We also have in stock (Fildena,fildena 25,fildena review,fildena super active,fildena extra power 150 mg,sildenafil fildena,fildena 100,fildena 50 purple,fildena 150,Blue pills) which is used to treat the same indications.

Fildena 150 said...

Appropriate consumption of Fildena pills can help sexually aroused men with max 6 hours of effective outcomes. For attaining maximum effective outcomes, take the ED pill in presence of complete sexual arousal before the planned session.We also have in stock (Fildena,,Fildena 150,fildena 25,fildena 100,fildena reviews,fildena 100 side effects,erectile dysfunction,What is fildena,fildena For sale) which is used to treat the same indications.

Cenforce 150 said...

Men continue an erection during sensual interaction after using Cenforce 150 medication.

Thomas hardy said...

Finding out the best way to cure Malegra 100 is not a straightforward task but research has shown that men can use Ginkgo Biloba to treat the treatment of erectile dysfunction. It is a simple and natural treatment. It is vital to apply this supplement and other prescribed or natural remedies with care from a qualified doctor. If you buy an herbal Ginkgo supplement, you're not certain of the amount of ginkgo in the pills, therefore getting the right advice from your doctor or health healthcare professional is required.


In men, erectile dysfunction is also referred to as impotence, can affect many males. Sometimes, the issue is only temporary. In other instances, Hotmedz an ongoing problem. The prevalence that ED is a cause of ED has been found to be 4 times greater among men who are over 60 than in the 40s and 50s.