A biography of cancer

In his book “The Emperor of All Maladies: A Biography of Cancer“, published in November 2010, Dr. Siddhartha Mukherjee weaves an ironically beautiful story of the life and times of one of health’s greatest adversary – cancer.

It is no wonder that this book won the Pulitzer Prize for General Non-Fiction, is on magazine TIME as one of the most influential 100 books in the last century and the New York Times magazine as among the 100 best works of non-fiction.

The sad truth is, we all have one immortal illness. From the day we are conceived, there is an interplay of existence between normal and abnormal cells in our body. “Cancer is not one disease but many diseases. We call them all ‘cancer’ because they share a fundamental feature: the abnormal growth of cells.” Both normal and abnormal cells reside in each and everyone of us. Like good and evil, they both co-exist. The dichotomy in the opposites of life. Yin and Yang. Black and White. Justice and injustice. Heaven and earth. Cancer cells are part of us. When abnormal cells proliferate, they take over the cellular regeneration of other cells in our body. The normal cells are eventually replaced by abnormal ones. Because life is one real battlefield. And survival, is that of the fittest.

Cancer, we now know, is a disease caused by the uncontrolled growth of a single cell. This growth is unleashed by mutations – changes in DNA that specifically affect genes that incite unlimited cell growth. In a normal cell, powerful genetic circuits regulate cell division and cell death. In a cancer cell, these circuits have been broken, unleashing a cell that cannot stop growing.

Cancer is built into our genomes: the genes that unmoor normal cell division are not foreign to our bodies, but rather mutated, distorted versions of the very genes that perform vital cellular functions. And cancer is imprinted in our society as we extend our life span as a species, we inevitably unleash malignant growth (mutations in cancer genes accumulate with aging; cancer is thus intrinsically related to age). If we seek immortality, then so, too, in a rather perverse sense, does the cancer cell.

“The Emperor of all Maladies: A Biography of Cancer” by Siddhartha Mukherjee

As early as almost five thousand years ago, the Egyptian physician Imhotep had reference to the disease, in his writings that describe and affliction characterized by “bulging of the breast”, and resistant to any known therapies. From Bennett to Virchow to Farber…this history of cancer is by far a deep and perplexing. Several thousand years down the road and we have barely notched the iceberg of neoplastic diseases. As various therapeutical modalities are developed to address what we do now know of certain cancers, the cancer cells seem to adapt for their own survival as well. No matter how we look at any form of disease wrought by cancer, all were deeply connected at the cellular level. They had one characteristic – an uncontrollable pathological urge to cell divide.

In a National Geographic article, it notes that the likely reason “cancer is a relative newcomer in the historical record is that it commonly afflicts those 65 years and older, and for a long time, few people lived long enough for cancer to be a concern.” While this may not be exactly good news for those growing older, it is inevitably the disconsolate painful truth. As Susan Sontag puts it bluntly, “Now it is cancer’s turn to be the disease that doesn’t knock before it enters.”

As Mukherjee puts is succinctly, “Civilization did not cause cancer, but by extending human life spans, civilization unveiled it.” The longer we live, the more likely that we will all have some form of cancer. Which will be our most likely exit from this world.

In the biography of cancer, Mukherjee takes us to a labyrinth of medical history, so graphically written and accurately detailed it makes one feel like part of the explorative journey to the root of the emperor. And like a Netflix series, his story telling ability will keep you mesmerized. A page-turner in every sense of the word, his graphic and dramatic description of cancer as an omnipotent lord of maladies will make even a layperson understand the history, physiology, pathology, treatment and outcome of cancer.

Cancer is not simply a clonal disease; it is a clonal evolving disease. If growth occurred without evolution, cancer cells would not be imbued with their potent capacity to invade, survive, and metastasize. Every generation of cancer cells creates a small number of cells that is genetically different from its parents. When a chemotherapeutic drug or the immune system attacks cancer, mutant clones that can resist the attack grow out. The fittest cancer cell survives. This mirth, relentless cycle of mutation, selection, and overgrowth generates cells that are more and more adapted to survival and growth. In some cases, the mutations speed up the acquisition of other mutations. The genetic instability, like a perfect madness, only provides more impetus to generate mutant clones. Cancer thus exploits the fundamental logic of evolution unlike any other illness. If we, as a species, are the ultimate product of Darwinian selection, then so, too, is this incredible disease that lurks inside us.

“The Emperor of all Maladies: A Biography of Cancer” by Siddhartha Mukherjee

The fundamental science of oncology has nothing to do with the evolution of cancer. These abnormal cells are with us in some strange way. From the air we breath, the food we eat, the living conditions or even some viral infection (Hepatitis B, Human Papilloma Virus, Ebstein Barr Virus, to name a few) that has triggered the transformation of normal cells to atypical ones and eventually to a cancerous disease has remained perplexing, mysterious, and a formidable foe to medical science.

The turn of the 20th century saw vaccines as the biggest contributor to preventing infectious diseases from eliminating the human population. The discovery of vaccines has dramatically averted morbidity and mortality from microorganisms that once upon a time had practically eradicated a nation. Drug discovery programs addressed treatment for chronic non-communicable illnesses, thereby improving the outcome and prognosis for diseases that used to have debilitating consequences.

The 21st century together with the rapid advances of science and technology changed the landscape of medicine. While the environment we live in has become more livable and human survival is at an all time high (70 is the new 60), living up to a century old has now become the goal. The search for immortality is at a frenzy. We all want to live forever. But forever will always have a price tag to pay.

The laws of medicine are really laws of uncertainty, imprecision, and incompleteness. They apply equally to all disciplines of knowledge where these forces come into play. They were laws of imperfection.

Law One:

A strong intuition is much more powerful than a weak test.

Law Two:

“Normals” teach us rules; “outliers” teach us laws.

Law Three:

For every perfect medical experiment, there is a perfect human bias.

“The Laws of Medicine” by Siddhartha Mukherjee

In spite of the rapid developments in the diagnosis and treatment of various diseases affecting human health, the scourge and challenge of cancer has remained a tough “cookie” to crack.

The formidably beautiful writing style engrosses the reader to a beautiful story on medical history; discovery of preventive medicine and epidemiology; of pharmacology, physiology, anatomy and biochemistry; of science being ensconced in myths and finally the realization of an entangled labyrinth of why a disease as terrible as cancer is the face of an enemy that has remained an enigma since time immemorial.

Mukherjee has masterfully immortalized the story of why cancer deserves to be the Emperor of All Maladies.

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