Jervoise Andreyev

Care or cure?

Cancer is usually associated with death.

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The Emperor of All Maladies: A Biography of Cancer

Siddhartha Mukherjee

Fourth Estate, pp. 571, £

Cancer is usually associated with death. For the cancer specialist, however, cancer is more about life: not just patients’ lives; the cancer itself often lives the life of Riley. If it has a life, then, it is entitled to a biography. Here, Siddhartha Mukherjee, an obviously compassionate oncologist, provides that biography.

The basis of any biography is the story. In this book, there are four interwoven stories; that of people with cancer, full of fear, but increasingly often, surviving; that of scientists and doctors: stories of genius, perseverance, integrity, serendipity but also arrogance and fraud; the statistical story which tells us that the global burden of cancer doubled (thank you tobacco) in the last 25 years, 13 million people will be diagnosed this year but five million will survive and cancer specific death rates are falling by one per cent per year; and finally, the story of cancer itself, a major health burden after public hygiene measures eradicated infectious causes of death.

When cancer was first described almost four millennia ago, it had no name. Without a name, no one takes a disease seriously. Two millenia pass, it was named karkinos, and now could be classified, initially by semi-religious concepts of invisible forces — imbalance in the red, green, white and black humours, later miasmas, neuroses, hysterias — wrong in detail, but right in that from the beginning, cancer often affects the whole body.

Sixteenth-century developments in anatomy, 18th-century understanding that cancer passed through developmental stages and 19th-century invention of anaesthesia and anti-sepsis were critical milestones permitting a century-long, surgically led assault. Surgery carried out by master craftsmen, in their operating ‘theatres’, truly became a performance.

For inoperable tumours, 100 years ago radiotherapy became available; from the 1950s chemotherapy drugs emerged, indiscriminate inhibitors of cell growth with devastating effects on healthy and malignant tissues alike. Much too slowly oncologists started to understand that you need to combine systemic and local treatments to impact on cancer outcomes.

Yet it was the failure of these drugs even when combined with surgery and radiotherapy to improve death rates which led to the modern realisation that to achieve progress it was necessary to target the cause for cancer, namely, the accumulation of genetic defects in normal cells. The last 30 years has taught us that almost every individual cancer is genetically unique but they all contain a dozen or so critically transformed molecular pathways which virtually immortalise cells, empower them to ignore normal control signals and spread through the body. The pace of change has been startling. Today we have 24 agents targeting specific molecular abnormalities not even described 20 years ago. The dream is that as the genetic profile of each individual’s cancer is identified, they can have a personalised treatment specific for their cancer. Dream on!

Mukherjee is brilliant at using simple analogies to explain many complex phenomena which take cancer care to where it is now, but he also appears to be afraid to raise the very thorniest issues. Money is often mentioned but never analysed. How much has been spent on this war against cancer when so many still die? How much of the current ‘game’ is for the benefit of shareholders or the marketing men? How will the developing world pay for modern cancer treatment when they cannot afford the cheap anti-sickness drugs which are an essential part of treatment?

The hierarchical practice of medicine, its internal culture, its rituals of practice and powerful financial forces were ideally arranged to resist change and perpetuate orthodoxy. The lesson of the last 150 years in oncology is that orthodoxy was repeatedly wrong. For each dedicated doctor, there was a charlatan, for each new ‘therapy’ there was a drug company unwilling to invest because the profits were too small. Now regulation and its costs alone mean that there is no place left for independent researchers.

This is a book about the past not the future. Lots of talk about phenomenal successes in fortunately rare diseases, leukaemia, Hodgkins lymphoma and testicular cancer, but barely a word about pancreatic cancer, where treatment remains dismal. Nor about preventing cancer in the first place, unglamorous but a process which would save so much money and buckets of misery if ever implemented wholeheartedly. This long book bangs on about ‘cure’ when the majority still die and need ‘care’, and contains only three pages on symptom control.

In the UK, the birthplace of the hospice, it is sobering to realise that only 30 per cent of palliative care funding comes from government, the rest relies on charity; 25 per cent of people surviving cancer (11 million in the US, two million in the UK) are left with difficult chronic physical side effects of treatment, yet there is little expertise and virtually no money for research to know how best to treat or prevent these side effects and ‘survivorship’, barely mentioned.

Siddhartha Mukherjee begins each chapter with fine quotations. Let us end with another (from Vladimir Nabokov’s Speak, Memory):

A sense of security, of well-being, of summer warmth pervades my memory. That robust reality makes a ghost of the present. The mirror brims with brightness; a bumblebee has entered the room and bumps against the ceiling. Everything is as it should be, nothing will ever change, nobody will ever die.