Medicine is storytelling," writes acclaimed cancer specialist and now bestselling writer Dr. Siddhartha Mukherjee, author of "The Emperor of Maladies: A Biography of Cancer," named one of the Top Ten Books of 2010 by the New York Times as well as other publications. So I began my interview with the very busy Dr. Mukherjee by telling my cancer story.
I was diagnosed with Stage III colon cancer in 1996 after I finally agreed to a dreaded colonoscopy. My mom had been diagnosed with colon cancer a few months earlier and she and my wife Betsy, a nurse by training, urged me repeatedly to get a colonoscopy. I didn't want the test. I argued that my physicals and blood tests were normal, I was under 50 and I never had digestive problems. But the storm of solicitude was too much and I finally relented.
The colonoscopy itself was not painful or dreadful, but it revealed a tennis-ball size tumor of the colon in the same location as my mom's tumor. My doctor was stunned. He said the tumor could have caused a blockage -- probably curtains for me -- at any time. I soon had surgery followed by a year of chemotherapy. Fortunately, I've had no cancer problems since then. After treatment, I went on to testify before the state legislature and talk with groups on the importance of early screening.
Dr. Mukherjee graciously congratulated me on my recovery. He related my storytelling to "The Emperor of Maladies," a collection of stories from the 4,000-year recorded history of cancer interspersed with accounts of his work in medicine and the experiences of his patients: "You started our conversation with a story that contains in it a very personal dimension and captures a history of ideas and something cultural, and something political as you were testifying in Washington state about your screening and your colonoscopy. In the process of four or five minutes, you narrated a story that captures not just your history but also a political and cultural history. It's a reminder that medicine is constantly trying to capture stories and tell stories back. These are very intense stories because they have to do with culture, life, death, legacy, survival. Medicine is never far away, and if it strays far away, it needs to be brought back."
Dr. Mukherjee's book has been praised for its compulsive readability and surprising hopefulness. The book earned rare starred reviews from "Booklist" and "Publisher's Weekly." And Steven Shapin wrote in "The New Yorker:" "It's hard to think of many books for a general audience that have rendered any area of modern science and technology with such intelligence, accessibility, and compassion. 'The Emperor of All Maladies' is an extraordinary achievement."
Dr. Mukherjee is an assistant professor of medicine at Columbia University and a staff cancer physician at Columbia University Medical Center. He was a Rhodes scholar and he holds degrees from Stanford University, Oxford University and Harvard Medical School.
What inspired you to write a history of cancer?
The inspiration came from patients. When I was training in cancer medicine in Boston, cancer patients were interested in defining their history. In particular, one woman I was treating for stomach cancer said, "I'm willing to go on with my treatment but I need to know what it is that I'm fighting." It was amazing to me that, although this disease is enveloping more of our lives and we've poured literally our best scientific and public resources at it, there was no comprehensive attempt to write a story of where we are now, what happens next.
You call your book a biography of cancer rather than a history.
Exactly. I felt as if the word "history" was just too inert to describe not only my experiences, but also the experiences of patients. I was drawing a portrait over time of a family of diseases, a very heterogeneous disease, from many different viewpoints: someone considering it in 2500 BC and someone else looking at the same entity [hundreds of years] later. Drawing a portrait over time is of course a biography.
What is cancer?
Cancer is not one disease, but a family of diseases. They share a common feature: a cell that has lost control of cell division and is dividing abnormally. There are many more features. Cancer invades the immune system and metastasizes.
How does cancer kill us?
Different cancers kill for different reasons. Typically, cancers kill by virtue of metastasis by invading organs, growing in spaces where they're not supposed to grow, and taking over and destroying the function of organs. That's not the only way. For example, leukemias become lethal often when they wipe out normal growth of bone marrow and take over the bone marrow. By contrast, brain tumors don't kill by virtue of metastasis, but kill patients because they grow in that space and destroy brain tissue around it. Every tumor has a different pathology of killing, but the fundamental feature is the same: the abnormal growth of cells.
The book goes back more than four thousand years, yet cancer is thought of as a disease of modern civilization.
Cancer is thought of as a disease of modernity partly because rates of cancer are increasing [because] our population is aging overall and cancer is an age-related disease. There are other reasons that the cancer rate is rising. For instance, tobacco smoking has caused an increase in lung and possibly esophageal cancer. But one of the main reasons is that the population is aging over all. Put some numbers on it: The average life expectancy in the United States in 1900 was 40 or 50-odd years. That has increased to 70-odd years [and] cancer [usually] strikes in the decades from 50 to 70.
Aren't cancer rates in the developed world higher than in other regions of the world?
It's a complicated question partly because people [in the developed world] live longer and aren't dying of other diseases. Some cancers are more common in the developed world, particularly age-related cancers. For example, liver cancer is endemic in parts of Asia, [but] we're now vaccinating for hepatitis A and B. Similarly, cervical cancer can be vaccinated against, so there is a predominance of this in the non-developed world.
What was the understanding of cancer before the 19th century, before more recent treatments such as Dr. William Stewart Halsted's radical mastectomies of the late 1800s?
There have been several different understandings. [Roman physician] Galen posited a theory that the body was made up of four fluids: yellow bile, black bile, phlegm and blood. Cancer was an excess of black bile. Therefore, Galen argued that cancer was a systemic disease that the entire body was involved with. This theory persisted for a long time. It was only in the early 19th century that surgeons began to take out local forms of cancer and thereby cure patients. Halsted inherited the idea that if some surgery is good, more must be better, then took it to its logical conclusion. He performed increasingly aggressive variations of surgery in order to cure cancer patients completely and he called it radical mastectomy.
The main treatments that developed from that time were "cutting" or surgery, then "burning" or radiation, and then "poisoning" or chemotherapy. Is that a way of making sense of the progression of treatment?
Yes, although that is changing dramatically. First, these variations of cutting, burning and poisoning have often worked together. For example, with breast cancer today, a woman with Stage II or III breast cancer is treated with surgery followed by chemotherapy followed by radiation. So all three are used together. But we're looking at an era where we're finding new medicines that are not so poisonous, which selectively poison only the cancer cells and spare [healthy cells] with so-called targeted therapies. These therapies are actually a fourth part of the armamentarium in which, instead of cutting or burning or poisoning generally, they specifically attack cancer cells and spare normal cells.
You point out that the pioneering physicians used new treatments very aggressively on patients, but you have compassion for these physicians.
I do, but I certainly have more compassion for the patients who bore the brunt of these therapies. It's important to realize that the doctors -- and certainly patients -- have this urgency. Patients need treatment right there and then. So doctors have to balance the current state of knowledge against the current lack of knowledge and act in the moment. In the face of that, the idea that they would so quickly reach for the most aggressive tools that they had is not surprising. On the other hand, it speaks to the arrogance of medicine, and the fact that medicine is constantly trying to overreach its boundaries.
You show a great deal of empathy for your patients and bring them to center stage in your book. What have you learned from your patients?
So many things. One common thread is the idea that patients are incredibly inventive. They have surprising resilience and they carry forward resourcefulness that will amaze and surprise you. The book is a reminder of that.
Did you dream of being a doctor when you were a child?
I did, but I didn't know what kind of doctor. I was intrigued by the sciences as a child and sensed that I wanted to study something in that arena. I first studied cell biology and only later became interested in medicine, unlike many people who begin in medicine and eventually gravitate toward cellular biology. That probably has something to do with the way the book is written but also the way I approached this whole field.
I grew up in Delhi at a time when India was steeped in respect for science and medicine. I continue to be struck by the level of respect that the sciences command in India and it pays itself off in very good science education. We know the United States is lagging in the best science education, which is really unfortunate [and] will have ramifications in arenas like our fight against cancer. I would like to see powerful, strong scientific education emerging in this country.
Do you have thoughts on improving access to health care?
I have many thoughts. With cancer in particular, there is an incredible disparity [in] access to responsive cancer medicine. You can invent new therapies for cancer, but the invention is only as useful as getting to real patients in real time. So we need to improve our network of healthcare delivery, and make important, therapeutically successful strategies available to all patients.
What do you advise patients in terms of prevention with diet, exercise and other approaches? And don't we all have cancer?
It depends on the type of cancer we're talking about. Certainly, although cancer is absolutely linked to our genetics, various toxins unleash cancer, and smoking is one of them. There's cancer in the genes, but there are many ways to prevent cancer. Avoiding smoking [and] exposure to blistering sunlight. There's a link between diet and colon cancer, for example -- so avoid a low-fiber, red meat diet. Obesity has been linked to breast cancer. So there are a variety of things one can to do and the National Cancer Institute has been very good about informing us on the various strategies that have been successful and linked to prevention.
What do you hope readers come away with from your book, and what can they do to advance their understanding of cancer?
One thing readers can get from the book is how heterogeneous and complex this disease is, and not to be nihilistic about our capacity to turn around cancer mortality and suffering over time. And what readers can do at every level from education to funding to public advocacy is to encourage scientific research.
Many potential readers may see your book as a grim tome, yet you write of coming away from your work ebullient and joyful.
It's not grim. It's a book of stories. The history of cancer is something we need to come to terms with because it can show us what happens next and how we go on from here. It's a disease that's going to affect all our lives, so we really need to know about it. That's why I think it's important to read this history, and not just this book, but the history of science in general.
Robin Lindley is a Seattle attorney and writer whose articles have appeared in Real Change, Crosscut, and the History News Network, among others.