Abnormal Distortions of our Normal Selves
This is a tremendous piece of research and writing by a doctor, for the lay reader. To say that a book about cancer, that most dread of diseases, is deeply thought provoking, instructive and very entertaining indeed may seem a weird combination of experiences, but so it is. I’m not surprised that this book was a Pulitzer Prize Winner. It is quite brilliant.
Mukherjee examines this disease and its treatment historically from the first evidence of its appearance. It is a malady which appears to have been known and feared for at least as long as we have had any sort of written records – the ancient Egyptian physician Imhotep describes its aetiology in the Smith papyrus, thought to date from around 2,500 B.C, defining with precision what seems to be the presentation of breast cancer, with the dread advice to fellow physicians on treatment – There Is None.
Mukherjee intersperses the long and fascinating history of the search for initially, A Cure For Cancer, to more modern methods which look at multifactorial treatments, and specific treatments for individual cancers, with the narrative of specific patients. The historical journey weaves in, as it must, much fascinating information about changes in medical philosophies, ethics, the relationship between clinician and patient, the move away from a holistic view of disease inhabiting a person to views which see the clinician completely focused on the condition and ignoring the person with the condition. Stories about the extreme radicalism of surgical procedures for breast cancer `The Halstead approach’ in the latter part of the 19th and early 20th century make for shocking reading, and one can’t help but feel it was more about the glorious and theatrical daring of the surgeon than the benefit of the poor sufferer. This was medicine without the evidence to support it, happening none the less.
Even I (well aware that often `gold standard ` trials in medicine DON’T happen) was shocked to discover that the preferred treatment for breast cancer, – increasingly radical mastectomy, in use in America for nearly 100 years, – was not brought to the table for a proper trial. It was not until 1981 that the results were shown that survival rates following `extirpation’ (removal of the breast, axillary and sometimes even cervical lymph nodes) were no better a treatment than either simple mastectomy, or the even more conservative lumpectomy with radiotherapy. In fact, the name `lumpectomy’ was coined as a dismissive, by the radicals, to describe the early, effective and more conservative treatment initially pioneered, as early as 1924, by an English doctor, Geoffrey Keynes. It was a struggle for those trying less invasive treatments to get the orthodox radicalists to listen.
Interestingly, Mukherjee links the eventual move towards less disfiguring, yet equally effective treatments, with the rise of patient power, and, in the case of breast cancer, feminism’s challenge to a generally masculine medical model.
deviant art, commons
The development of radiotherapy and chemotherapy make fascinating reading. Synthesised chemistry initially grew out of the desire to find dyes for cloth in the 1850s, natural dyes being costly and not so effective, and was then further exploited by the war industry, most notably in the production of Mustard Gas in the trenches of the First World War.
Treatment of survivors of mustard gas showed they had severe anaemia – in fact, mustard gas depleted the blood-forming cells in bone marrow. Eventually this led to interesting conclusions which could be utilised in the search of a cure for leukaemia, abnormal and aggressive proliferation of white blood cells. An unlikely combination of the fashion industry and the war industry as the mother and father of chemotherapy, where chemical molecules are designed and developed for specific purposes.
There is a long and absorbing section on the woefully late entrance of funding, ideology and will, to the idea of Cancer Prevention, rather than the starrier and more dramatic search for a cure or cures. The section begins with a telling quote from 1975, published in the Chicago Tribune:
The idea of preventative medicine is faintly Un-American. It means, first, recognising that the enemy is us
He enters into the shocking and political story of the known links between tobacco and lung-cancer, and the length of time it took for anything meaningful to be done with the explosive information. Two studies done in 1948, one in the UK and one in the USA, were published in medical journals, already demonstrating the evidence. A later landmark study, as far as methodology is concerned, published in 1954, by the British team, in theory put the evidence clearly in the market place. Cover-ups and skilful manipulation by an extremely powerful lobby, the tobacco industry, kept the death toll caused by smoking-related lung cancer steadily rising. When America finally took action, and the health of its population became more important than the vested interests of the tobacco industry, that industry shifted its focus to emerging markets.
Future death-by-lung-cancer for citizens of the developing world awaits. Mukherjee pulls no punches on this, describing the condition from his observations of his patients afflicted with the condition.
There are fascinating stories about `public taste’ – an early campaigner seeking to set up support groups for breast cancer survivors in the 1950s tried to take out an ad addressed to such women in the New York Times. She was told that neither the word `breast’ nor indeed the word `cancer’ could possibly be mentioned. The suggested wording was `diseases of the chest wall’ . Mukherjee examines the history of advertising campaigns, and how that too had its part to play in changing public awareness of the unmentionable condition and, more importantly, generating the cash which would fund research into cures.
There is also an interesting fleeting look at how cancer – a condition after all of `immortality and excess’ – normal cells have `programmed death’ – apoptosis which cancerous cells over-ride, mutating into fast proliferating immaturity – may be a disease which could, to some degree, be symbolic of our times – in the same way that `consumption’ – TB, symbolised Victorian romanticism.
Movingly, the book is dedicated to a little 3 year old, Robert Sandler, 1947-1950, who was one of the earliest beneficiaries, if only for a very short time, of treatment with an early, chemical isolate, which was trialled (without patient consent) for experimentation on his leukaemia.
Mukherjee is a poetical scientist, a scientific poet, in his writing. His use of metaphor illuminates the hard science. The subtitle of the book, `A Biography of Cancer’ is also particularly well chosen – this disease is as complex, contradictory and multi-faceted as any person.
Particularly of interest to me was the long section detailing the struggle for some of the newer, more specific cancer drugs to be brought into treatments, and this section encapsulated a lot of the real, problematic ethics behind classic medical trials, and the often worrying split between `hard-science’ (or, indeed `hard profits’) and real-life living (and dying) patients. .
My only disappointment with the book is that he has only focused on mainstream approaches to cure or management of the condition. Mock though some will, there have been other, often combination treatments – mainstream WITH complementary, and there is evidence out there. I would have liked to have seen some information for example about the work of the Simontons, Getting Well Again: The Bestselling Classic about the Simontons’ Revolutionary Lifesaving Self-Awareness Techniques, about results with the now outlawed laetrile, and some mention of dietary approaches. There are oncologists and oncology units who routinely suggest patients have CAM treatments – NOT to treat the cancer itself, but to support the person who has the cancer. Understanding more about the interface between body and mind – Psychoneuroendoimmunology – gives credence to holism.
For once, the `puff’ about the book from published reviewers seems in no way an oversell. Impossible to praise highly enough! This book and the equally profound and moving The Immortal Life of Henrietta Lacks, both about cancer, cancer research and medical history, are unforgettable, meaningful books about much more than a disease which fills us with dread.
Apologies, if you made it, for the length of this review. Nearly as long as the book itself!
The Emperor of All Maladies Amazon UK
The Emperor of All Maladies Amazon USA