Keywords: Cancer, medicine, popular science

Title: The Emperor Of All Maladies

Author: Siddhartha Mukherjee

Publisher: Fourth Estate

ISBN: 978-0007250929


It feels strange to describe a book about cancer as gripping, but there is no other way to describe Siddartha Mukherjee's Emperor Of All Maladies. Billed as a 'biography of cancer', Mukherjee's book is much more than that. It is part history of oncology, part personal journey and part exploration of the nature of the disease. Yet it manages to weave these disparate elements into a single narrative that is hard to put down. What makes it all the more stunning is that Mukherjee is a medic, but he writes with the fluid ease of the best of today's science writers.

The historical scope takes us from the ancient Egyptians and Greeks through to the present day. For much of that period cancer was a disease that was often left untreated - there really was nothing that could be done. With no modern understanding of cells and genes, this mysterious and deadly disease was ascribed to black bile or bad humours or supernatural origins.

Later, as our understanding increased (slowly, in fits and starts, and there is still so much we don't know), so too did the first treatments. For a long time the emphasis in treating solid tumours was surgery - and here we learn about feats of surgical skill and endurance that stripped away the disease but often at huge cost to the patient. For a time the treatment of choice for breast cancer was radical surgery - not just the removal of the breast, but strings of lymph nodes, parts of the lung, ribs, shoulder blades. Surgeons cut out more and more in order to stop the disease recurring. But often it did, even after the most extreme surgeries imaginable. Without an understanding of how the disease spread - in other words the process of metastasis - surgeons were at a loss to understand why these most extreme operations would ultimately fail.

Chemotherapy is a relatively recent phenomenon, and Mukherjee devotes a good chunk of his book to one of the driving forces of this innovation: Dr Sidney Farber. Farber had the inspired idea of working on leukaemia for the simple reason that he could assess the effectiveness or otherwise of a treatment simply by looking at the effect on the patient's blood. With solid tumours there was no simple way of tracking the progress of a treatment - and this is still true, many forms of cancer do not have biomarkers that enable doctors to easily assess the progress of the disease. Working in the 1940's - the start of the golden age of drug discovery, kicked off by the discovery of antibiotics - Farber ultimately discovered a class of drugs called anti-folates, and with these he managed to produce the first remissions in the disease.

Farber's successes spurred him on, and eventually other people. It was a process that was as much political as medical, and the book details the partnership of Farber and philanthropist Mary Lasker, campaigning for funds, institutions and political support in a war against cancer.

Along with surgery and chemotherapy, the other standard treatment these days is radiotherapy, and again, Mukherjee describes the history - from the initial discovery of radioactivity to the use of it to kill cancer cells.

However, the book is not a bare historical narrative. Mukherjee weaves into the story his own experiences as a doctor. He describes his patients with great care and attention, looking through their eyes as well as his own. It's a grim reality that he does not flinch from illustrating for us. It is this humane touch that makes this such a compelling book. We meet one of his patients - Carla Reed - at the beginning of the book, and her story is a theme that recurs. Her story also ends the book, and as a reader you are grateful for that it does.

By the close of the book we are in the modern era. Chemotherapy, radiotherapy and surgery are still with us. And so is this disease, with patients still dying and no general cure in sight. In terms of treatments, Mukherjee describes the latest developments in terms of drugs that block specific pathways, anti-angiogenic treatments and hormonal approaches to breast and prostate cancer. And, along the way, we learn more about how the disease spreads, how it evolves and mutates and engages in an arms race against the drugs that are thrown against it.

What is interesting is what is not really discussed. Immunotherapy, for example, is not described - William Coley, a surgeon who fought cancer using bacteria at the turn of the 20th century, is only mentioned in a footnote. But this is not Mukherjee's fault - immunotherapy has lots of promise but is still only just moving from the laboratory to the clinic.

But this is a minor point, and overall the book cannot be recommended enough. It is a fine piece of writing, and tackles a large and difficult subject with a deft and humane touch.

Contents © London Book Review 2011. Published November 24 2011