It has taken me a whole quarter of the year to read this book. Partly because of a mere lack of commitment. Partly because the book is complex.
You see, The Emperor of All Maladies is History, Chemistry, Anatomy, Physiology, Genetics, Pharmacology, Medicine and Literature all between the same covers.
It is also for the above reason that I will do the review in two parts. In Part One, I give a summary of the biography of cancer.
The Origin of Cancer
“Cancer is not merely a lump in the body; it is a disease that migrates, evolves, invades organs, destroy tissues and resist drugs.”
Contrary to popular opinion, cancer is not a modern disease. It first appeared in text in 400BC; a strange illness that attacked Attosa, the Queen of Persia. A plausible explanation is that cancer is an age-related disease. For instance, breast cancer occurs in 1 in 9 in women aged 70 but only 1 in 400 in women aged 30. Therefore, by increasing life expectancy, civilization just unveiled cancer.
Hippocrates believed that the body is composed of four fluids; blood, black bile, yellow bile and phlegm. Illness would occur as a result of imbalance in any of the four. This theory led to the first attempt at understanding the origin of cancer by Claudius Galen who suggested that cancer is the accumulation of black bile.
Since then, many scientist have endeavored to understand its origin and cause. In 1910, Peyton Rous demonstrated that cancer in chicken can be caused by a virus. In 1914, Theodor Boveri wrote that tumors occur when there is chaos in blue chromosomes. In the 1920s, environmental carcinogens such as radium and dye-by-products were responsible for most tumors. Other carcinogens like radiation and tobacco were also brought to light between 1930 and 1950.
By the 70s, scientists focused on genetic studies. Oncogenes and proto-oncogenes (their precursors) were discovered and named. To date, the origin of cancer is still an enigma. There is no unitary cause, rather it is often from a combination of all of these factors.
Fighting the War
The race to finding a cure for cancer has been synonymous to war, and many doctors and scientists have enlisted over the years.
Initially, the mainstay treatment for cancer was surgery. However, removal of tumors did not cure cancer, most patients relapsed and died. In the 1890s, William Steward Halsted started conducting radical mastectomies, an illustration of the extent to which surgeons were willing to go to rid the body of this malady.
The goal of a radical mastectomy was to extract all breast cancer by not only removing the breast but any nearby tissue with potential for new growth. The surgery therefore involved removal of the breast, the pectoralis minor, the pectoralis major, the collar bone and sometimes the ribs and media-sternum.
“Halsted and his disciples would rather evacuate the entire contents of the body than be faced with recurrence of cancer.”
Between 1850 and 1950, surgeons bettered their field through continuous studying and practice, entangled with trial and error. Discovery of anesthesia and antisepsis was a major incentive.
The use of X-rays as a treatment option was initiated by Emil Grubbe in 1896. It was limited by two things. First, the therapy was not suitable for metastasized cancer. Secondly, radiation itself causes cancer.
Nonetheless, in 1950, Henry Kaplan revolutionized the treatment of Hodgkin’s Lymphoma using X-rays. His approach was to stage the cancer appropriately and only treat patients in early stages of the disease.
Today, chemotherapy is among the first line treatments for cancer. This was not always the case. Sydney Farber (the father of chemotherapy), is famous for his role in developing drugs for the management of leukemia and for popularizing the National Cancer Institute (NCI), an institution that has oversight for cancer research.
Several clinical trials of single and combination drug therapy were conducted over the years. I must point out that conducting such trials was not a walk in the pack. It not only needed scientific knowledge and some level of obsession but also political connections and social currency. This saw the rise of movements such as The Jimmy Fund.
For a period, The NCI was pumping out drugs like a candy factory. The regimens had unique abbreviations; VAMP, ABVD, BEP, C-MOPP, ChlaVIP, CHOP, ACT and so on. they all represent different combinations of different chemicals, all in a bid to find the magical drug and dose that will completely wipe out the enemy.
“All medicine are poisons in one form or another merely diluted to an appropriate dose. But chemotherapy is poison even at the correct dose.”
Most of the chemotherapeutic agents are also toxic to the normal cell. For instance, Cisplatin a go-to drug in the late 70s was responsible for violent bouts of nausea, causing suffering in equal proportions to the cancer itself. However, some wonderful drugs like Herceptin, effective for breast cancer, were developed in the process.
Palliative medicine, was resurrected in the late 40s by Cecily Saunders, a nurse turned physician. She was attempting to restore some sanity to medicine by allowing patients to experience dignity in dying, and who could blame her. Still, she experienced resistance from oncologists who thought it as acknowledging defeat.
Prevention is the Cure
After decades of pyrrhic victories and defeat, some scientists started shifting their efforts to prevention. The premise of cancer prevention is to identify an avoidable carcinogen. Unfortunately proving such kind of associations often requires very large populations, creating a host of limitations.
In the 40s, Tobacco was the identified enemy with regards to lung cancer. Anti-smoking campaigns became very popular. However, tobacco companies have deep pockets, and there was no way of stopping its production and distribution. After several law suits, they settled for printing warning messages on their packaging, a practice that is in existence to date.
Other prevention strategies include Mammography for breast cancer and Pap Smears for cervical cancer named after George Papanicolaou. Apart from his name, its is also interesting to know that he conducted most of his work on his wife.
There has been links between nutrition and certain cancers. For instance, colon cancer has been associated with low fiber diet and high consumption of red meat. Breast cancer has been linked to obesity.
In the end…
Cancer is indeed the emperor of all maladies. There are over 200 types of cancer and after centuries of horrid experiments and fanatic-like dedication, there is still no universal cure for cancer.
Reading the book, my heart goes out to the numerous patients who had to endure disfiguring and extremist surgical procedures and the effects of toxic drugs and chemical, all in the name of experiment.
I also hail all cancer warriors, past, present and future. The battle is far from over.