Book Review: The Emperor of All Maladies (A Biography of Cancer) - part 1

I first heard about this book from a radio interview of the author, Siddhartha Muhkerjee.  In the 15 minutes that I was listening, Muhkerjee, an oncologist, was able to explain some incredibly complex concepts (genetic mutations, radiology, surgical procedures) in a way that a non-scientific audience could not only understand but appreciate.  The man is brilliant (graduated from Stanford, Oxford, and Harvard, a Rhodes scholar, and now professor and physician at Columbia).  After the interview, I took my phone out and wrote down the name of the book (yes, while driving).  I bought it soon after and really enjoyed reading it.  Here are some of the interesting things I learned from the book. 

Summary

The book is a history of cancer and cancer treatments, interwoven with stories about the author’s cancer patients. 

The real history of treatment picks up in the 1800’s, when the only remotely effective method of treating cancer was with the knife.  The surgical removal of malignant tumors and lumps.  This was an awful time for cancer patients.  Not that being a cancer patient is ever easy, but up until the 1950s, surgeons, seeing some limited success from their surgeries, continuously expanded the reach of their knife.  Take, for example, breast cancer patients.  A mastectomy is the removal of the breast in breast cancer patients in an attempt to remove the tumor.  Gradually, surgeons started chasing after metastasized (see definition below) tumors and began cutting more and more of the patient’s insides away.  The radical mastectomy, as it was called, would sometimes reach all the way to the neck and armpit area of patients.  After surgeries, the patients would be permanently disfigured and sometimes lost normal control of their arms.  It wasn’t until controlled studies and major statistical efforts proved that there was no added benefit from such radical surgeries that they began to be phased out.  Regular mastectomies, however, are still common today. 

The next form of treatment discussed was radiation.  Marie Curie discovered the element radium in 1902.  Subsequent discoveries that radium (and X-rays) attacks DNA and consequently kills cells led to the practice of radiation treatment on cancer patients.  The key effect of radium on cells is that it causes them to cease to divide.   And what divides most rapidly?  Cancer cells.  Radiation treatment preferentially kills cancer cells!  It has numerous adverse effects though, including anemia (definition below).   Marie Curie herself died of leukemia due to repeated exposure to radiation.  Radiation treatment is still used to this day. 

A third form of cancer therapy is chemotherapy: the use of toxic chemicals to kill cells (both normal and cancerous).  The effect is most visible when fast-reproducing cells are killed (such as hair).  Some drugs occur naturally, and others are bioengineered.  Scientists today have expansive programs to develop new drugs, but a great many were and still are stumbled upon.  Modern oncologists tend to treat patients with a mix of chemotherapy drugs, as there are inevitably some peripheral cancer cells that escape death from a single drug and continue to divide.  The supplementary drugs can often kill those rogue cells. 

Unfortunately, none of these treatments reach the core of cancer.  For hundreds of years, scientists and doctors were approaching cancer backwards.  They simply tried to figure out how to kill cancer after it had progressed, without a fundamental understanding of the genesis of cancer.  It was a reactive, rather than a proactive, approach.  The latest, and most hopeful, assault on cancer, however, attempts to understand the origins of cancer.  Excluding carcinogens such as smoking, cancer is fundamentally a genetic disease.  Genes, as I was forced to remember from freshman biology, are carried on a cell’s 23 pairs of chromosomes.  The Human Genome Project, completed in 2003, was the first full sequence of the approximately 23,000 genes in a normal cell.  Researchers are now working on the next logical step: sequencing the genomes of common cancer cells.  The leader of the HGP predicts that this could end up being the equivalent of more than 10,000 HGP’s, which itself took 13 years.  This will allow researchers to identify every single mutated gene.  From there, work can begin on determining which mutations occur most frequently in cancer cells, which mutations drive cancerous behavior, and, finally, how to block those mutations.  One early success story is the development of the drug Gleevec, which inactivates the hyperactive kinase in CML (a variant of leukemia) cells.  Long story short, there is hope for alleviating cancer through genetic research.