Saturday, July 14, 2012

Compelling biography of a monster (Books - The Emperor of all Maladies by Siddhartha Mukherjee)

Siddhartha Mukherjee's The Emperor of all Maladies is an impressive book in two ways.  It is a comprehensive history of cancer made plain for the lay-reader - what science and medicine have understood its mechanisms to be and how, as that understanding has changed, its treatment has changed.  It is also a book about one of the scourges of modern life - 1 in 3 people will likely develop a cancer in their lifetime and 1 in 4 will probably die of one.  It is a monster most of us fear and Mukherjee's achievement is having produced a book that keeps the reader wanting to turn the pages as one does when reading a mystery or a thriller.

The mechanism fueling the readability of a book that one could expect to be dryly factual, scientifically complex, graphic, scary - anything but the addictive read that it is - is Mukherjee's compassion.  It seems to drive his caring as a physician, his curiosity as a researcher, and his desire to communicate as a writer.  He interleaves what he calls a biography of cancer with the story of Carla, a severely ill leukemia patient, humanizing the story.  He is frank in discussing his own experience of the conflict between professional distance and caring.  He gives equal time to the political movement that has grown up around the desire to find a cure - one that has had an impact on the entire field of modern biomedical research - and the development of cancer science.  Mukherjee can make even the complexity of oncogenes into compelling reading.

The take-home message isn't that we know everything there is to know about cancer and that full-scale cures and eternal life for all are on the foreseeable horizon, nor is it that our knowledge is scant,the treatments that we can offer as a result of it primitive, and the prognosis hopeless.  As usual with science and the way it intersects with the healing arts, knowledge progresses fitfully.  Deviant thinking breaks the mold from time to time, and then the minds which are brilliant at absorbing and synthesizing accepted knowledge must catch up.  This means that if you look at any moment in time, there are going to be camps of divergent opinions.  That doesn't mean that science doesn't know anything, it means it knows many things.  Mukherjee writes:
By the early 1950s, cancer researchers had thus split into three feuding camps.  The virologists, led by Rous, claimed that viruses caused cancer, although no such virus had been found in human studies.  Epidemiologists, such as Doll and Hill, argued that exogenous chemicals caused cancer, although they could not offer a mechanistic explanation for their theory or results.  The third camp, of Theodor Boveri's successors, stood at the farthest periphery.  They possessed weak, circumstantial evidence that genes internal to the cell might cause cancer, but had neither the powerful human data of the epidemiologists nor the exquisite experimental insights of the chicken virologists.  Great science emerges out of great contradiction, and here was a gaping rift slicing its way through the center of cancer biology.  Was human cancer caused by an infectious agent?  Was it caused by an exogenous chemical?  Was it cause by an internal gene?  How could the three groups of scientists have examined the same elephant and returned with such radically variant opinions about its essential anatomy?
The truth in biology isn't either/or, it is usually both.  As our knowledge increases, the scale at which we can understand a problem changes.  It isn't that the theory that cancer is cell division gone amok has to be wrong in order to replace it with the notion of chemical cascades regulated by genes - both are true.  The genes are the mechanism whereby cell division changes, but our previous knowledge did not allow us to measure what the genes were doing.  We couldn't see them.  It isn't that cancer is a disease caused by oncogenes that are endemic to human biology OR that it comes from external mutagens  - BOTH processes contribute to the changes that can produce cancer.  The accomplishment of The Emperor of all Maladies is the clarity with which Mukherjee builds our understanding of biology until we are reading about processes sitting near the cutting edge of biomedical research and the excitement with which he allows the story of how we have used our progressing knowledge to unfold.

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