The Emperor of All Maladies: A Biography of Cancer

by Siddhartha Mukherjee

a clotting factor used to control bleeding in patients with hemophilia; in 1985, it created a recombinant version of human growth hormone—all created by engineering the production of human proteins in bacterial or animal cells.

In 1971, about half the patients diagnosed with multiple myeloma died within twenty-four months of diagnosis; the other half died by the tenth year. In 2008, about half of all myeloma patients treated with the shifting armamentarium of new drugs will still be alive at five years. If the survival trends continue, the other half will continue to be alive well beyond ten years. In 2005, a man diagnosed with multiple myeloma asked me if he would be alive to watch his daughter graduate from high school in a few months. In 2009, bound to a wheelchair, he watched his daughter graduate from college. The wheelchair had nothing to do with his cancer. The man had fallen down while coaching his youngest son’s baseball team.

The revolution in cancer research can be summed up in a single sentence: cancer is, in essence, a genetic disease. —Bert Vogelstein

If one compares two breast cancer specimens, the set of mutated genes is far from identical. “In the end,” as Vogelstein put it, “cancer genome sequencing validates a hundred years of clinical observations. Every patient’s cancer is unique because every cancer genome is unique. Physiological heterogeneity is genetic heterogeneity.” Normal cells are identically normal; malignant cells become unhappily malignant in unique ways.

Taken to its logical extreme, the cancer cell’s capacity to consistently imitate, corrupt, and pervert normal physiology thus raises the ominous question of what “normalcy” is. “Cancer,” Carla said, “is my new normal,” and quite possibly cancer is our normalcy as well, that we are inherently destined to slouch towards a malignant end. Indeed, as the fraction of those affected by cancer creeps inexorably in some nations from one in four to one in three to one in two, cancer will, indeed, be the new normal—an inevitability. The question then will not be if we will encounter this immortal illness in our lives, but when.

Cancer is a flaw in our growth, but this flaw is deeply entrenched in ourselves. We can rid ourselves of cancer, then, only as much as we can rid ourselves of the processes in our physiology that depend on growth—aging, regeneration, healing, reproduction.

It is unclear whether an intervention that discriminates between malignant and normal growth is even possible. Perhaps cancer, the scrappy, fecund, invasive, adaptable twin to our own scrappy, fecund, invasive, adaptable cells and genes, is impossible to disconnect from our bodies. Perhaps cancer defines the inherent outer limit of our survival. As our cells divide and our bodies age, and as mutations accumulate inexorably upon mutations, cancer might well be the final terminus in our development as organisms.