The Emperor of All Maladies: A Biography of Cancer

by Siddhartha Mukherjee

“As the decade ended,” Bruce Chabner, former director of the NCI’s Division of Cancer Treatment, recalled, “it was as if the whole discipline of oncology, both prevention and cure, had bumped up against a fundamental limitation of knowledge. We were trying to combat cancer without understanding the cancer cell, which was like launching rockets without understanding the internal combustion engine.”

But others disagreed. With screening tests still faltering, with carcinogens still at large, and with the mechanistic understanding of cancer in its infancy, the impatience to deploy a large-scale therapeutic attack on cancer grew to its bristling tipping point. A chemotherapeutic was a poison, and one did not need to understand a cancer cell to poison it. So, just as a generation of radical surgeons had once shuttered the blinds around itself and pushed the discipline to its terrifying limits, so, too, did a generation of radical chemotherapists. If every dividing cell in the body needed to be obliterated to rid it of cancer, then so be it. It was a conviction that would draw oncology into its darkest hour.

February was my cruelest month. The second month of 2004 arrived with a salvo of deaths and relapses, each marked with the astonishing, punctuated clarity of a gunshot in winter.

One morning, finding Steve alone on one of the reclining chairs of the infusion room, I asked him whether he would rather have the chemotherapy alone, in a private room. Was it, perhaps, too much for his family—for his children? He looked away with a flicker of irritation. “I know what the statistics are.” His voice was strained, as if tightening against a harness. “Left to myself, I would not even try. I’m doing this because of the kids.”

In his poignant memoir of his mother’s illness, Susan Sontag’s son, David Rieff, describes a meeting between Sontag and a prominent doctor in New York.

Sontag’s new physician also told her precisely the same information, without ever choking off the possibility of a miraculous remission. He moved her in succession from standard drugs to experimental drugs to palliative drugs. It was all masterfully done, a graded movement toward reconciliation with death, but a movement nonetheless—statistics without stasis.

For cancer therapeutics, the mid and late 1980s were extraordinarily cruel years, mixing promise with disappointment, and resilience with despair. As physician-writer Abraham Verghese wrote, “To say this was a time of unreal and unparalleled confidence, bordering on conceit, in the Western medical world is to understate things.… When the outcome of treatment was not good, it was because the host was aged, the protoplasm frail, or the patient had presented too late—never because medical science was impotent.

The quest to combat cancer thus turned inward, toward basic biology, toward fundamental mechanisms. To answer these questions, we must turn inward, too. We must, at last, return to the cancer cell.

200 “The clinician, no matter how venerable”: Bernard Fisher, “A Commentary on the Role of the Surgeon in Primary Breast Cancer,” Breast Cancer Research and Treatment 1 (1981): 17–26.