The Emperor of All Maladies: A Biography of Cancer

by Siddhartha Mukherjee

Since metastasis is what kills patients with breast cancer, it is, of course, generally true that the ability to detect and remove premetastatic tumors saves women’s lives. But it is also true that just because a tumor is small does not mean that it is premetastatic. Even relatively small tumors barely detectable by mammography can carry genetic programs that make them vastly more likely to metastasize early. Conversely, large tumors may inherently be genetically benign—unlikely to invade and metastasize. Size matters, in other words—but only to a point. The difference in the behavior of tumors is not just a consequence of quantitative growth, but of qualitative growth. A static picture cannot capture this qualitative growth. Seeing a “small” tumor and extracting it from the body does not guarantee our freedom from cancer—a fact that we still struggle to believe. In the end, a mammogram or a Pap smear is a portrait of cancer in its infancy. Like any portrait, it is drawn in the hopes that it might capture something essential about the subject—its psyche, its inner being, its future, its behavior. “All photographs are accurate,” the artist Richard Avedon liked to say, “[but] none of them is the truth.”