The Emperor of All Maladies: A Biography of Cancer

“Cancer cells grow faster, adapt better. They are more perfect versions of ourselves.” 

In the Prologue, Mukherjee posits the idea that cancer is not foreign but is part of ourselves. Throughout the book, he presents the science that shows cancer cells come from our genome. They are parts of us, but parts that often evolve more quickly and ingeniously than our normal cells do. Mukherjee presents cancer as a formidable enemy. 

“In new and sanitized suburban towns, a young generation thus dreamed of cures—of a death-free, disease-free existence.” 

The post-World War II period was one of great health advances. Companies launched new medications into the market, and public health increased. With better health care, people expected better cures. 

“The illness lived on the borderlands of illnesses, a pariah lurking between disciplines and departments—not unlike Farber himself.” 

Farber was able to make inroads in cancer research in part because he toiled in isolation. Other kinds of doctors had abandoned leukemia because interns and surgeons did not know how to handle a disease of the blood. Farber was able to claim the disease and study it. 

“He was throwing down a gauntlet for cancer medicine. It was then up to an entire generation of doctors and scientists to pick it up.” 

Farber’s chemical treatment of leukemia resulted in some remissions among his pediatric patients. While the cancer returned, his results suggested that a cure for cancer was possible. He opened the door to research and to future doctors to find a cure.

“This image—of cancer as our desperate, malevolent, contemporary doppelgänger—is haunting because it is at least partly true.” 

Cancer cells, the author writes, are like doubles of our regular cells. They use the same process of growth as healthy cells. However, cancer is like an evil twin, or doppelgänger, as the cells’ growth harms us rather than helps us. 

“To arrive at that sort of logic—the Hippocratic oath turned upside down—demands either a terminal desperation or a terminal optimism. In the 1930s, the pendulum of cancer surgery swung desperately between those two points.” 

In the early 20th century, surgeons were conducting radical surgeries to try to remove all traces of cancer from patients’ bodies. In this climate, a group of surgeons wrote that it was rare for a physician not to have killed many patients. These doctors almost subverted the Hippocratic oath—the vow doctors take to do no harm—in their quest to eradicate their patients’ bodies of cancer.

“A disease needed to be transformed politically before it could be transformed politically.” 

Farber realized that to cure childhood leukemia, he would need to raise a great deal of money. He started the Jimmy Fund to raise this money. In the process, he recruited organizations such as the Boston Red Sox to promote his cause, as he realized that he had to conduct a political campaign before his medical campaign against cancer would be successful.

“‘I am opposed to heart attacks and cancer [...] the way one is opposed to sin.’” 

Mary Woodward Lasker said this about her campaign to eradicate disease. She felt that cancer should be medically treatable. To this end, she launched herself into fundraising and raising awareness of the disease. 

“This sense of common purpose and coordination galvanized the Laskerites: they wanted a Manhattan Project for cancer.” 

The followers of Mary Woodward Lasker opposed the idea of basic scientific research. Instead, they wanted cancer research that focused on the problem at hand. Their model was the Manhattan Project, which had produced the atomic bomb during World War II. 

“‘I feel as if I slipped through. I don’t know why I deserved the illness in the first place, but then I don’t know why I deserved to be cured. Leukemia is like that. It mystifies you. It changes your life.’” 

Ella, a 56-year-old woman who first received her leukemia diagnosis as an 11-year-old in 1964, said these words to Mukherjee. She was among the early recipients of the four-drug VAMP regimen. She was also one of the only survivors of these early trials of chemotherapy. 

“‘A revolution [has been] set in motion.’” 

DeVita wrote this after the success of the chemotherapy trials in Bethesda and Memphis. After he and others treated patients successfully with radiation and chemotherapy, there was a change in the way people regarded cancer treatment. A cure seemed to be around the corner. 

“The rot, the horror—the biological decay and its concomitant spiritual decay—was now relocated within the corpus of society and, by extension, within the body of man. American society was still threatened, but this time, the threat came from inside.” 

Mukherjee writes that the American obsession with cancer in the late 1960s and early 1970s mirrored the psychological neuroses of the society. In the 1950s, Cold War threats seemed to pose dangers from without. Now, contagion from within, corruption in society and decay in the body, seemed to pose the greatest risk. As a result, people became obsessed with cancer and the war to find its cure. 

“Political feminism, in short, was birthing medical feminism—and the fact that one of the most common and most disfiguring operations performed on women’s bodies had never been formally tested in a trial stood out as even more starkly disturbing to a new generation of women.” 

For a long time, the medical establishment in the United States was reluctant to test the efficacy of radical mastectomies. However, in the 1960s and 1970s, women began to challenge their doctors. This change helped lead to the testing of radical surgery to treat breast and other cancers. 

“For the first time in the history of cancer, a drug, its target, and a cancer cell had been conjoined by a core molecular logic.” 

The testing of tamoxifen showed that breast cancer with estrogen receptors were responsive to the drug, while those without the receptors were not. The doctors who conducted the experiments leading to tamoxifen understood how the drug worked. This was different than the blind use of cytotoxins to cure cancer that had predominated medicine previously. 

“Tobacco, like the nylon stockings of cancer epidemiology, thus vanished from the view of preventive medicine.” 

Tobacco use was so prevalent by the 20th century that its effects were not readily apparent. Instead, the effects of tobacco disappeared into statistical background noise. Therefore, the prevention of cancer through controlling tobacco use took some time. 

“Congress had turned out to be ‘the best filter yet.’” 

In the 1950s, the cigarette industry added filters to their products, claiming they made smoking “safer.” When the Federal Trade Commission (FTC) proposed that cigarette manufacturers include the new scientific evidence of the link between smoking and lung cancer in their marketing, Congress watered down the proposal. The result was that Congress functioned as a kind of filter, protecting the tobacco industry from admitting the link between cancer and cigarettes.

“Our encounter with cancer has rounded us off; it has smoothed and polished us like river rocks.”

The author describes how his medical oncology fellowship has changed him. Although he has always been interested in lab research, the clinical work of treating patients deeply affects him. He notes that the experience of the fellowship has altered the fellows, and as a result, they are more balanced doctors.

“‘In our adventures, we have only seen our monster more clearly and described his scales and fangs in new ways—ways that reveal a cancer cell to be, like Grendel, a distorted version of our normal selves.’” 

Varmus said this when he received the Nobel Prize, along with Bishop, in 1989. He proved that oncogenes—the monster of cancer—comes from within our own cells, not from an external source. 

“‘How can one capture genes that behave like ghosts […]?’” 

Weinberg, an MIT biologist, said this about the process of finding suppressor genes. It was a more straightforward process to find oncogenes because they cause normal cells to divide and produce foci. However, suppressor genes were harder to find because they stopped growth rather than causing it, and they did not create foci that could be used to indicate their presence.

“In genetic terms, our cells were not sitting on the edge of the abyss of cancer. They were dragged toward that abyss in graded, discrete steps.” 

Cancer develops over time as proto-oncogenes are activated and tumor suppressor genes are inactivated. Although the potential for cancer exists, the human body does not explode with cancer without going through several steps.

“‘Jimmy’s story [...] had become a story that I could not hold.’” 

The real “Jimmy,” the original inspiration for the Jimmy Fund, was a boy named Einar Gustafson. He was long presumed dead, but his sister, Phyllis Clauson, wrote to the Dana-Farber Cancer Institute in 1997 to let them know Jimmy was still alive. He was a truck driver and the father of three who lived in Maine, and he revisited the Dana-Farber about 50 years after treatment.

“Cancer is not a concentration camp, but is shares the quality of annihilation: it negates the possibility of life outside and beyond itself; it subsumes all living.” 

Mukherjee compares living with cancer to Primo Levi’s writing on what living in a concentration camp during the Holocaust was like. Levi writes that life in the concentration camp blocked out all sense of what life was like outside. In a comparable way, those going through cancer treatment lose all sense of life outside their illness. It becomes a kind of metaphorical prison.

“In a broader sense, the Red Queen syndrome—moving incessantly just to keep in place—applies equally to every aspect of the battle against cancer.” 

Mukherjee compares cancer treatment to the race of the Red Queen in Through the Looking-Glass. In this race, Alice runs but stays in place. Comparatively, the race to find treatments for cancer is ever-changing and advances are often met with retreats.