Siddhartha Mukherjee: The Emperor of All Maladies

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What is Siddhartha Mukherjee’s The Emperor of All Maladies about? What is the key message to take away from the book?

The Emperor of All Maladies by Siddhartha Mukherjee is an overview and rough timeline of the fight against cancer. The book’s subtitle, A Biography of Cancer, reflects Mukherjee’s feeling that cancer is a living and evolving entity—an entity that fought modern medicine to a stalemate for hundreds of years.

Below is a brief overview of The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee.

The Emperor of All Maladies: A Biography of Cancer

Siddhartha Mukherjee, a doctor and biologist who specializes in immunology (the study of the immune system) and oncology (the study of cancer), has spent much of his career on the front line of that fight. Though The Emperor of All Maladies was first published in 2010, cancer remains one of the most frightening diseases of our time, and doctors are still working to fully understand and treat it, despite advances in research and practices. 

Aside from the Pulitzer-winning The Emperor of All Maladies, Siddhartha Mukherjee wrote The Gene: An Intimate History, and has also written for The New York Times and The New Yorker. He earned a PhD from Oxford University and an MD from Harvard. 

What Is Cancer?

Mukherjee says that cancer is, essentially, a corruption of our biological processes; the functions that normally keep us alive and healthy instead work to build and repair deadly tumors inside our bodies.

In simple terms, cancer is uncontrolled cell division. Mitosis is the process of cells dividing to create new, identical cells—it’s how we grow and how our bodies repair the damage. Normally mitosis is strictly regulated by biological signals that control when it starts and when it stops, but cancerous cells don’t respond correctly to those signals. As a result, they replicate quickly and endlessly, eventually amassing in a tumor.

The author adds that it’s crucial to understand cancer is not a single disease, but a type of disease—for instance, lung cancer and leukemia are both cancers, but they have different causes, symptoms, and treatments. That’s part of the challenge in finding a universal cure for cancer.

Pre-1900s

Understanding Cancer

Until relatively recently, doctors didn’t truly know what cancer was or how it occurred, let alone how to treat it. Therefore, a great deal of the history of cancer research is just trying to answer those basic questions about the disease.

Mukherjee says that cancer has probably existed for as long as our species has—for example, a human jawbone dated to approximately 2 million BC shows signs of a cancerous tumor invading it. However, cancer was extremely rare until recently because most people died young, and cancer rates increase exponentially with age. 

In 130 AD the Greek physician Galen asserted that an imbalance of black bile in the body causes cancer. While Galen was wrong (in fact, there’s no such thing as “black bile”), Mukherjee says this theory was remarkable for recognizing that cancer is a systemic issue (affecting the entire body) rather than a localized tumor. Modern medicine wouldn’t rediscover that fact for nearly two millennia.

In 1775, surgeon Percivall Pott noted that a certain type of scrotal cancer appeared almost exclusively in chimney sweeps. He eventually concluded that soot particles lodged in the skin had caused it. This finding had two major implications:

1. Something external (a carcinogen) caused the cancer, as opposed to Galen’s “imbalance of black bile.”
2. If cancer has definite external causes, it should be possible to prevent cancer by limiting exposure to those carcinogens. 

(Shortform note: While Pott was correct that carcinogens exist, and that limiting exposure to them is an important way to prevent cancer, in practice it might be more difficult than he expected. The latest Report on Carcinogens from the US Department of Health and Human Services lists 256 substances that Americans are commonly exposed to, and that are either known or suspected to increase cancer risk. The list includes common substances like alcohol, wood dust, and soot—therefore, totally avoiding carcinogens would be extremely impractical.)

Treating Cancer

Mukherjee says that two major medical advancements of the late 1800s—anesthesia and antisepsis—allowed surgeons to safely perform much more extensive procedures. Though it wasn’t a cure in and of itself, Mukherjee writes that the ability to remove malignant tumors was a major step forward in the fight against cancer. 

Using these advancements in anesthesia and antisepsis, surgeons William Halsted and Willy Meyer pioneered the radical mastectomy to treat breast cancer. This procedure involves removing the entire breast, as well as the underlying muscle and lymph nodes—as much tissue as the surgeon can remove without killing the patient. 

The radical mastectomy was rooted in Halsted’s own “centrifugal theory” of cancer: Halsted believed that cancer started at a localized point in the body and spread out in widening arcs. By cutting away as much tissue as possible, surgeons hoped to outpace cancer’s spread through the patient. The procedure was effective in the short term, but the majority of patients relapsed within a few years, no matter how much tissue the surgeons removed. 

Mukherjee explains that cancer is difficult (often impossible) to cure with surgery, because if even a single cancerous cell is left behind, it can continue to grow and spread through the body. Furthermore, cancer’s pattern isn’t as predictable as Halsted thought: Cancer cells can enter the bloodstream or the lymphatic system and spread to distant parts of the body without affecting the tissue in between. If the cancer has already spread in this fashion, then surgery—which only removes the localized tumor—is futile.  

1900-1950

Advancements in Understanding

Mukherjee tells us that, in 1914, biologist Theodor Boveri observed that cancer cells all have chromosomal abnormalities: damage or mutations in the cell’s DNA. He theorized that chromosomal damage causes cancer. 

Advancements in Treatment

Mukherjee tells us about several important advancements during this time period: Destroying tumors without surgery, killing cancer cells throughout the body with toxic drugs, and starving out cancer cells by depriving them of key nutrients. These represented powerful new weapons in humanity’s war against cancer.

In the early 1900s, the discovery of X-rays gave doctors the ability to destroy cancer cells through radiation, without the risks of surgery or the need to remove parts of patients’ bodies. However, Mukherjee says that this new treatment ran into the same problem as surgical removal: Radiation therapy only targets a localized area, and it does nothing for systemic cancers. Furthermore, radiation comes with its own side effects and risks, including potentially causing cancer in previously healthy tissue.

Mukherjee says the next major step forward came in the early 1920s, when physiologist Charles Huggins discovered that cancerous prostate cells retain the “nature” of the original prostate cells, which required testosterone to grow and divide. This offered a new approach to treating prostate cancer: Huggins cured the disease in male dogs by castrating them. 

For human patients, rather than surgical castration, Huggins performed what he called chemical castration: He injected prostate cancer patients with estrogen in order to suppress their testosterone and thereby starve the cancer cells. Unlike surgery, chemical castration was reversible, and therefore considered much more humane. 

Mukherjee tells us about a series of experiments in the 1940s: Yale scientists Alfred Gilman and Louis Goodman studied using tiny doses of sulfur mustard—commonly called mustard gas—and nitrogen mustard (a derivative of sulfur mustard) to treat lymphoma. 

They based these studies on the observation that mustard gas destroyed bone marrow, and thereby greatly reduced white blood cell counts. Gilman and Goodman theorized that controlled doses could be used to destroy cancerous bone marrow, and thus cure lymphoma patients. Initial results were promising, but in every case the cancer returned after a few months, and the treatment was much less effective a second time.

Next, Mukherjee explains that Sidney Farber, a pathologist studying childhood leukemia, recognized similar symptoms between that disease and a certain type of anemia (a blood cell deficiency) that comes from a lack of folic acid in the diet. In 1947, after some trial-and-error, Farber concluded that since bone marrow requires folic acid to function properly, he could starve out the leukemia cells with a drug that stops the body from processing folic acid (an antifolate). As with Gilman and Goodman’s mustard injections, patients went into remission and their symptoms all but vanished—however, also like the mustard treatments, the recovery only lasted for a short time.

1950-2010

Advancements in Understanding

According to Mukherjee, the period from 1950 to 2010 saw researchers working to understand and treat cancer at the microscopic level. Many doctors believed that the key to curing cancer lay in discovering which genes were mutated in cancer cells, and what specific effects those mutations had. They hoped that, by learning exactly how cancer works, they could find new ways to stop it. 

Mukherjee says that cancer was clearly and thoroughly defined for the first time in 1999, when biologists Robert Weinberg and Douglas Hanahan created a list of six qualities that all cancer cells possess:

1. Automatic mitosis. Cancer cells don’t need chemical signals to divide; they’re always “on.” 
2. Non-responsive to antigrowth signals. Cancer cells do not respond to chemical signals that normally stop cell division. 
3. “Immortality.” Cancer cells do not respond to chemical signals that normally trigger cell death (called apoptosis). 
4. Limitless replication. Normal cells can divide a limited number of times; cancer cells bypass this limit, allowing for apparently infinite cell division. 
5. Self-sustaining. Cancer cells induce nearby blood vessels to grow into the tumor, sustaining the tumor with oxygen and nutrients. 
6. Mobility. Cancer cells can travel through the bloodstream and attach to other areas of the body (this is called metastasis). 

Cancer Cell Genomes and Pathways

The next major development came in 2006, when a project called the Cancer Genome Atlas began sequencing the genomes (complete DNA sequences) of various cancer cells, looking for the specific collections of mutations that give rise to cancer. Early results commonly showed anywhere from five to 80 mutated genes, depending on the type of cancer. Mukherjee says these results mean that cancer cells are extremely diverse, and finding the exact mutations in any given cancer patient to inform treatment would be difficult and time-consuming. 

However, Mukherjee adds that a much less daunting approach would be to identify which biological pathways are affected in an individual patient and repair those, which would theoretically cure any form of cancer. Most biological processes happen through pathways—numerous genes working together to produce a single effect—and therefore many different mutations can lead to the same outcome because they all affect the same pathway. Researchers believe that the typical cancer cell has anywhere from 11 to 15 disrupted pathways, with an average of 13. 

Understanding cancer at the microscopic level—through the Cancer Genome Atlas as well as other research methods—can also help scientists identify possible carcinogens; they can directly test whether particular chemicals activate cancer-related genetic pathways. 

Advancements in Treatment

Chemotherapy is a cornerstone of cancer treatment even today. Many of the major advancements in recent decades have centered around making chemotherapy more effective—more reliably sending patients into remission, as well as preventing relapses.

Mukherjee says that the first case of chemotherapy truly curing cancer happened in 1956. An oncologist named Min Chiu Li tracked the progress of a patient’s cancer by measuring a chemical the cancer cells secreted, rather than observing visible tumors. 

Li continued treatment until that chemical marker was completely gone, which required many more doses over a much longer time period than treatment based on tumor observation. Although other doctors argued that he was being cruel and hurtful—continuing to administer nauseating and toxic drugs for no reason—Li’s patient never relapsed.

Several new discoveries showed that curing cancer usually requires—at minimum—using a combination of different treatments, and continuing the treatment regimen until all signs of cancer are gone. 

A series of trials from 1957-1962 showed that drug cocktails (mixtures of multiple drugs) are significantly more effective than individual drugs. Unfortunately, according to Mukherjee, using multiple drugs also increases the danger to the patient: Drugs don’t discriminate between cancerous cells and healthy ones, so more potent treatments kill more of both types of cells.

Mukherjee writes that, in addition to combining drugs in chemo cocktails, doctors began using chemotherapy and radiation therapy together. Sidney Farber—the pathologist who studied childhood leukemia—was the first to try this approach, in 1958. He treated Wilms’ tumor (a type of kidney cancer that often spreads to the lungs) with a combination of X-rays and a drug called actinomycin D. Farber found that the combination was significantly more effective than using either treatment alone. 

Around the same time, a researcher named Howard Skipper discovered that chemotherapy kills cancer cells in clear fractions of whatever remains: For instance, the first treatment might take the number of cancer cells in a patient from 1000 to 100, the second from 100 to 10, the third from 10 to 1, and a fourth round of chemotherapy finally takes the number to zero (remember that even a single surviving cancer cell can rapidly divide and cause the patient to relapse). 

Chemotherapy-Resistant Cancer and the Rise of Total Therapy

Despite advancements in chemotherapy, doctors found that some cancers are resistant to the treatment. In 1962, trials of a new drug cocktail called VAMP sent leukemia patients into remission. However, most patients relapsed after approximately a year with leukemia cells in their spines and brains. Mukherjee explains that the blood-brain barrier—a protective layer of densely packed cells that separates the brain’s blood vessels from the actual brain tissue—makes the central nervous system (the brain and spine) impervious to most chemotherapy. 

In 1962, a year after becoming the director of St. Jude Children’s Research Hospital, oncologist Donald Pinkel began developing a comprehensive course of treatment for childhood leukemia that he called “total therapy.” This development was based on four key innovations:

1. More elaborate drug cocktails, carefully mixing up to eight different drugs to maximize effectiveness while keeping toxicity to survivable levels
2. Bypassing the blood-brain barrier by injecting the drugs directly into the spinal fluid
3. Using X-ray radiation therapy to directly kill cancerous cells in the brain 
4. Continuing treatment long after visible signs of cancer are gone—potentially for years—in order to make sure that every trace of cancer is scoured from the patient 

In 1998, researchers made another step in treating chemotherapy-resistant cancers when they developed two cancer antibodies—drugs designed to specifically target cancer cells—that sent patients into remission during clinical trials. Mukherjee says that these two drugs show that it is possible to treat cancer by targeting key genes and proteins that the disease relies on to survive. In the decade following these trials, the National Cancer Institute listed 24 drugs similar to those two as targeted cancer therapies: treatments that pinpoint a particular type of cell, as opposed to killing cells indiscriminately.

The Social Aspects of Cancer

Although a lot of The Emperor of All Maladies is about the history of cancer research and treatment, Mukherjee says that we mustn’t focus so much on the disease that we lose sight of the people. After all, curing cancer isn’t just an interesting puzzle to solve—fighting cancer is about helping people.

Considering the Person, Not Just the Disease

In the 1950s, an English physician named Cecily Saunders introduced the idea of palliative medicine to cancer treatment: end-of-life care designed to preserve comfort and dignity, rather than cure the disease at any cost. 

Mukherjee says that, despite its name, palliative medicine was more of a social advancement than a medical one. Many doctors had refused to even consider palliative care because it felt like admitting defeat; furthermore, many people fought for the slightest chance that their loved ones could be healed, no matter the cost or the impact on the patient. However, Saunders argued that subjecting patients to painful and nauseating treatments with little hope of curing them did more harm than good—that there came a time when doctors and loved ones should let the patient stop suffering and die peacefully. 

Saunders opened the world’s first modern hospice center in England in 1967. In 1974, the first American hospice opened at Yale-New Haven Hospital. By the early 1980s, hospice centers based on Saunders’s model could be found all over the world. 

The Social Aspects of the Fight Against Cancer

Mukherjee observes that fighting cancer is as much a social battle as a medical one. Funding cancer research requires people to first acknowledge that cancer exists (an unpleasant topic that many prefer to ignore), and then recognize that doctors and researchers need vast amounts of funding and resources to combat it. 

Furthermore, preventing cancer often requires us to change our lifestyles and laws: For example, giving up alcohol (a personal change) and carefully regulating pesticides (a legal change) both help reduce the risk of cancer. People are often reluctant to make the necessary changes, or even to believe that they are necessary. Therefore, alongside the scientific and technological advances in cancer research, Mukherjee describes a series of social advances (and setbacks) that helped shape the fight against cancer over the years. 

The National Cancer Institute and the American Cancer Society

In 1937, US president Franklin Roosevelt created the National Cancer Institute (NCI), a federally funded organization intended to coordinate and lead a national effort to cure cancer. Mukherjee says that this was the first time cancer had been in the national spotlight. However, America entered World War II in 1941, just a few years later. As a result, funds and resources (as well as public attention) unfortunately were redirected from the fight against cancer to the fight against the Axis. 

However, Mukherjee says that the distraction didn’t last long. In 1943—before the war was even over—Reader’s Digest published a series of articles on detecting and screening for cancer, thereby bringing the disease back into the public eye.

In 1944, a group of professional businesspeople took advantage of the renewed interest in cancer to take over the American Society for the Control of Cancer (ASCC). Mukherjee describes the old ASCC as a small and ineffective nonprofit group staffed by medical professionals: people whose skills lay in medicine, not in business or public relations. The new board renamed the ASCC to the American Cancer Society (ACS) and began an aggressive campaign of public education and fundraising. Donations to the ACS increased exponentially, from around $300,000 in 1943 to over $12 million in 1947.

The Fight Against Tobacco Advertising

In 1964, a scientific report conclusively showed that smoking cigarettes increases the risk of lung cancer. According to Mukherjee, the Federal Trade Commission (FTC) proposed that an explicit warning be put on every package of cigarettes to dissuade people from smoking. However, Congress severely weakened the FTC’s suggested warning in order to protect the tobacco industry. The final warning, which went into effect in 1965, read, “Caution: Cigarette smoking may be hazardous to your health.” That vague, watered-down message didn’t have nearly the impact on smoking rates that the FTC had hoped for.

A few years later, in 1968, a landmark court case ruled that anti-tobacco ads had to be given proportional airtime with pro-tobacco ads on TV. As a result, Mukherjee says, public opinion began to swing against the tobacco industry, and tobacco use in America steadily declined starting in 1974. 

However, Mukherjee adds that—for that generation—the damage from a lifetime of smoking and tobacco addiction was already done. It would take decades to see a corresponding drop in rates of lung cancer, because that drop would mostly occur in the next generation.

The National Cancer Act

In 1971, President Nixon signed the National Cancer Act, committing a total of $1.5 billion to cancer research over three years. However, Mukherjee says that many scientists and advocates were disappointed with the bill, which heavily prioritized clinical drug trials—testing specific drugs and treatments—at the expense of further research into the nature of cancer and other possible methods of treatment. 

In 1985, a biologist named John Cairns assembled a comprehensive report on the progress of cancer treatments since the National Cancer Act of 1971. That report, along with a 1986 report by his colleagues John Bailar and Elaine Smith, showed that cancer-related deaths had actually increased during that time period. 

According to Mukherjee, Cairns’s explanation was that the extreme focus on cancer treatment was misguided. Citing precedents like cholera, scurvy, and tuberculosis, Cairns argued that the greatest results always came from preventing diseases, and the same principle must be applied to cancer. 

The Good News

Cancer is a difficult topic with a bleak history, but Mukherjee does have some good news for us: From 1990-2005, cancer mortality declined by about 1% per year—an unprecedented 15% decrease overall. Mukherjee says that this decrease was the result of earlier advancements in cancer prevention, screening, and treatment, such as the pushback against the tobacco industry in the 1960s and 1970s. 

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• An overview and rough timeline of the fight against cancer
• A look into the more technical aspects of cancer and cancer treatment
• The social aspects of the fight against cancer

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