Saturday, April 22, 2017

The Emperor of All Maladies: A Biography of Cancer

Contrary to what alarmist clickbait articles say, our species had coexisted with cancer since our emergence.  At its roots, cancer is a copying error, and the older we get, the more likely we are to accumulate enough errors to knock out the safeguards against our cells' uncontrolled growth.  It's such a terrifying disease, eating the patient from within and leaving strange growths, that doctors would hide the diagnosis from their patients.  We've declared war on cancer and have to wonder whether cancer has won.

Siddhartha Murkerjee alternates between telling the overall history of cancer with a chronicle of his fellowship year at Dana Farber Cancer Institute.  The first great leaps in treatment didn't come from a doctor who focused on patient care but from Sidney Farber, a pathologist who with the help of antifolates formulated by chemist Yella Subbarow, managed to induce brief remissions in his young leukemia patients.  He'd only postponed the inevitable by a few months, but from there doctors moved onto drug combos and eventually to modern chemotherapy.  That, in turn, led to battles between the surgeons and chemotherapists, neither believing the other was in the right and both more concerned at times with killing the disease than saving the patient.  In the aftermath of AIDS activism, patients stood up and fought for more responsive care - less disfiguring surgeries, drug dosages correlated to cure the disease and spare healthy cells, and palliative treatments.

Murkerjee doesn't neglect prevention.  The first recognized environmental cancer was scrotal cancer in chimney sweeps.  Naked young boys were sent into the tight shafts and many developed a cancer almost unheard of in the general population.  Strangely, that explains why the link between smoking and lung cancer didn't jump out at researchers in the 1950s - smoking was so common that it threw off the signal-to-noise ratio.  Researchers linked chronic inflammation to some cancers, leading to a fall in liver cancer with the advent of hepatitis vaccines and in stomach cancer with better sanitation and the antibiotic treatment of ulcers.  I remember as a child hearing about the search for cancer vaccines, and while that hasn't panned out, less than a decade of vaccination against HPV is already causing a decline in the incidence of cervical cancer.  There's also secondary prevention, like mammograms and colonoscopies which find cancers early when they're more treatable.  With the identification of oncogenes, researchers are developing treatments which can turn off those genes, stopping tumor growth without harming surrounding tissues.  

Periodically, Murkerjee brings us back to 2004 and the cancer wards at Dana Farber.  We see patients struggle through treatment.  Some survive and some don't, and occasionally the patient comforts the doctor who has to say, "There are no more options."  He opens and closes the book with one patient, 30-year-old kindergarten teacher Carla Reed.  Her fatigue, odd bruises, headaches, and bleeding gums  were symptoms of acute leukemia, and Muurkerjee's intake notes say that she'll probably die during treatment.  Six years later, he visits her with flowers - not on a gravesite, but at her suburban house where they drink tea and discuss her treatment while her children and dogs play in the garden.  At 5 years, her remission can be considered a cure.

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