Sometime around 2600 BCE the Egyptian genius Imhotep—statesman, architect and physician—compiled a medical manual. Case 45 described “bulging masses on the breast, hard and cool to the touch.” As for therapy, he wrote only, “there is none.” His careful clinical language is a textbook description of breast tumours, according to New York oncologist Siddhartha Mukherjee, author of The Emperor of All Maladies, a beautifully written account of all the ingenuity, hubris, courage and utter confusion humankind has brought to its attempts to grapple with cancer.
As Imhotep’s terse remarks illustrate, it has been killing us, on the record, for 5,000 years. In reality, for much longer: since cancer is a matter of uncontrolled cell growth, of our own bodies turning on us, it is the oldest human disease. “Cancer is us,” Mukherjee adds in an interview, except more perfect—we seek to extend our years, but the undying cancer cell is already immortal. We have dispatched so many of cancer’s rival diseases that we have cleared its path to us and our age-related cellular mutations: today we are both available for cancer and prone to it. The disease is still reaping its lung-cancer harvest from the 1900s, the century of the cigarette. Cancer, in fact, is entering upon its glory days. In Canada and the U.S., one in three women will contract it, and one in two men.
For 100 years we have viewed the disease’s climb up the mortality tables through the lens of a martial metaphor. We are locked in a “war against cancer,” with wonder drugs touted as “magic bullets,” and victims perishing after “long battles.” It’s a conceptual framework that equates “victory” with a cure, Mukherjee says, a way of thinking that results in manic highs, when new insights are gained or new routes of attack invented, and pessimistic lows, when the endlessly mutable disease continues to flourish.
Pioneering 19th-century surgeons like William Halsted, distressed that their breast cancer patients relapsed and died scant months after simple mastectomies, thought they could cure cancer if they cut out every last piece of diseased tissue. So they sliced ever deeper, removing ever more layers of muscle in disfiguring and debilitating operations. Half a million women underwent radical—in the original meaning of down to the root—mastectomies. Few benefited: for local tumours, far less invasive surgeries would have sufficed, and for cancers that had already spread into organs, any surgery was futile.
The champions of chemotherapy and radiation were just as driven—and reckless. By 1896, Emile Grubbe was blasting tumours with X-rays, destroying some and causing others. It’s very easy to kill cancer cells, Mukherjee sardonically notes; the trick is to do so without also annihilating healthy tissue. Grubbe achieved no miracles, but he did lose all his fingers, amputated one by one, as the radiation consumed him too. And all this time the “Big C” was wrapped in secret shame. When a 1950s breast cancer survivor asked the New York Times to insert a notice about a support group, she was told that Times notices did not allow either word, breast or cancer.
By the 1990s, as the magic bullets missed their mark and final victory seemed as far off as it did on the Western Front in 1916, the oncological mood was alarmingly nihilistic, says Mukherjee, despite enormous piecemeal progress (especially in children’s cancers). What’s needed now, he argues, is hope and humility, and a redefining of “victory” from cure to manageability. “We are not going to obliterate this disease, so intrinsic to us, from human history. But we can make it chronic and livable.” Perhaps even make most cancers what prostate cancer is now: something most sufferers die with, not from.
That will still require serious dedication. Five years ago, Mukherjee was present at his daughter’s birth—not just to experience the moment with his wife but to extract blood from the umbilical cord. The stem cells in it, too often flushed down hospital sinks, are a prime source for bone marrow transplants, and the very stuff of life for Mukherjee’s leukemia patients. Even in a transcendent moment, he was not about to give an inch to the great adversary.