Last week, my wife and I saw a touring version of a Broadway musical. The show had received extensive media exposure, awards, and rave reviews. I went with high expectations, and although I enjoyed the experience, I left wanting more from the performance. The songs were great and they were performed with style and energy, but the story, which was biographical, was disjointed, superficial and inevitably glossed over facts and detail for the sake of the overall message of the story.
The Emperor of All Maladies by Siddhartha Mukherjee, described by the author as a “Biography of Cancer,” left with me a similar feeling. As a “biography,” it suffers from many of the same shortcomings as the musical I’d just seen. Given the scope of the subject and the size of the book, this is maybe not surprising; nevertheless, it is disappointing for a book that has received so many accolades—including the 2011 Pulitzer Prize for General Nonfiction.
The concept of the book is bold and novel—a history of cancer medicine dating from 3000 B.C. to the present day. In this respect, Mukherjee excels—he describes the incremental gains in knowledge of cancer biology and punctuates this throughout the book with illustrative, personal stories of individual patients he has seen in his own clinical practice as an oncologist. This gives landmark discoveries in cancer biology and medicine a human relevance that might otherwise be lost on the reader.
The major focus of the book is on the last 50 or 60 years, and it provides an insight not only into the science and medicine of this disease but also into the personalities and egos of many of the key figures fighting it—as well as the politics of funding and fundraising for cancer research. The section covering the link between smoking and lung cancer and the ensuing legal and political battles is brilliantly written and encapsulates many years of controversy, political maneuvering, and the distortion of facts into an intriguing, readable “short story.”
On the whole, the author does a good job of conveying difficult concepts in cancer biology and treatment in an accessible way for a general readership; unfortunately, he doesn’t do this consistently. For example, the science behind the revolutionary drug, Gleevec, is complex and might be difficult for the general reader to grasp from Mukherjee’s account. This inconsistency in style is, to my mind, one of the problems with this book—I’m not really sure whom it was intended for. In places, it seems to be directed at healthcare professionals, at other times towards a general readership, then at times, towards those whose lives are affected by this disease.
As a practicing oncologist, I was looking forward to reading this book, not least because many of my colleagues had recommended it and described it as a “must read” for anyone involved in taking care of those affected by cancer. I couldn’t agree. Although it is engaging in its style, and the content is very interesting, the nuances of the writing reflect the author’s training and bias to an extent that might trouble me more than a ‘general’ reader. For example, while no one would dispute the role of many early researchers in the North Eastern United States, many contributions to our understanding of cancer from other parts of the country and the World are down played. For example, the author chooses to frame his account of high dose chemotherapy and bone marrow transplantation around an unsuccessful application of this treatment in breast cancer and a story of scientific misconduct from South Africa. A general reader would be unaware that thousands of lives have been saved by this treatment, which is still widely used for other cancers. Of course, the author of any biography has the luxury to place his or her own emphasis on the course of a life. The “facts” are always subject to debate and the overall sweep of the story is bigger than these.
Still, I am a little surprised by the success of this book; not because it is poorly written or uninteresting, but because I’m puzzled by who is reading it. As an oncologist, I found it easy to read, but it didn’t provide me with new insights into the history of cancer—just a briefer and more accessible account. For those whose lives are affected by cancer, this book may provide them with new insights and hopefully some practical support, although that doesn’t seem to be Mukherjee’s primary aim.
For those with an interest in the progress of medicine in general, and cancer in particular, this book does provide a glimpse into the science, personalities, and politics of academic medicine. In my opinion, that is the book’s biggest strength.
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About the author: John Sweetenham, MD, FRCP, is Professor of Medicine and Director of Clinical Research at the Cleveland Clinic Taussig Cancer Institute. Dr. Sweetenham graduated BSc (Hons), MBBS from the St Bartholomew’s Hospital Medical College & University of London in 1980, and received a Doctorate in Medicine research degree from the University of Southampton in 1989. He is a fellow of the Royal College of Physicians of the UK, has served as head of Medical Oncology at the University of Southampton, director of Hematologic Malignancies/Bone Marrow Transplant at the University of Colorado Health Sciences Center, and subsequently was professor of Medicine and Director of Clinical Research, Arizona Cancer Center. He joined Cleveland Clinic in 2005.