The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee – review

This magnificent study of cancer suggests that, for all medicine's advances, we cannot beat a disease that is a distorted version of ourselves
Cancer Treatment
A patient receiving treatment for breast cancer in 1955. Photograph: Three Lions/Getty Images

Three quarters of the way through his "biography" of cancer, the New York-based oncologist Siddhartha Mukherjee pauses to set the scene in his laboratory, a beehive of esoteric activity and impenetrable jargon. In lesser hands, such a passage would leave non-specialist readers bewildered and bored. But then he describes himself in the simplest of scientific poses, looking into a microscope. And what he gazes at is one of the more sinister mysteries of human – or anti-human – life. The leukaemia cells he is examining came from a woman who has been dead for 30 years. Unlike their discarded host, these cells are "immortal".

In this small but typical moment, Mukherjee manages to convey not only a forensically precise picture of what he sees, but a shiver, too, of what he feels. "The cells look bloated and grotesque, with a dilated nucleus and a thin rim of cytoplasm, the sign of a cell whose very soul has been co-opted to divide and to keep dividing with pathological, monomaniacal purpose."

The yoking of scientific expertise to narrative talent is rare enough, but the literary echoes of The Emperor of All Maladies suggest a desire to go further even than fine, accessible explanation. "Normal cells are identically normal; malignant cells become unhappily malignant in unique ways."

It takes some nerve to echo the first line of Anna Karenina and infer that the story of a disease is capable of bearing a Tolstoyan treatment. But that is, breathtakingly, what Mukherjee pulls off. He calls this great and beautiful book a biography, rather than a history, because he wants his reader to understand his subject not just as a disease, a scientific problem or a social condition, but as a character – an antagonist with a story to tell through its eerie relationships to the wider biological and animal world that is also, inexorably, our story.

Though it has many historical antecedents, the epic medical quest to understand and treat cancer only really took shape as it emerged as a defining disease of modernity. This is the case not just in the metaphorical sense that it speaks potently to our industrialised terrors, but in the direct sense that cancer only became a leading cause of death in the world when we began to live long enough to get it.

People in the past tended to die of other diseases – as they still do in poorer countries today. Cancer now ranks just below heart disease as a cause of death in the US, but in low-income countries with shorter life expectancies, it doesn't even make the top 10. At the beginning of the 20th century, life expectancy at birth in America was 47.3 years. Now, the median age at diagnosis for breast cancer is 61; for prostate cancer, 67. As we extend our lives, Mukherjee writes, "we inevitably unleash malignant growth".

Thus the scene is set for a monumental scientific, political and human struggle. Mukherjee assembles a teeming cast of characters: from ancients such as Atossa, the Persian queen who in 500BC self-prescribed the first recorded mastectomy, to Mukherjee's own patients. There are tales of grizzly surgical techniques and astonishing medical discoveries. But, as with any epic narrative, the central drama marches towards a war.

The full-blown campaign against cancer began with the meeting in the 1940s of an American socialite, Mary Lasker, in search of a great medical cause, and the driven cancer researcher, Sidney Farber, one of the creators of chemotherapy. Mukherjee describes it as the coming together of two travellers, "each carrying one half of a map". The battlefield at the middle of the map was Washington DC and the political alliance that Lasker and Farber eventually formed was with Richard Nixon. The passing in 1971 of the National Cancer Act enshrined the idea of cancer as sovereign among diseases and bequeathed it the language of a world war.

But as Mukherjee's narrative unearths his central character, and our understanding of cancer accumulates depth and complexity, the notion of a war becomes ever more threadbare. Its combatants had been configuring the enemy they needed to fight the war they wanted. Yet the story of science, Mukherjee observes, is not just one of discovery, but of the discovery of failure. The practitioners of surgery, radiation and chemotherapy had proceeded to treat cancer without understanding its fundamental mechanisms.

Crusaders for a magic bullet, including Farber, were scornful of calls to wait on the development of genetic research, or to emphasise prevention, or to appreciate the need for care as much as "cure". To many who had worked on the front lines, relentlessly pushing patients to the brink of death to save them, such calls seemed academic. And then the academics called time out.

In 1986, in The New England Journal of Medicine, John Bailar and Elaine Smith published a cold assessment of comparative trends in cancer mortality over the years. This revealed what they called a "qualified failure". Between 1962 and 1985, though duration of survival had improved in certain areas, the war on cancer had not only failed to show overall progress, but deaths from cancer had actually increased by 8.7%. Even accounting for the postwar boom in smoking-related lung cancer, Mukherjee writes, this "shook the world of oncology by its roots".

It is from here, as he reaches for the final act in his historical drama, that it becomes clear that Mukherjee is doing more than providing an account of medical developments, scientific discovery and human suffering. The underlying structural dynamic of his book turns out to be the riddle of progress itself, the application of reason and science to chaos and disease – the uber-project of modernity that, even if it has achieved too much to be called a failure, can never finally succeed.

As he turns inwards, to questions of the basic biology of the cancer cell, Mukherjee modifies his assessment of the war on cancer, from qualified failure to qualified success. There may have been no movement of the front lines of death, but if the aims could change, from utopian notions of eradicating death to more modest ambitions for the extension of life, then the result for medical science is a "dynamic" equilibrium rather than a "static" one.

He returns to the cell itself, as genetic knowledge began to offer results that could be applied clinically – the search for causes finally coming together with the search for cures. By the end of the 1990s, the development of Gleevec as a genetics-based drug treatment for chronic myeloid leukaemia had, as one researcher put it, proved a principle: "It demonstrates that highly specific, non-toxic therapy is possible."

The cellular composition of cancer is Mukherjee's own field, but he is under no illusions that the new era will leave history behind, or that gene-based therapies will lead us out of the cancer age. Harold Varmus, accepting his Nobel prize for the cellular origin of retroviral oncogenes in 1989, turned to Beowulf: "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."

The idea that cancer cells are copies of who we are is, Mukherjee emphasises, not a metaphor. "We can rid ourselves of cancer," he concludes, "only as much as we can rid ourselves of the processes in our physiology that depend on growth – ageing, regeneration, healing, reproduction."
