The Emperor of All Maladies

The Book of the Week is “The Emperor of All Maladies, A Biography of Cancer” by Siddharta Mukherjee, published in 2010. Through this tome, the author, an attending cancer physician, researcher and assistant professor of medicine, discusses the history of cancer– how it came to be named, treated and researched through the centuries, and how it develops on the cellular level. He also talks about how cancer statistics can be manipulated to give people the impression that the illness is more common than it really is (to scare people into getting tested and treated), or– that treatment (including drugs and surgery) is more effective than it really is.

In ancient times, cancer was rare because lifespans were short. Several other diseases (tuberculosis, dropsy, cholera, smallpox, leprosy, plague or pneumonia) killed people before cancer would. More prevalent cancer testing has also made cancer a more common culprit in the cause of death, rather than, say, the labels, “abcess” or “infection.”

In modern times, specific factors, (like smoking and changes in public hygiene and diet) have increased the incidence of some kinds of cancer, and reduced the incidence of others.

The author points out the difficulties in determining whether detecting cancer early, helps save lives. Some cancers are quick-killing and others are slow-growing. If someone is diagnosed with an early stage of quick-killing cancer. whose treatment is rigorous and unsuccessful, is that a better situation than one in which someone has the quick-killing kind without knowing it, but goes about blissfully living his life, and dies quickly once he is diagnosed? Perhaps the former person lived six months longer, but given his lack of enjoyment of life after diagnosis, he might as well have died sooner.

The  author also writes regarding testing, “Using survival as an end point for a screening test is flawed because early detection pushes the clock of diagnosis backward.” Say we have the hypothetical scenario of cancer patients A and B. They both developed the exact same kind of quick-killing cancer at the same time. Say patient A’s illness was diagnosed in 1985 and she died in 1990. Patient B’s illness was diagnosed in 1989 and she died in 1990. But since doctors diagnosed A’s cancer earlier, it seems, falsely, that she lived longer and that the screening test was beneficial.

In 1976, a highly regarded mammography study was done on 42,000 women in Malmo, Sweden. The results showed that a significant number of women 55 years and older benefited from breast cancer screening– the lives of one fifth of them were presumably saved than otherwise. “In younger women, in contrast, screening with mammography showed no detectable benefit.” Many additional studies thereafter reinforced this conclusion by 2002: “In aggregate, over the course of fifteen years, mammography had resulted in 20-30 percent reductions in breast cancer mortality for women aged fifty-five to seventy. But for women below fifty-five, the benefit was barely discernible.”

Mukherjee also describes a moral issue that can arise when it comes to the testing of cancer drugs. A company was reluctant to spend hundreds of millions of dollars to do further testing on what appeared to be a promising new drug for a rare kind of leukemia that might (or might not) benefit only thousands of people. Thousands is considered a small number, compared to millions of individuals whom a drug might help in the long run. The company could spend the same amount of money helping millions. Patients for whom all other treatments had failed, aggressively pushed to be included in the drug trial, arguing it could save their lives. The company did eventually agree to test the drug, but on a small scale. The drug was wildly successful in its first decade for those few who were treated with it. However, a few years later, cancer cells had become resistant to the drug. A next-generation drug had to be developed to continue to keep those patients alive.

The author tries to explain why, even with all the resources currently poured into research for a cancer cure and improving treatment, many cases are still fatal even in industrialized countries. Nevertheless, he points out– there are pitifully few resources being thrown into prevention. I suspect it is just not as lucrative as research and treatment.

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