REVIEW: EMPEROR OF ALL MALADIES

Death is inevitable, and since about 3000 BC, what we now know as cancer has existed. Today, cancer is behind only heart disease as the leading cause of death in the United States. The statistics are frightening: about 50% of men and 33% of women will develop cancer during their lifetime. Since the incidence (new cases) of cancer increases with age, one can expect that the longer life is extended with modern medicine, the rates of cancer may remain high for the foreseeable future. Grimmer is the fact that despite the reduction in certain preventable types of cancer such as lung cancer, the rates of cancer continue to increase, not decrease.

The word cancer was first used by the famous physician Hippocrates, who described tumors as carcinos or carcinoma. Cancer has been described in many different ways, but the most logical definition is to that cancer is the phenomenon when normal cells change and begin rapidly dividing, forming two cells from one. This rapid growth exceeds that of normal cells, owing to unrelenting growth of tumors and other forms of cancer.

Even for physicians, understanding the causes of cancer can be complex and confusing. Unfortunately, we are likely at our infancy in understanding cancer. As a result, we have spent the past few centuries attempting radical treatments, with very modest success.

Many scientists, clinicians, and other scholars have tried to enhance our understating of cancer. More challenging has been our attempts to convey these thoughts and theories to the public. Indeed, the public has faced cancer in their families and friends, with a dearth of knowledge about what causes cancer and how it can be cured. That mystery has enveloped the medical field, as it has struggled to reach breakthroughs in cancer prevention, detection, and treatment.

Dr. Siddhartha Mukherjee won a Pulitzer Prize for his book entitled “The Emperor of All Maladies: A Biography of Cancer”. His book chronicled the history of cancer and man’s labors to overcome this scourge. Dr. Mukherjee’s book was later developed into a three-part documentary that aired on PBS, presented by Ken Burns and directed by Barak Goodman called “The Emperor of all Maladies”. It is illuminating that this title is perfectly applicable to the prior and current state of cancer.

I had the fortune to watch the documentary. From a historical, scientific, and human perspective, I found this to be one of the best documentaries I have ever seen. The documentary provides the viewer with an opportunity to look into the prism of cancer while gaining an education about not only cancer, but medicine, and ultimately, ourselves.

Barak Goodman’s documentary is exhaustive, disquieting, alarming, and encouraging at the same time. Goodman and Mukherjee walk the viewer through time and in doing so, allow us to look into the window of medicine’s past while gently glancing into the future. The documentary has value for everyone. For a physician like me, learning about the way that past physicians and scientists perceived and approached cancer was very informative. For those without a formal medical or science education, the documentary is presented in a manner that educates without interjecting unnecessary or confusing medical jargon.

As a society, we learn that our own views of cancer have evolved, albeit slowly. The fight against cancer is analogous and metaphoric to our fight against our own mortality. Mukherjee, Burns and Goodman take us through history and describe societal attitudes and mores about cancer. From the early Egyptians who viewed first documented cancer on scrolls through modern times, we have feared, loathed, and been bewildered by cancer.

The most challenging part for me while watching the documentary was to remain optimistic. The documentary is sprinkled with real-life cases which take one through the journey of many cancer sufferers and victims. These cases are displayed with the appropriate caution that one must approach cancer. Yet, they reveal the soul of the patients, and in doing so, tell us about ourselves. There is the case of the young surgeon who has a husband and small child and learns that she has breast cancer. Another story revolves around a young child who has battled leukemia for several years and is facing one last radical and experimental treatment option for survival. There is the compelling story of an elderly man with melanoma who receives experimental immunotherapy. The simultaneous struggles of the healthcare provider and patient are revealing: we are all in this battle together and there are only winners if everyone wins. These cases focus not only on the patient and family’s struggles, but on the interaction between a healthcare system flawed with inconsistencies and cost restrictions, yet unencumbered by pessimism.

Despite the inevitable and unavoidable hopelessness that surrounded cancer in the early 1900s, Goodman documents the early and pivotal philanthropic efforts of Mary Lasker, who inspired politicians and other philanthropists in the 1960s and 1970s to provide money and time to fight cancer. Her labors included testimonies before Congress and other lobbying endeavors, along with partnering with other philanthropists and leading cancer specialists to educate government officials, and the public about cancer. Her efforts stimulated President Richard Nixon to declare a war on cancer. To this day, that war is being fought, with mixed results.

While highlighting the setbacks, Mukherjee, Goodman and Burns remind us that while cancer is humbling, its lessons are informative for society, but especially for the medical field. The landscape is littered with the innovative and selfless discoveries of radiation therapy by Marie Curie in the early 1900s (who died herself of leukemia attributed to her work with radiation) to the indefatigable commitment to chemotherapy by Dr. Sidney Farber (of the famed Dana-Farber Cancer Institute in Boston) until modern times, where there seems to be optimism for the roles of immunotherapy (helping our own immune system fight cancer) and therapy that targets cancers caused by specific, identifiable genes. Through the efforts of these and other cancer pioneers, we learn of the benefits and risks of originality and caution. These discoveries humble us to realize that scientific discovery and progress is not merely a recent phenomenon, but we have made incredible advances over many centuries that laid the foundation for current research.

Despite the inconceivable advances in medicine over the past half century since Mary Lasker led the crusade against cancer, there is far more that we don’t know than we do know. For example, the documentary discusses the ability if cancer cells to adapt to their environment. While we have identified various cancer genes (also called oncogenes) that cause cancer, we have also unearthed the resiliency and adaptability of the cancer cell to survive by changing its genetic expression. It is fascinating but depressing to learn that the enemy has found ways to not only defeat us, but deceive us. This is not to diminish the sincere efforts to treat cancer with radical surgery, radiation therapy, and chemotherapy. However, the documentary highlights the false hopes such as the identification of specific environmental causes and potential cures (like the cancer vaccine in the 1970s) have spurred cynicism and skepticism. Yet, scientists and clinicians have sustained and increased their efforts to find causes and cures.

Through the trials and tribulations of the many personal stories highlighted in the documentary one is left with the painful truth: cancer has been around for all of time and is not ready to exit stage any time soon. Alarmingly, we seem to be at the very beginning of a long, a hard struggle. We are often deluded to believe that medical miracles are around the corner. Indeed, as the documentary declares, the discovery of the human genome created a false sense of hope that disease diagnoses and cures were in our immediacy. Sadly, the advances in medicine, albeit impressive as they are, have led to as many questions as answers.

However, while facing the tallest of hills to climb, society now faces cancer with a more optimistic attitude than even a half century ago when Nixon declared a war on cancer. The successes of therapy for childhood cancer such as leukemia and other examples have provided the foundation for hope. The documentary concludes on a binary cautious but somewhat optimistic note. The lack of therapeutic achievements since the 1970s is tempered by the hope that the discovery of the human genome and innovations in scientific research can pave the way towards more widespread and effective therapies for many types of cancer.

Ultimately, as Mukherjee, Burns and Goodman explain, the fastest pathway to reduce death from cancer is not cure, but prevention. The significant decline in certain types of lung cancer was spurred by the discovery (albeit concealed from the public for many years by tobacco manufacturers) of the link between smoking and lung cancer. While there have been some therapeutic developments for lung cancer, the best way to reduce the death rate from lung cancer is to avoid smoking. The filmmakers emphasize that while certain causes of cancer such as asbestos and smoking have been confirmed, our society has not been successful in identifying, or eradicating, other potential causes.

Ironically, the narrator of the documentary, Edward Herrmann, was battling a brain tumor while taping. While watching the documentary, I was unaware of that fact. Mr. Hermann’s perseverance is admirable and inspiring. That said, he lost his battle with cancer three months before the documentary first aired in 2014. This is chilling, but telling about how cancer affects all of us.

Many mistakes and misperceptions regarding cancer have been made, often with fatal consequences, but not without the best intentions. The scientific process, flawed as it can often be, has endured and cleared the path for progress.

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