The Emperor of All Maladies: A Biography of Cancer

I have said it more than once, The Emperor of All Maladies has become my touchstone for
medicine. Siddhartha Mukherjee writes in a poignant and humanist voice as he beautifully
captures the Biography of Cancer. Interlacing science, stories, and his experiences as an
oncology fellow, Mukherjee begins his examination of cancer in the Egyptian times with the story
of Imhotep, and carries us through to the 21st century diagnosis and management of cancer.
From laboratory to bedside, Mukherjee provides both a panoramic and microscopic view of the
advances and setbacks of cancer discovery, definition, and understanding.
As a scientist, this book appeals to the cerebrum: delving into the details of laboratory
examination of cells, early gene discovery, pharmaceuticals and clinical trials, the use of
monoclonal antibodies, and the ever-expanding world of person-specific and cancer-specific
treatment. Mukherjee explores the evolution of modern medicine through the centuries,
illustrating how the notion of modern evolves over millennia. At the same time, he draws
connections between technological advances of present day, and the historical foundation upon
which they formed: time past is always contained in time future. Mukherjee also captures
snapshots of history, demonstrating how cancer impacted civilizations around the world, as well
as how social and political circumstances affect the perception and treatment of cancer.
This book also illuminates to the reader the depth of emotionality of clinical medicine.
Recounting the stories of his patients, and the experiences of his co-fellows, Mukherjee
demonstrates that oncology (and medicine) is as much an art and experience, as it is a science.
As we see in our own clinical experiences, cancer is so intimately connected to its host, and
Mukherjee demonstrates how the history of cancer cannot, therefore, be told without the stories
of people. Mukherjee gracefully articulates how cancer touches the lives of researchers,
patients, and physicians. Through his narrative we see the impact that oncology has on him as a
clinical fellow and the researchers who spend their lives endeavouring to understand the
disease. Through his clinical work, we are offered a bedside look into the life of one of his
patients, Carla Reed whom we follow from diagnosis through treatment over the course of the
book.
As one would expect the journey through cancer for patients, families, clinicians, and
researchers can be long, arduous, and tumultuous. There are moments of optimism, cautious
hope, and joy. There are also moments of bereavement, frustration, and anger. The story comes
together towards the end as Mukherjee recounts one of his last nights as an oncology fellow.
What will remain for me as one of the most powerful moments in the book is the evening when
each of the fellows, having completed their fellowship, is creating patient lists for the incoming
fellowship class. As readers, we are privy to an impromptu memorial service behind the closed
doors of their office as they recount not only the diagnosis of each patient whom they have lost

over their fellowship, but also the person who was host and carrier of the malignant cells. It is
moments like this that demonstrate the weight, responsibility and burden that cancer puts on all
those who become intertwined with its story.

1) In Part 5 (p338), Mukherjee describes how medicine has changed his colleagues:
Eric, cocksure, ambitious, and smart, is humbler and more introspective. Edwin, preternaturally
cheerful and optimistic in his first month, talks openly about resignation and grief. Rick, an
organic chemist by training, has become so infatuated with clinical medicine that the doubts that
he will return to the laboratory. Lauren, guarded and mature enlivens her astute assessments
with jokes about oncology. Our encounter with cancer had rounded us off; it had smoothed and
polished us like river rocks.
Patient interactions change the way we not only see medicine, but also each other and
ourselves. Does medical education provide sufficient time and space to allow learners to reflect
on their personal changes as they begin to interact with patients? How can we help capture and
foster the reflection necessary for learners to understand these changes in themselves?

2) (p400) It is an old complaint about the practice of medicine that it inures you to the idea of
death. But when medicine inures you to the idea of life, to survival, then it has failed utterly
This is especially applicable in the ED where we as clinicians see extremes of life, death, and
disease; as such there is much discussion about burnout and jadedness in emergency
medicine. Is it possible to prevent yourself from becoming inured to the idea of death? What
advice would you give learners and juniors to not become inured to the idea of life, and death?

3) (p401) Mukherjee describes how cancer mortality changed in the early 21st century:
incremental advances can add up to transformative changes.
At this point he is speaking of the scientific advances that led to a decline in cancer mortality.
Mukherjee also describes how the New York Times refused to print the word cancer in the
paper in the 1950s. Over the past few years there has been an increase of the presence of
cancer in media: with blogs, online support groups, twitter chats, and patient-focused websites
becoming a part of a patients cancer experience.

How has the incrementally increasing presence of cancer in the media changed the discussion
of cancer between a doctor and patient? In what way does it help or hinder the doctor-patient
relationship?
4) (p338) How does one memorialize a patient?
5) On page 13 we are introduced to a young Rudolf Virchow, and we hear of his initial
involvement in the renaming of leukaemia. One of the most profound impressions of this
researcher was his stepwise and fundamental approach to new problems, that allowed new
breakthroughs in the understanding of cancer in its early laboratory years. Virchow relied on
what he could see in the lab and under the microscope (not invisible forces as touted by other
researchers at the time) to understand the disease.
Today in the 21st century we have multiple imaging tools with which to examine a patient. Do
you believe that the more you see, the more you know?, or do you think that perhaps the
emphasis on imaging has swung too far and is now impeding our clinical practice?
6) Mukherjee calls this book the Biography of Cancer. Is it possible to write a biography of a
disease?