April 17th, 2011

_Emperor of All Maladies_ by Siddhartha Mukherjee (kindle)

I remember looking at this in a bookstore a couple of times and thinking, wow, I really would rather read this as an ebook. My wrists hurt just thinking about manhandling that thing. The kindle can really, really mess with my head, however, because I just have not internalized a sense of how long a book is based on location information -- but I sure can tell when I've been reading a book for a while and there's still more than half of it left to go. And that happened a lot with this book, despite how much I was enjoying it.

Mukherjee's rhetorical structure is nominally a biography, but like a lot of non-fiction I like to read, he is very present in the book as well: interacting with patients and struggling to figure out how to structure the book. It has a lot in common with a form of narrative non-fiction I used to read more of, corporate biography, or, the story of of a company or an industry. In this case, it is the related entities of "cancer" as a disease category and the myriad people who struggle against it.

As I noted earlier, it's strikingly well-written; I'll happily pick up the next book he puts out. OTOH, given how things went with Atul Gawande and his work after _Complications_, I will endeavor to be philosophical if there is a downhill slide. Parts of the story I have substantial, detailed knowledge of from other, recent reading, and longer term research. In general, Mukherjee's summaries are excellent. They are concise and thus skip over detail, but they are accurate and evocative. Except.

There's sort of a bad guy in this story. Mukherjee spends quite a lot of time describing all the things that have been attempted with various forms of cancer over the centuries (millenia?). The main story, however, is treatments developed and deprecated in the 20th century. He does a fantastic job of capturing the excitement of discovery and early successes and then the long slog of then trying to convert a possible treatment for a specific cancer into a general cure and the horror show that results. He spends a lot of time on Sidney Farber and Mary Woodard Lasker and the "War on Cancer", strongly suggesting and at times outright saying it was premature to attempt cures when cancer was still so poorly understood, particularly given how immensely damaging the therapies were. That theme continues past the death and/or retirement of Farber and Woodard Lasker, in the activism to legislate insurance companies paying for a particularly lethal form of breast cancer treatment. I'm sympathetic to that as a "bad guy", but not necessarily for the reasons that I think Mukherjee was going for. Mukherjee suggests (and, through quotations, gives voice to others who outright said" that a premature effort to cure cancer would result in perhaps fatal damage to the long term cause. The bluntness of chemo spoiled the field for more carefully matched medicines later on.

And there I am less certain I am in agreement with him. Mukherjee does recognize that for a lot of cancer, regardless of the progress to date, things really haven't changed in treatment terms from thousands of years ago. Yet he can still find it in him to believe that prophylactic double mastectomies and removal of ovaries reduces risk for women who have BRCA-1 genes -- and that "reducing risk" _means_ something real. I guess the only way to know how that one turns out is to wait a decade or three and learn the slow way what the future holds.

It's a long book but (yeah, improbable, based on the subject matter) and enjoyable read. Its worth seems apparent on the face of it and delivers in practice. Should you read it? Sure! But try not to get _too_ sucked into the optimistic, rah rah bits in the last fifth of the book.