I can’t quit dwelling on medicine’s flaws. I recently reviewed Mind Fixers by historian Anne Harrington and Medical Nihilism by philosopher Jacob Stegenga, which critique psychiatry and medicine as a whole, respectively. In this post I’ll discuss The Emperor of All Maladies, Siddhartha Mukherjee’s history of cancer medicine.
In spite of its grim subject, Emperor became a bestseller when it was published in 2010 (as well as winning a Pulitzer Prize and inspiring a PBS series), and with good reason. Mukherjee is a gifted writer, and his status as an insider, a professor of oncology at Columbia, gives his book a compelling personal dimension. He keeps you riveted with stories about patients, including his own, desperate to be cured, and physicians, including himself, desperate to cure them.
The emotional effect of Emperor is thus quite different from that of Nihilism and Fixers. The overall tone of the latter two books is critical, with an edge of righteous anger toward the medical community. Emperor, in contrast, is inspirational. Mukherjee expresses, for the most part, admiration for his follow oncologists. But the substance of all three books is essentially the same. All tell tales of scientific arrogance, over-reaching and failure on a massive scale.
Medieval doctors, Mukherjee informs us, cut out tumors, burned them and doused them with acid. Modern researchers sought to move past these primitive methods by finding “magic bullets,” which attack disease without harming healthy tissue. But by the 20thcentury, the major treatments for cancer were surgery, radiation and chemotherapy, which cut, burn and poison the body. Early chemotherapies, Mukherjee notes, were inspired by mustard gas, a chemical weapon, and radiation causes cancer.
Physicians kept making treatments more “radical” in their efforts to eradicate every last vestige of cancer, so that it would not return. Physicians cut more and more tissue from patients’ bodies and administered higher and higher doses of chemotherapy and radiation, bringing patients closer and closer to death. Physicians adhered to a bravado that Mukherjee describes as “the Hippocratic oath upside down.”
In 1933 surgeons discussing stomach cancer quoted, approvingly, an old Arab saying that “he is no physician who has not slain many patients.” Concern for patients’ quality of life was castigated as “mistaken kindness.” In 1962, a ward where children were administered multiple chemotherapy agents was called a “butcher shop.”
Switching to the realm of politics, Mukherjee recounts how cancer researcher Sydney Farber and philanthropist Mary Lasker mastered the arts of marketing and fundraising and turned the struggle against cancer into a crusade. Their efforts culminated in the so-called National Cancer Act, signed into law by Richard Nixon in 1971, which boosted federal funding for cancer research. Farber assured Congress, “We will in a relatively short period of time make vast inroads on the cancer problem.”
Skeptics warned that declarations of imminent victory were grossly premature, and they turned out to be right. In 1986 physician/statistician John Bailar and co-author Elaine Smith reported that between 1962 and 1985 cancer mortality rates rose by 8.7 percent. “We are losing the war on cancer,” they announced. The article “shook the world of oncology by its roots,” Mukherjee writes. Over the subsequent decade, oncologists insisted they were making progress. But in a 1997 article, “Cancer Undefeated,” Bailar and Helen Gornik presented evidence that between 1970 and 1994, as funding for research rose sharply, cancer mortality increased by 6 percent.
More bad news followed. In the 1990s bone-marrow transplants--in part because of intense lobbying by patient-advocacy groups--became a popular therapy for breast cancer in spite of their complexity, toxicity and cost. About 40,000 women worldwide were treated for a cost as high as $4 billion. Transplants were “big business,” Mukherjee writes, “big medicine, big money, big infrastructure, big risks.” A 1999 trial found that transplant therapy conferred “no discernible benefits.” The treatment gave some women acute leukemia, which was “far worse than the cancers they had begun with.”
There have been genuine victories, which Mukherjee details. Researchers have found virtual cures for certain uncommon types of cancer, such as lymphoblastic leukemia and Hodgkin’s lymphoma, especially in children. They have developed medications that extend lives, such as Herceptin and tamoxifen for breast cancer and Gleevec for leukemias and other cancers. And they have unraveled the complex biology of cancer, tracing it to genes, hormones, viruses and retroviruses as well as to carcinogens like those found in cigarettes.
In a section at the end of his book titled “The Fruits of Long Endeavors,” Mukherjee asserts that oncologists’ hard work is finally paying off. Between 1990 and 2005, the age-adjusted U.S. cancer mortality rate fell 15 percent, “a decline unprecedented in the history of the disease.” Because cancer rates go up with age, mortality rates are adjusted for the aging of the population. Mukherjee attributes the drop to declines in smoking as well as tests such as mammograms and advances in chemotherapy.
He tempers his optimism, suggesting that the more we learn about cancer’s hideously complex, shape-shifting etiology, the less likely it seems that we will vanquish it once and for all. Knowledge of cancer’s biology “is unlikely to eradicate cancer fully from our lives,” Mukherjee writes. No “simple, universal, or definitive cure is in sight—and is never likely to be.” We must accept this fact, he says, and yet keep fighting, avoiding the extremes of delusional hope and defeatism.
This is wise advice, and Emperor is a splendid piece of science journalism, but Mukherjee’s insider status is a weakness as well as strength. He doesn’t want to offend colleagues, and as a researcher he must believe his efforts will bear fruit. I kept wondering how a more neutral scholar—like Harrington or Stegenga--would have treated the same material, updated to the present. Such a scholar might have raised the following points:
*Cancer remains undefeated. The decline that Mukherjee celebrated in 2010 has continued at a pace of about one percent per year. U.S. mortality rates have fallen 27 percent since 1991, according to the American Cancer Institute. But this decrease came after a long increase that peaked in the early 1990s and followed a rise in smoking. The linkage of cancer to tobacco, which led to declines in smoking (another story well told by Mukherjee), has probably saved more lives than all other cancer-related scientific advances put together.
The current mortality rate for all cancers in the U.S. is roughly what it was in 1930. According to the invaluable website Our World in Data, mortality from lung cancer, by far the biggest killer, has returned to its 1970 rate. Although the death rates of some cancers, notably of the stomach and breast, have recently declined, death rates of liver, pancreatic and brain cancer have increased. Absolute death tolls from cancer keep climbing, increasing from 278,561 in 1990 to over 400,000 in 2017.
*Tests do more harm than good. In Emperor, Mukherjee has an excellent discussion of the limits of mammograms and other tests for cancer (which he revisits in a 2017 New Yorker article.) He notes that screening cannot catch some fast-growing cancers, and it flags tumors that if left alone would never have caused harm, a trend called overdiagnosis. He nonetheless claims that testing has helped bring down cancer mortality rates.
That claim looks increasingly dubious. To paraphrase Mukherjee, testing represents an inversion—or perversion--of the Hippocratic oath to do no harm. A 2015 review of screening methods for cancer and other diseases found that none extend life, when all causes of mortality are taken into account. Studies have revealed that tests such as mammograms and screening for prostate cancer have led to massive overdiagnosis and overtreatment.
A 2018 study warned that “more harm than benefit is created for most commonly used tests.” The following passage deserves emphasis: “Screening is big business: more screening means more patients, more clinical revenue to diagnostic and clinical departments, and more survivors in need of care and follow‐up. Critics are met with fierce opposition and not much changes. We believe, however, that a major, radical change is urgently needed after more than four decades of enormous investments and failing expectations.”
*The profit motive corrupts cancer medicine. The costs of cancer care in the U.S. are expected to reach $175 billion next year, up from $125 billion in 2010. Mukherjee is certainly worried about surging costs. In a recent New Yorker article, he expresses concern that new immunotherapies, on which he is working, cost hundreds of thousands of dollars per patient, and more than a million if follow-up care is included. He hopes that “continuous, iterative improvements” will make the drugs affordable.
Mukherjee is understandably reluctant to accuse his fellow oncologists of bad faith, that is, greed. But last April, The New York Times reported that top officials at Sloane Kettering Cancer Center “repeatedly violated policies on financial conflicts of interest, fostering a culture in which profits appeared to take precedence over research and patient care.” Sloane Kettering and other cancer centers, which compete for patients, spent $173 million in 2015 on what one critic called “misleading” advertisements that exploit “false hopes.”
The ferocious competition for grants might also have adverse effects. Since Nixon declared war on cancer in 1971, the budget for the National Cancer Institute has risen from $400 million to $5.74 billion. A 2012 examination of 53 “landmark” cancer studies found that only 6 could be reproduced. The so-called Reproducibility Project: Cancer Biology has examined more recent highly-cited studies. So far, only 5 of 14 have been confirmed without qualification.
*Cancer kills fewer people in countries that spend less on care. The U.S. spends far more per capita on health care, including cancer care, than any other country, but higher expenditures have not led to longer lives. Quite the contrary. Europe, which spends much less on cancer care than the U.S., has lower cancer mortality rates, according to a 2015 study. So do countries such as Mexico, Italy and Brazil, according to Our World in Data. These data corroborate concerns that the aggressive, expensive American approach to cancer is doing more harm than good.
In their books, Stegenga and Harrington advocate that psychiatry and other branches of medicine be practiced more sparingly, with more humility and caution. Stegenga calls this “gentle medicine.” Gentle cancer medicine would mean much less testing and treatment, which should lead to lower costs and better health.
Gentle cancer medicine seems unlikely in our hyper-capitalist culture. It can only take root if we consumers demand it, and stop insisting on getting dubious tests and treatments. We may never cure cancer, which results from the collision of our complex biology with entropy. But if we can curtail our fear and greed, our cancer care will surely improve.
See also my free online book Mind-Body Problems.