The Emperor of All Maladies

The Emperor of All Maladies, Siddhartha Mukherjee. Scribner (ISBN: 9781668047033) 2025 (My review is of the 2010 edition).

Summary: A biography of the disease, our understanding of its nature, and approaches to treating it.

Excuse my bluntness. Cancer sucks. I’ve watched friends and beloved relatives die cruel deaths from it. The survivors I know, including those in my own family, while grateful to be alive, bear the marks of their experience. The fear of recurrence is never far away. I’ve had my own brushes with cancer with skin lesions and precancerous polyps. Early detection and treatment made these just brushes. The truth is, all of us will have some form cancer or know someone close to us who does. And for anyone with a serious cancer diagnosis, life changes irrevocably on the day they receive that diagnosis.

The marvel of Siddhartha Mukherjee’s The Emperor of All Maladies is to write beautifully, elegantly, clearly, and honestly about this ugly fearsome disease. The title recognizes the powerful adversary cancer is. It arises when the normal cellular mechanisms that check growth and multiplication go haywire. Also, additional changes allow it to spread and resist our own defenses as well as external agents.

Mukherjee also calls this a biography of cancer. He chronicles a four thousand year history of the disease from the Egyptian physician Imhotep, who first described it to the Persian Queen Atossa, who had a slave remove a breast to fight breast cancer in 440 BC, futilely as it turned out because the cancer had spread. He traces that history down to the present discussing both our slowly growing understanding of the disease and key figures in the history of its treatment. Mukherjee also personalizes it with Carla, one of his patients, whose journey he traces at various points of the book.

He begins with when cancer was thought to be “black bile.” Yet doctors found no such substance, even in cadavers. Early on, a cancer diagnosis simply was a death sentence. Apart from quack remedies, there was no treatment. Only palliative care was possible. With the advent of antiseptic measures, surgeries were used to remove cancers, such as William Halsted’s radical mastectomies, often quite extensive and disfiguring. But quickly, doctors learned that if cancer was not local, surgery was futile. Another blunt instrument was radiation, again effective with local cancers (although it could also cause cancer).

Mukherjee introduces us to Sidney Farber, who moved from the laboratory to the clinic to fight childhood leukemia and other cancers. Antifolates and other early chemotherapies extended the lives of children. Farber teamed up with Mary Lasker to lead an effort to secure funding for research into other chemotherapies. They created the Jimmy Fund, named after a young boy, Einar Gusfson, with leukemia who was dubbed “Jimmy.” A baseball fan, he won the hearts of Boston’s baseball teams, and money poured in.

From the 1950’s to the 1970’s, Mukherjee chronicles burgeoning, hubristic efforts to win the “war on cancer” with chemotherapy. More and more extreme combinations of drugs resulted in both victories and a lot of failures. But something was missing. While throwing all these therapies at cancer, clinicians gave little time to understanding how cancer worked. Not only that, but those who researched the cellular mechanisms of cancer weren’t talking to the clinicians who treated it.

Then, beginning in the 1980’s, there was an explosion in understanding the nature of cancer, and the genetic mechanisms behind its uncontrolled multiplication and spread. Just as the human genome has been sequenced, so are cancer genomes, tracing pathways by which normal cells turn cancerous. This has been accompanied by advances in both prevention and therapeutics, including identifications of mutations like the BRCA gene that leads to some breast cancers.

Since 2010, there have been an avalanche of advances in cancer biology, prevention, and treatment. So in 2025, Mukherjee released an updated edition of the book with four new chapters detailing these advances.

Despite the heartbreaks and latent fears I’ve known, I found Mukherjee’s account fascinating. Mukherjee weaves into the history and the science real people, both those who die and those who survive. His book stands as a warning against hubris in announcing “cures for cancer.” He helps us understand why cancer is such a difficult to conquer emperor and what has been and is being done. He reflects the realistic hope of every cancer survivor who speaks, not of cures, but of “no evidence of disease” that allows one to live another day. Mukherjee also reminds us of the army of people working to prevent cancer and treat it, not giving up on conquering the emperor.