Emperor Of All Maladies Quotes

History repeats, but science reverberates.

The art of medicine is long, Hippocrates tells us, "and life is short; opportunity fleeting; the experiment perilous; judgment flawed.

In God we trust. All others [must] have data. - Bernard Fisher

Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing. —Voltaire

Cancer was not disorganized chromosomal chaos. It was organized chromosomal chaos

Down to their innate molecular core, cancer cells are hyperactive, survival-endowed, scrappy, fecund, inventive copies of ourselves.

It remains an astonishing, disturbing fact that in America - a nation where nearly every new drug is subjected to rigorous scrutiny as a potential carcinogen, and even the bare hint of a substance's link to cancer ignites a firestorm of public hysteria and media anxiety - one of the most potent and common carcinogens known to humans can be freely bought and sold at every corner store for a few dollars.

A model is a lie that helps you see the truth.

Cancer's life is a recapitulation of the body's life, its existence a pathological mirror of our own.

One swallow is a coincidence, but two swallows make summer.

This was yet another colonial fascination: to create the conditions of misery in a population, then subject it to social or medical experimentation.

All cancers are alike but they are alike in a unique way.

In 2005, a man diagnosed with multiple myeloma asked me if he would be alive to watch his daughter graduate from high school in a few months. In 2009, bound to a wheelchair, he watched his daughter graduate from college. The wheelchair had nothing to do with his cancer. The man had fallen down while coaching his youngest son's baseball team.

But the story of leukemia--the story of cancer--isn't the story of doctors who struggle and survive, moving from institution to another. It is the story of patients who struggle and survive, moving from on embankment of illness to another. Resilience, inventiveness, and survivorship--qualities often ascribed to great physicians--are reflected qualities, emanating first from those who struggle with illness and only then mirrored by those who treat them. If the history of medicine is told through the stories of doctors, it is because their contributions stand in place of the more substantive heroism of their patients.

Indeed, cancer’s emergence in the world is the product of a double negative: it becomes common only when all other killers themselves have been killed.

Comparison to others is the emperor of all emotional maladies. It kills the spirit and creates divisions in our social interactions.

How can one capture genes that behave like ghosts," Weinberg wrote, "influencing cells from behind some dark curtain?

Cancer thus exploits the fundamental logic of evolution unlike any other illness. If we, as a species, are the ultimate product of Darwinian selection, then so, too, is this incredible disease that lurks inside us.

Cancer is an expansionist disease; it invades through tissues, sets up colonies in hostile landscapes, seeking “sanctuary” in one organ and then immigrating to another. It lives desperately, inventively, fiercely, territorially, cannily, and defensively—at times, as if teaching us how to survive. To confront cancer is to encounter a parallel species, one perhaps more adapted to survival than even we are.

Every era casts illness in its own image. Society, like the ultimate psychosomatic patient, matches its medical afflictions to its psychological crises; when a disease touches such a visceral chord, it is often because that chord is already resonating.

It was Disney World fused with Cancerland.

I had a novice's hunger for history, but also a novice's inability to envision it.

In the laboratory, we call this the six-degrees-of-separation-from-cancer rule: you can ask any biological question, no matter how seemingly distant—what makes the heart fail, or why worms age, or even how birds learn songs—and you will end up, in fewer than six genetic steps, connecting with a proto-oncogene or tumor suppressor.

The revolution in cancer research can be summed up in a single sentence: cancer is, in essence, a genetic disease. —Bert Vogelstein

Scientists often study the past as obsessively as historians because few other professions depend so acutely on it. Every experiment is a conversation with a prior experiment, every new theory a refutation of the old.

I am not opposed to optimism, but I am fearful of the kind that comes from self-delusion.

In Lewis Carroll’s Through the Looking-Glass, the Red Queen tells Alice that the world keeps shifting so quickly under her feet that she has to keep running just to keep her position. This is our predicament with cancer: we are forced to keep running merely to keep still.

Cancer begins and ends with people. In the midst of scientific abstraction, it is sometimes possible to forget this one basic fact.…

Leukemia is cancer of the white blood cells—cancer in one of its most explosive, violent incarnations. As one nurse on the wards often liked to remind her patients, with this disease “even a paper cut is an emergency.

Science begins with counting. To understand a phenomenon, a scientist must first describe it; to describe it objectively, he must first measure it.

And it is solely by risking life that freedom is obtained. —Hegel

In God we trust,” he brusquely told a journalist. “All others [must] have data.

If we, as a species, are the ultimate product of Darwinian selection, then so, too, is this incredible disease that lurks inside us.

Nineteenth-century doctors often linked cancer to civilization: cancer, they imagined, was caused by the rush and whirl of modern life, which somehow incited pathological growth in the body. The link was correct, but the causality was not: civilization did not cause cancer, but by extending human life spans—civilization unveiled it.

But in 1960, oncology was not yet ready for this proposal. Not until several years later did it strike the board that had fired Li so hastily that the patients he had treated with the prolonged maintenance strategy would never relapse. This strategy--which cost Min Chiu Li his job--resulted in the first chemotherapeutic cure of cancer in adults.

Science is often described as an iterative and cumulative process, a puzzle solved piece by piece, with each piece contributing a few hazy pixels of a much larger picture. But the arrival of a truly powerful new theory in science often feels far from iterative. Rather than explain one observation or phenomenon in a single, pixelated step, an entire field of observations suddenly seems to crystallize into a perfect whole. The effect is almost like watching a puzzle solve itself.

Cancer is a tremendous opportunity to have your face pressed right up against the glass of your mortality.” But what patients see through the glass is not a world outside cancer, but a world taken over by it—cancer reflected endlessly around them like a hall of mirrors.

Cancer is not a concentration camp, but it shares the quality of annihilation: it negates the possibility of life outside and beyond itself; it subsumes all living.

The word metastasis, used to describe the migration of cancer from one site to another, is a curious mix of meta and stasis—“beyond stillness” in Latin—an

Unidentified flying objects, abominable snowmen, the Loch Ness monster and human cancer viruses. —Medical World News, 1974, on four “mysteries” widely reported and publicized but never seen

Pierre and Marie (then Maria Sklodowska, a penniless Polish immigrant living in a garret in Paris) had met at the Sorbonne and been drawn to each other because of a common interest in magnetism.

It is said that if you know your enemies and know yourself, you will not be imperiled in a hundred battles; if you do not know your enemies but do know yourself, you will win one and lose one; if you do not know your enemies nor yourself, you will be imperiled in every single battle. —Sun Tzu

Whether epidemiology alone can, in strict logic, ever prove causality, even in this modern sense, may be questioned, but the same must also be said of laboratory experiments on animals. —Richard Doll

This was the tenth month of my "fellowship" in oncology - a two-year immersive medical program to train cancer specialists - and I felt as if I had gravitated to my lowest point. In those ten indescribably poignant and difficult months, dozens of patients in my care had died. I felt as if I was slowly becoming inured to the deaths and the desolation - vaccinated against the constant emotional brunt.

That this seemingly simple mechanism—cell growth without barriers—can lie at the heart of this grotesque and multifaceted illness is a testament to the unfathomable power of cell growth. Cell division allows us as organisms to grow, to adapt, to recover, to repair—to live. And distorted and unleashed, it allows cancer cells to grow, to flourish, to adapt, to recover, and to repair—to live at the cost of our living. Cancer cells can grow faster, adapt better. They are more perfect versions of ourselves.

The daughter of Lithuanian immigrants, born with a precocious scientific intellect and a thirst for chemical knowledge, Elion had completed a master's degree in chemistry from New York University in 1941 while teaching high school science during the day and preforming her research for her thesis at night and on the weekends. Although highly qualified, talented, and driven, she had been unable to find a job in an academic laboratory. Frustrated by repeated rejections, she had found a position as a supermarket product supervisor. When Hitchings found Trudy Elion, who would soon become on of the most innovative synthetic chemists of her generation (and a future Nobel laureate), she was working for a food lab in New York, testing the acidity of pickles and the color of egg yolk going into mayonnaise. Rescued from a life of pickles and mayonnaise…

Cancer, we now know, is a disease caused by the uncontrolled growth of a single cell.

Medicine, I said, begins with storytelling. Patients tell stories to describe illness; doctors tell stories to understand it. Science tells its own story to explain diseases.

To understand cancer as a whole, he reasoned, you needed to start at the bottom of its complexity, in its basement.

A patient, long before he becomes the subject of medical scrutiny, is, at first, simply a storyteller, a narrator of suffering—

Cancer, Auerbach argued, was a disease unfolded slowly in time. It did not run, but rather slouched to its birth. Auerbach

Specificity refers to the ability of any medicine to discriminate between its intended target and its host. Killing a cancer cell in a test tube is not a particularly difficult task: the chemical world is packed with malevolent poisons that, even in infinitesimal quantities, can dispatch a cancer cell within minutes. The trouble lies in finding a selective poison—a drug that will kill cancer without annihilating the patient. Systemic therapy without specificity is an indiscriminate bomb. For an anticancer poison to become a useful drug, Meyer knew, it needed to be a fantastically nimble knife: sharp enough to kill cancer yet selective enough to spare the patient.

To take care of cancer patients is an enormous privilege, but it also involves deploying everything in your toolbox: the emotional, the psychological, the scientific, the epidemiologic.

Emblematic of this era was the prolific Viennese surgeon Theodor Billroth. Born in 1821, Billroth studied music and surgery with almost equal verve. (The professions still often go hand in hand. Both push manual skill to its limit; both mature with practice and age; both depend on immediacy, precision, and opposable thumbs.)

In 2010, about six hundred thousand Americans, and more than 7 million humans around the world, will die of cancer. In the United States, one in three women and one in two men will develop cancer during their lifetime. A quarter of all American deaths, and about 15 percent of all deaths worldwide, will be attributed to cancer. In some nations, cancer will surpass heart disease to become the most common cause of death.

...lung cancer incidence in men increased dramatically in the 1950s as a result of an increase in cigarette smoking during the early twentieth century. In women, a cohort that began to smoke in the 1950s, lung cancer incidence has yet to reach its peak.

And despite its many idiosyncrasies, leukemia possessed a singularly attractive feature: it could be measured. Science begins with counting. To understand a phenomenon, a scientist must first describe it; to describe it objectively, he must first measure it.

Children with cancer, as one surgeon noted, were typically “tucked in the farthest recesses of the hospital wards.” They were on their deathbeds anyway, the pediatricians argued; wouldn’t it be kinder and gentler, some insisted, to just “let them die in peace”?

Ehrlich hedged. The cancer cell, he explained, was a fundamentally different target from a bacterial cell. Specific affinity relied, paradoxically, not on “affinity,” but on its opposite—on difference. Ehrlich’s chemicals had successfully targeted bacteria because bacterial enzymes were so radically dissimilar to human enzymes. With cancer, it was the similarity of the cancer cell to the normal human cell that made it nearly impossible to target.

La ciencia encarna el deseo humano de entender la naturaleza; la tecnología conjuga ese deseo con la ambición de controlarla.

The search for a way to eradicate this scourge… is left to incidental dabbling and uncoordinated research. —The Washington Post, 1946

One leukemia doctor wrote, “I know the patients, I know their brothers and sisters, I know their dogs and cats by name.… The pain is that a lot of love affairs end.

I don’t know why I deserved the illness in the first place, but then I don’t know why I deserved to be cured. Leukemia is like that. It mystifies you. It changes your life.

Cancer researchers knew that X-rays, soot, cigarette smoke, and asbestos represented vastly more common risk factors for human cancers.

Is there something I can do to kill the cancer germ? Can the rooms be fumigated…? Should I give up my lease and move out?

Li had stumbled on a deep and fundamental principle of oncology: cancer needed to be systemically treated long after every visible sign of it had vanished.

It was, I suspected, not the first time that a patient had consoled a doctor about the ineffectuality of his discipline.

By the early 1940s, asking about a connection between tobacco and cancer was like asking about an association between sitting and cancer.

Its palliation is a daily task, its cure a fervent hope. —William Castle, describing leukemia in 1950

There is a difference between the “cost” of a drug and the “price” of a drug. A pill of Gleevec—I mean, the chemical that we call Gleevec—can be synthesized

The approach required more persistence than imagination, but it produced remarkable results.

A model is a lie that helps you see the truth. —Howard Skipper

How many of us have asked the question, ‘If this great country of ours can put a man on the moon why can’t we find a cure for cancer?

Prostate cancer represents a full third of all cancer incidence in men—sixfold that of leukemia and lymphoma.

Cancer, then, is quite literally trying to emulate a regenerating organ—or perhaps, more disturbingly, the regenerating organism. Its quest for immortality mirrors our own quest, a quest buried in our embryos and in the renewal of our organs. Someday, if a cancer succeeds, it will produce a far more perfect being than its host—imbued with both immortality and the drive to proliferate. One might argue that the leukemia cells growing in my laboratory derived from the woman who died three decades earlier have already achieved this form of “perfection.

The universe,” the twentieth-century biologist J. B. S. Haldane liked to say, “is not only queerer than we suppose, but queerer than we can suppose”—and so is the trajectory of science.)

It remains an astonishing, disturbing fact that in America—a nation where nearly every new drug is subjected to rigorous scrutiny as a potential carcinogen, and even the bare hint of a substance’s link to cancer ignites a firestorm of public hysteria and media anxiety—one of the most potent and common carcinogens known to humans can be freely bought and sold at every corner store for a few dollars.

We have not slain our enemy, the cancer cell, or figuratively torn the limbs from his body,” Varmus said. “In our adventures, we have only seen our monster more clearly and described his scales and fangs in new ways—ways that reveal a cancer cell to be, like Grendel, a distorted version of our normal selves.

I’m sorry, Ms. Rosenow, but the Times cannot publish the word breast or the word cancer in its pages. “Perhaps,” the editor continued, “you could say there will be a meeting about diseases of the chest wall.

A cancer cell is an astonishing perversion of the normal cell. Cancer is a phenomenally successful invader and colonizer in part because it exploits the very features that make us successful as a species or as an organism.

My book is an attempt to answer her question by going back to the origin of the disease and showing its development through history. I called it “a biography of cancer,” because it draws a portrait of an illness over time.

When a disease insinuates itself so potently into the imagination of an era, it is often because it impinges on an anxiety latent within that imagination. AIDS loomed so large on the 1980s in part because this was a generation inherently haunted by its sexuality and freedom; SARS set off a panic about global spread and contagion at a time when globalism and social contagion were issues simmering nervously in the West. Every era casts illness in its own image. Society, like the ultimate psychosomatic patient, matches its medical afflictions to its psychological crises; when a disease touches such a visceral chord, it is often because that chord is already resonating.

The landscape of carcinogens is not static either. We are chemical apes: having discovered the capacity to extract, purify, and react molecules to produce new and wondrous molecules, we have begun to spin a new chemical universe around ourselves. Our bodies, our cells, our genes are thus being immersed and reimmersed in a changing flux of molecules--pesticides, pharmaceutical drugs, plastics, cosmetics, estrogens, food products, hormones, even novel forms of physical impulses, such as radiation and magnetism. Some of these, inevitably, will be carcinogenic. We cannot wish this world away; our task, then, is to sift through it vigilantly to discriminate bona fide carcinogens from innocent and useful bystanders.

Activating or inactivating any single gene, he postulated, produced only the first steps toward carcinogenesis. Cancer’s march was long and slow and proceeded though many mutations in many genes over many iterations. In genetic terms, our cells were not sitting on the edge of the abyss of cancer. They were dragged toward that abyss in graded, discrete steps.

Those who have not been trained in chemistry201 or medicine may not realize how difficult the problem of cancer treatment really is. It is almost—not quite, but almost—as hard as finding some agent that will dissolve away the left ear, say, and leave the right ear unharmed. So slight is the difference between the cancer cell and its normal ancestor. —William Woglom Life

Today when I see a patient with CML, I tell them that the disease is an indolent leukemia with an excellent prognosis, that they will usually live their functional life span provided they take an oral medicine, Gleevec, for the rest of their lives.

In an essay titled A View From the Front Line, Jencks described her experience with cancer as like being woken up midflight on a jumbo jet and then thrown out with a parachute into a foreign landscape without a map: "There you are, the future patient, quietly progressing with other passengers toward a distant destination when, astonishingly (Why me?) a large hole opens in the floor next to you. People in white coats appear, help you into a parachute and — no time to think — out you go. "You descend. You hit the ground....But where is the enemy? What is the enemy? What is it up to?...No road. No compass. No map. No training. Is there something you should know and don't? "The white coats are far, far away, strapping others into their parachutes. Occasionally they wave but, even if you ask them, they don't know the answers. They are up there in the Jumbo, involved with parachutes, not map-making.

Cancer, we have discovered, is stitched into our genome. Oncogenes [cancer causing cells] arise from mutations in essential genes that regulate the growth of cells. Mutations accumulate in these genes when DNA is damaged by carcinogens, but also by seemingly random errors in copying genes when cells divide. The former might be preventable, but the latter is endogenous [originating from within]. Cancer is a flaw in our growth, but this flaw is deeply entrenched in ourselves. We can rid ourselves of cancer, then, only as much as we can rid ourselves of the processes in our physiology that depend on growth — aging, regeneration, healing, reproduction.

Every generation of cancer cells creates a small number of cells that is genetically different from its parents. When a chemotherapeutic drug or the immune system attacks cancer, mutant clones that can resist the attack grow out. The fittest cancer cell survives.

Cancer is an expansionist disease; it invades through tissues, sets up colonies in hostile landscapes, seeking “sanctuary” in one organ and then immigrating to another. It lives desperately, inventively, fiercely, territorially, cannily, and defensively—at times, as if teaching us how to survive. To confront cancer is to encounter a parallel species, one perhaps more adapted to survival than even we are. This

Far more potently than any miracle medicine, relatively uncelebrated shifts in civic arrangements--better nutrition, housing, and sanitation, improved sewage systems and ventilation--had driven TB mortality down in Europe and America. Polio and smallpox had also dwindles as a result of vaccinations. Cains wrote, "The death rates from malaria, cholera, typhus, tuberculosis, scurvy, pellagra, and other scourges of the past have dwindled in the US because humankind has learned how to prevent these diseases.... To put most of the effort into treatment is to deny all precedent.

In the neighboring town of Carlisle, Lister had observed sewage disposers cleanse their waste with a cheap, sweet-smelling liquid containing carbolic acid. Lister began to apply carbolic acid paste to wounds after surgery. (That he was applying a sewage cleanser to his patients appears not to have struck him as even the slightest bit unusual.) In

The secret to battling cancer, then, is to find means to prevent these mutations from occurring in susceptible cells, or to find means to eliminate the mutated cells without compromising normal growth. The conciseness of that statement belies the enormity of the task. Malignant growth and normal growth are so genetically intertwined that unbraiding the two might be one of the most significant scientific challenges faced by our species. Cancer is built into our genomes: the genes that unmoor normal cell division are not foreign to our bodies, but rather mutated, distorted versions of the very genes that perform vital cellular functions. And cancer is imprinted in our society: as we extend our life span as a species, we inevitably unleash malignant growth (mutations in cancer genes accumulate with aging; cancer is thus intrinsically related to age). If we seek immortality, then so, too, in a rather perverse sense, does the cancer cell.

Oncologists and their patients are bound, it seems, by an intense subatomic force. So, albeit in a much smaller sense, this was a victory for me as well. I sat at Carla’s table and watched her pour a glass of water for herself, unpurified and straight from the sink. She glowed radiantly, her eyes half-closed, as if the compressed autobiography of the last five years were flashing through a private and internal cinema screen. Her

Mutations litter the chromosomes. In individual specimens of breast and colon cancer, between fifty to eighty genes are mutated; in pancreatic cancers, about fifty to sixty. Even brain cancers, which often develop at earlier ages and hence may be expected to accumulate fewer mutations, possess about forty to fifty mutated genes. Only a few cancers are notable exceptions to this rule, possessing relatively few mutations across the genome. One of these is an old culprit, acute lymphoblastic leukemia: only five or ten genetic alterations cross its otherwise pristine genomic landscape.* Indeed, the relative paucity of genetic aberrancy in this leukemia may be one reason that this tumor is so easily felled by cytotoxic chemotherapy. Scientists speculate that genetically simple tumors (i.e., those carrying few mutations) might inherently be more susceptible to drugs, and thus intrinsically more curable. If so, the strange discrepancy between the success of high-dose chemotherapy in curing leukemia and its failure to cure most other cancers has a deep biological explanation. The search for a “universal cure” for cancer was predicated on a tumor that, genetically speaking, is far from universal. In

The Human Genome Project, the full sequence of the normal human genome, was completed in 2003. In its wake comes a far less publicized but vastly more complex project: fully sequencing the genomes of several human cancer cells. Once completed, this effort, called the Cancer Genome Atlas, will dwarf the Human Genome Project in its scope. The sequencing effort involves dozens of teams of researchers across the world. The initial list of cancers to be sequenced includes brain, lung, pancreatic, and ovarian cancer. The Human Genome Project will provide the normal genome, against which cancer’s abnormal genome can be juxtaposed and contrasted. The result, as Francis Collins, the leader of the Human Genome Project describes it, will be a “colossal atlas” of cancer—a compendium of every gene mutated in the most common forms of cancer: “When applied to the 50 most common types of cancer, this effort could ultimately prove to be the equivalent of more than 10,000 Human Genome Projects in terms of the sheer volume of DNA to be sequenced.

In a particularly memorable exchange, Edell quizzed Liggett’s president697 about why the company had spent nearly $5 million to show that tobacco could cause tumors to sprout on the backs of mice, and then systematically chose to ignore any implications for carcinogenesis in humans: Edell: What was the purpose of this [experiment]? Dey: To try to reduce tumors on the backs of mice. Edell: It had nothing to do with the health and welfare of human beings? Is that correct? Dey: That’s correct. . . . Edell: And this was to save rats, right? Or mice?

In 1997, the NCI director, Richard Klausner, responding to reports that cancer mortality had remained disappointingly static through the nineties, argued that the medical realities of one decade had little bearing on the realities of the next. “There are far more good historians than there are good prophets,” Klausner wrote. “It is extraordinarily difficult to predict scientific discovery, which is often propelled by seminal insights coming from unexpected directions. The classic example—Fleming’s discovery of penicillin on moldy bread and the monumental impact of that accidental finding—could not easily have been predicted, nor could the sudden demise of iron-lung technology when evolving techniques in virology allowed the growth of poliovirus and the preparation of vaccine. Any extrapolation of history into the future presupposes an environment of static discovery—an oxymoron.

But the pigs--seventy pounds of porcine weight that did not take kindly to weekly endoscopies--did not sprout any ulcers. And testing the theory on humans was ethically impossible: how could one justify infecting a human with a new, uncharacterized species of bacteria to prove that it caused gastritis and predisposed to cancer? In July 1984, with his experiments stalled and his grant applications in jeopardy, Marshall performed the ultimate experiment: "On the morning of the experiment, I omitted my breakfast….Two hours later, Neil Noakes scraped a heavily inoculated 4 day culture plate of Helicobacter and dispersed the bacteria in alkaline peptone water (a kind of meat broth used to keep bacteria alive). I fasted until 10 am when Neil handed me a 200 ml beaker about one quarter full of the cloudy brown liquid. I drank it down in one gulp then fasted for the rest of the day. A few stomach gurgles occurred. Was it the bacteria or was I just hungry?

Yet the hunger to treat patients still drove Farber. And sitting in his basement laboratory in the summer of 1947, Farber had a single inspired idea: he chose, among all cancers, to focus his attention on one of its oddest and most hopeless variants—childhood leukemia. To understand cancer as a whole, he reasoned, you needed to start at the bottom of its complexity, in its basement. And despite its many idiosyncrasies, leukemia possessed a singularly attractive feature: it could be measured. Science begins with counting. To understand a phenomenon, a scientist must first describe it; to describe it objectively, he must first measure it. If cancer medicine was to be transformed into a rigorous science, then cancer would need to be counted somehow—measured in some reliable, reproducible way. In this, leukemia was different from nearly every other type of cancer. In a world before CT scans and MRIs, quantifying the change in size of an internal solid tumor in the lung or the breast was virtually impossible without surgery: you could not measure what you could not see. But leukemia, floating freely in the blood, could be measured as easily as blood cells—by drawing a sample of blood or bone marrow and looking at it under a microscope. If leukemia could be counted, Farber reasoned, then any intervention—a chemical sent circulating through the blood, say—could be evaluated for its potency in living patients. He could watch cells grow or die in the blood and use that to measure the success or failure of a drug. He could perform an “experiment” on cancer.