Star Wars in the Empire of All Maladies

Bruce D. Cheson, MD


March 02, 2012

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Welcome to another episode of Medscape Hematology. I am Bruce Cheson at Georgetown University Hospital, Lombardi Comprehensive Cancer Center. Yesterday we had an interesting event here: our first book club. Our fellows are supposed to be reading journals and textbooks, but I thought I would introduce them to the more human side of things, so we are going to have a book club.

The first book we read was The Emperor of All Maladies. This is the Pulitzer Prize-winning book by Siddhartha Mukherjee. It tells the history of cancer. I had the fellows first tell us their global impression of the book and then discuss a character who impressed them the most -- the one they liked the most, hated the most, or who gave them some sense of what the world was all about.

In general, they liked the book, although one of them disliked the author. He did an in-depth online search on the author and didn't care much for him. Virtually everybody thought the book had a bit too much melodrama in it, but they all basically enjoyed the book. They were impressed by a number of things, such as the fact that there really was a history to what they were practicing now. They never knew where things came from, and now they had some idea of the process that led from not knowing what to do with breast cancer to the concept of adjuvant therapy.

They really enjoyed learning about the history, and that cancer was actually made into something more tangible, an object that could be attacked; that there were people who were not affected directly by cancer but who really rallied around the cause. They were mostly impressed by the fact that it has been 40 years now since Nixon said "we are going to cure cancer," and we are still quite a way off.

With respect to characters, I hoped that each reader would pick a different character, but it didn't turn out that way. Two fellows picked William Halsted and for the same reasons. One reason was his "omnipresence" -- the fact that he was in charge, he knew what he wanted, and he put his people (his scions) in different positions. If you weren't one of his boys, you weren't going anywhere. They were also impressed by the "more is better" idea: Take off as much breast tissue, clavicle, muscle, skin as you can, leaving these poor women disfigured, and still the disease came back.

They were interested in the "more is better" concept that went into the breast cancer transplant; they couldn't believe that people did transplants in breast cancer. I had to keep introducing my own personal involvement in this and how I was opposed to what we now would think of as madness. One of them was also impressed by a character named Gianni Bonadonna, although he thought that Bonadonna was not a very important character because he wasn't dealt with much. I said, "Not important?" and told them of Gianni Bonadonna and his work with ABVD [adriamycin, bleomycin, vinblastine, decarbazine] not only for breast cancer, but also for Hodgkin disease.

One of the fellows was impressed by Dennis Slamon and how he was so determined to get drug companies to help develop trastuzumab. His determination was really overwhelming. It was very impressive to the fellows.

A Chinese fellow of ours really stole the show. He picked as his favorite character Dr. Zhen Yi Wang, who was the person who discovered that all-trans retinoic acid (ATRA) was effective therapy for acute promyelocytic leukemia (APL). Our fellow actually tried to contact the doctor, who is in his late 80s now, but hasn't heard back yet. He was told that the doctor still uses his wife's email address, even though his wife has been dead for a number of years. He discussed this character and the history of ATRA (in which I was involved because I reviewed the first paper that was submitted to a real US journal). Dr. Wang lived in China when ATRA was being developed. Everybody was poor to the point where it was almost impossible to get retinoids; Wang went to the factory to get something called "transretinoic acid" which was being used for dermatologic applications.

The rest is history. ATRA led to our knowledge of the molecular biology of APL. It was really an interesting experience to see how the fellows' perceptions differed from mine, because I was there during the times of Bezwoda and the fabrication of data, and I was there for a lot of what they thought was history. There was Guy Carbone -- I knew these people. To the fellows, it was just remarkable history. It really made me feel good to see how impressed they were by the long and tedious process that cancer research has gone through.

I asserted myself most strongly when we talked about the old days when Emil Freireich, Tom Frei, and George Canellos could take an idea -- just say, "I've got an idea, let's do it," and they went out and did it. Now it takes us years of process, to the detriment of progress. We also talked about informed consent and how stringent the institutional review boards have become to the point where instead of protecting patients, sometimes it is to the detriment of patients. We discussed the balance.

The Emperor of All Maladies was certainly not a perfect book; it's a good book, and it's worth reading, particularly for those of us in the field. It was a great experience for the fellows to read this and to see where the field came from, where it is now, and to get some ideas of where it is going and what it will take to get there.

The next book will be The Immortal Life of Henrietta Lacks, which was one of the best books I read last year, so in a few months we will be back having another of these Medscape sessions, again talking about how that book group went. In the meantime, I hope you will read [The Emperor of All Maladies], and I hope you read the next one, so that when I talk about Henrietta Lacks, the "HeLa cell lady," you'll be able to participate in this intellectually and enjoy the discussion.


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