The Emperor of All Maladies: A Biography of Cancer. By Siddhartha Mukherjee. Scribner, New York, 2010. ISBN: 978-1-4391-0795-9. 571 pp. Hardcover, $30.
The pink ribbon is a widely recognized symbol of the war on breast cancer. Pink-ribbon culture has turned breast cancer into a consumer item: you can buy products or wear the brand logo. You can laugh for the cure, buy shoes for the cure, even test drive a BMW for the cure. You can feel good about yourself because you think you are supporting efforts that will end breast cancer. The reality is more complex, as Gayle Sulik explains in her new book, Pink Ribbon Blues: How Breast Cancer Culture Undermines Women’s Health.
Pink-ribbon culture has been instrumental in raising awareness of breast cancer, making it acceptable to talk about it and providing support to victims, but it’s not all good. The culture exaggerates the benefits of mammography, supports an industry that makes huge profits, and promotes an image of the “she-ro” survivor that doesn’t fit the experience of many women.
“Mammography saves lives,” the slogan goes. Yes, but far fewer than most people believe. For every 2,000 women who are screened for ten years, ten will be treated unnecessarily and only one will have her life prolonged. The concept of carcinoma in situ is being reevaluated: it is not really cancer but only a risk factor for subsequent development of cancer. Many women have undergone surgery and chemotherapy for a lesion that would never have caused them any harm. And the radiation from mammography has the potential to cause a few other cancers.
Mixed metaphors about “war” and “femininity” have re-framed our thinking about the fight against breast cancer. Women have been made to feel guilty for not conforming to pink-ribbon ideals of heroism and optimism. The tyranny of pink-ribbon culture has usurped the voices of many diagnosed women who don’t conform to its stereotypes. Perhaps because the benefits of mammography screening have been exaggerated, research into possible environmental causes of cancer has lagged. Corporations have arguably benefited more than patients; they are making big bucks from mammography equipment, pharmaceuticals, and other products. Women’s issues and consumerism cloud clear thinking.
Sulik says that “fighting the good fight” has taken precedence over winning the war. She questions the value of a pink-ribbon culture that limits how we talk and think about breast cancer; disempowers, demeans, and objectifies women; and engages in fear-mongering that leads to overdiagnosis and overtreatment. She suggests taking a road less pink and rethinking our approach to research on effective prevention and treatment.
These issues are worth thinking about, but Sulik’s book is repetitive and takes an interminable 379 pages to deliver its message. I was bored and had to force myself to finish reading it. Sulik concentrates on social issues, but I thought her understanding of the science behind cancer research and treatment was incomplete and her expectations for a victory in the war against cancer were simplistic and unrealistic.
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While I was reading Sulik’s book, I happened upon a book that is far more worthwhile and much better written: The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee, a cancer physician and researcher. It is a history of cancer that touches on how science gradually came to understand some of cancer’s realities, cutting-edge knowledge, and of exciting new directions in research. It is also a riveting read with a plot like a detective story and entertaining vignettes about the successes and failures, and personalities, of the people involved—including scientists, doctors, activists, and patients.
For example, Mukherjee’s book tells of how America’s foremost surgeon developed the radical mastectomy operation based on a misconception of cancer biology. It was a terrible mistake: it had no chance of helping women whose cancer had already started to metastasize, and it unnecessarily mutilated those whose cancer was localized and could have been treated just as effectively with a lumpectomy. One early chemotherapy researcher found a permanent cure for one type of cancer, choriocarcinoma, and was rewarded by being fired. One researcher’s procrastination and poor housekeeping led to a serendipitous discovery on culture plates that he hadn’t gotten around to discarding: it turned out the virus he was looking for grew far more slowly than he had imagined.
Early scientific gropings gradually bore fruit. Today we know that cancer is not one disease but a collection of diseases characterized by uncontrolled cell growth. We know it is produced by a series of mutations and by changes in the expression of genes. We know its abnormalities are only exaggerations of normal processes essential to our welfare. We understand what processes have gone astray in the cancer cell. We are sequencing cancer genes just as we have sequenced the human genome, and instead of treatments that damage normal cells while destroying cancer cells, we are developing targeted treatments that interfere with the biological processes of individual cancer strains with little or no harm to normal cells.
Gleevec is a stunning example. It targets a specific enzyme that is overactive in chronic myelogenous leukemia (CML). Before Gleevec, patients with CML were told that they had a fatal disease that would kill half of them within three to six years and that the only available treatment had devastating side effects; today, CML patients can be told they have a chronic disease that will not shorten their life span as long as they take a pill for the rest of their lives.
Some mutations are caused by carcinogens in the environment: we can hope to minimize or prevent these. Other mutations arise from random copying errors during the normal process of cell division: these may be an unpreventable fact of life. We may have to redefine what constitutes victory in the war against cancer. Instead of eliminating the beast, we may succeed in de-fanging it—turning it into a tame chronic disease that can be controlled with medication.
Although Pink Ribbon Blues has a limited message that may be of particular interest to sociologists and feminists, most readers will find The Emperor of all Maladies a far more profitable and enjoyable use of their time.
This article was originally published in Skeptical Inquirer.