Cancer: An Interview with the author of The Emperor of All Maladies: A Biography of Cancer

Ideas in Action with Jim Glassman is a new half-hour weekly series on ideas and their consequences.

Dr. Siddhartha Mukherjee, an oncologist and medical researcher at Columbia University, has written a comprehensive book examining the history of cancer. Through the stories of several cancer patients and researchers who have made great strides in understanding and fighting the disease, Mukherjee sounds an optimistic note about future medical advances in understanding and fighting cancer.

Transcript

JIM GLASSMAN:

Welcome to Ideas in Action a television series about ideas and their consequences. I'm Jim Glassman. This week: the history and future of cancer. Everyday it kills more than 20 thousand people around the globe. Whether in Mogadishu or Washington, cancer is one of humanity's most relentless diseases. We've made a lot of progress at fighting it, but the war on cancer is far from over. How far have we come? And what more do we need to do? Joining me to discuss this topic is Dr. Siddhartha Mukherjee, he is an oncologist at Columbia University Medical Center, a cancer researcher, and the author of The Emperor of all Maladies: A Biography of Cancer. The topic this week: conquering the emperor of all maladies. This is Ideas in Action.

 

ANNOUNCER:

Funding for Ideas in Action is provided by Investor's Business Daily. Every stock market cycle is led by America's never ending stream of innovative new companies and inventions. Investor's Business Daily helps investors find these new leaders as they emerge. More information is available at Investors.com

 

JIM GLASSMAN:

600,000 people in the U.S die from cancer each year. Five percent of those cases are hereditary and nearly half could be prevented. But after billions of dollars and decades of research there still is no cure. President Obama, like Richard Nixon before him, has promised to find a cure for cancer in our time and although oncologist and cancer researcher Siddhartha Mukherjee warns we may never find one cure for all cancers, his book is a surprisingly optimistic account of the diseases persistent bond with man. Dr. Sid Mukherjee welcome to Ideas in Action.

 

DR. SIDDHARTHA MUKHERJEE:

Thank you for having me.

 

JIM GLASSMAN:

So why did you decide to write about cancer as a biography?

 

DR. SIDDHARTHA MUKHERJEE:

So The Emperor of All Maladies is a history of cancer but part of the reason I reframed it as a biography is because the word history seemed to be a little too inert to describe what I was describing and as you know the stories of my patients, particularly this woman called Carla who I was treating in Boston is stitched into the book and therefore it made much more sense to talk about it as if it was-- as if I was not writing about something but about someone. And hence the word biography.

 

JIM GLASSMAN:

Tell us about her.

 

DR. SIDDHARTHA MUKHERJEE:

So she was a young woman in her 30s who was diagnosed with acute lymphoblastic leukemia cancer which is very aggressive and usually presents in children and one of the things that was important while writing the book is while I was writing the book I didn't know whether she would live or die at the end of the book. So it was like driving without a destination and I think that made the book particularly poignant for me because I didn't know the answer.

 

JIM GLASSMAN:

And that disease is just particularly terrible. The symptoms are horrifying.

 

DR. SIDDHARTHA MUKHERJEE:

The symptoms are often-- they present very aggressively. In children, interestingly-- and this is the story that's contained in the book-- the cure of lymphoblastic leukemia in children really was one of the emblematic diseases-- this was one of the emblematic diseases to be cured and thereby launched the famous war on cancer-- that-- the thinking behind it. Now in adults it's much rarer-- this is a disease of children-- but in adults, for reasons we don't understand the survival sinks down to about 30 to 40 percent.

 

JIM GLASSMAN:

Let's tell our viewers what cancer is.

 

DR. SIDDHARTHA MUKHERJEE:

Well cancer is a very heterogeneous group of diseases all lumped together because they happen to share some deep biological themes. I would say the central biological theme there is that cancer is a disease of cells that are proliferating without control. Normal cells, if you can imagine the cell as a molecular machine, has accelerators and brakes that either accelerate their division or put breaks on their division when that's stopped. And that's why we grow out into multi-cellular organisms but then don't-- keep growing and growing and growing forever. In a cancer cell those accelerators have been jammed and the brakes have been broken such that this is a machine that doesn't know how to stop and thereby the cell is replicating over and over again and doesn't know when to stop.

 

JIM GLASSMAN:

So what does it actually do? Does it sort of drive out the good cells?

 

DR. SIDDHARTHA MUKHERJEE:

So it does many things. People often ask the question, 'well how do patients with cancer die?' And the answer is they die through a variety of mechanisms that are a result of this malignant proliferation of cells. But it does many things it drives out in certain circumstances cells-- the normal function of cells. The other way cancers can kill people is by-- their solid effect. In other words, they go and they metastasize to places like the brain or the liver and they take over that place and keep growing in that area and thereby affect the normal functions of these organs.

 

JIM GLASSMAN:

Now you talk in your book about an Egyptian, Imhotep, saying that breast cancer is incurable; I mean what's changed in the 4000 years?

 

DR. SIDDHARTHA MUKHERJEE:

Well for breast cancer in particular the change has been enormous, especially for some types of breast cancer, some subtypes of breast cancer. The subtypes that's estrogen receptors positive, which is a significant fraction of breast cancer-- a woman with this form of breast cancer now in today undergoes surgery she will under-- she will then have chemotherapy, followed by an anti estrogen such as Tamoxifen and we think that this is substantially impacted her life span probably by-- on the order of 17 to 20 years. That is a substantial advance.

 

JIM GLASSMAN:

And how recent is that advance?

 

DR. SIDDHARTHA MUKHERJEE:

Well so you know the book talks about the history of each of these advances Tamoxifen comes to us from you know the 1960s and 1970s, the chemotherapeutic trials in breast cancer again come to us from about the 1970s and 1980s but that's not the end of it, Herceptin which is also part of the armamentarium of drugs comes to us from the 1980s and there are medicines in development today that are changing already the way we treat women with breast cancer.

 

JIM GLASSMAN:

And you talk in the book about surgery that was done on breast cancer in the past, these radical mastectomies which also include you know taking out ribs and-- how did that happen and really was that a big mistake?

 

DR. SIDDHARTHA MUKHERJEE:

Well one thing we learn in this story is of course hindsight is 20-20 and what becomes-- what are mistakes were then considered the best piece of wisdom at that time so one has to be humble--

 

JIM GLASSMAN:

Well intentioned.

 

DR. SIDDHARTHA MUKHERJEE:

Yes exactly.  That said the radical mastectomy grew out of the dictum which is actually-- run its way so many times through cancer medicine and cancer history which is that if something is good then more of it has to be better. And so the idea-- the kernel of the idea was that if you had a local tumor and if you cut it out and you still had relapses, which was what was being observed in the 1890s and 1900s, that if you-- you must need to cut out more. And that reminds us what a humbling history this is, it took 90 years before this incredibly aggressive form of surgery was finally shown not to extend lives or survival.

 

JIM GLASSMAN:

And as you say hindsight is 20-20 but it looks almost as though that-- those kinds of procedures were almost barbaric. I mean do you think that chemotherapy will viewed that way at some point?

 

DR. SIDDHARTHA MUKHERJEE:

I think some aspects of chemotherapy will be viewed that way-- chemotherapy is a word that of course includes many things, it includes even the most modern therapies which actually don't make your hair fall out or make your skin-- are chemotherapies. Chemotherapy really refers to the idea of a chemical therapy. But the way-- the chemotherapy that we're most used to thinking about are these poisonous drugs that nearly kill the body but in fact are directed to killing cancer cells. I do think that there will be a role for these drugs in the future but I'm hoping that we will invent far more specific therapies that will kill cancer cells and spare the rest of the body and the book gives two very striking examples of the recent developments of such therapies, Gleevec and Herceptin are two such--

 

JIM GLASSMAN:

Tell us about that.

 

DR. SIDDHARTHA MUKHERJEE:

So I'll choose one of them. Gleevec is an excellent example. Gleevec is a drug that was developed through a series of serendipitous experiments, but really championed by Brian Druker, and Gleevec attacks a particular kind of leukemia called chronic myelogenous leukemia or CML, the word chronic there is sort of euphemism it's chronic only by the standards of leukemia. 

 

JIM GLASSMAN:

Chronic means lasts a while.

 

DR. SIDDHARTHA MUKHERJEE:

Lasts a while exactly. But chronic myelogenous leukemia was a legal disease. It could be treated with transplantation but it was generally a lethal disease until some researchers were looking for a drug that might affect the biology of the heart and Brian Druker made the leap that this drug that was sitting in Basel, Switzerland could actually attack these leukemic cells and inactivate a crucial protein in these leukemic cells and it's an exquisitely targeted therapy. There's a chemist who describes, and I talk about him in the book, who says Gleevec, this drug, is like an arrow directed at the heart of this leukemic cell-- it's a very beautiful image because it doesn't touch most of the other cells in the body but kills these leukemic cells specifically.

 

JIM GLASSMAN:

And that's the real problem with chemotherapy is that it may kill the cancer cells but it's so toxic and so undirected that it's killing a lot of other parts of the body as well?

 

DR. SIDDHARTHA MUKHERJEE:

That's exactly right. So we use this term specificity to try to understand how specific is a therapy against one cell or one disease versus the rest of the body. And for the traditional forms of chemotherapy, these toxic chemotherapies that window of specificity is rather narrow such that you know small change in those can become very toxic to the body.

 

JIM GLASSMAN:

You know there has been so much in the way of resources spent on cancer, why has it been so difficult to conquer?

 

DR. SIDDHARTHA MUKHERJEE:

Well part of the reason of course, we said this a little bit before, cancer is not one disease but a whole group of diseases but there are deep biological themes that run through these diseases and part of the answer is that for the longest time we didn't know what made the cancer cell tick in a very fundamental sense. The war on cancer was launched in 1971 with the idea that you know, you didn't need to know everything about the cancer cell in order to solve the ca-- the problem of cancer. And as you know that has been a humbling experience.

 

JIM GLASSMAN:

Now you refer to-- you referred earlier to breast cancer and to this form of leukemia as being cancers where there's been some success. What other cancers-- where has there been the most success?

 

DR. SIDDHARTHA MUKHERJEE:

Well acute lymphoblastic leukemia, the cancer that really threads through this-- through my book is now, for children, 80 or 90 percent curable, depending on the circumstances. Testicular cancer, again, nearly 80 or 90 percent curable, depending on the circumstances, several kinds of lymphoma, Hodgkin's lymphoma, so the list is quite large. Perhaps even more strikingly there are cancers much like breast cancer that have been made chronic diseases and that's a real frontier, to convert a disease that was inexorably lethal into a chronic disease is a major victory in the war on cancer.

 

JIM GLASSMAN:

So chronic means that-- there's kind of a low-grade effect or maybe no effect at all? You still have it.

 

DR. SIDDHARTHA MUKHERJEE:

That's correct. So many people are living with cancer as opposed to dying of cancer.

 

JIM GLASSMAN:

I also noticed in looking at some statistics that the five-year survival rate for prostate cancer is basically 100 percent.

 

DR. SIDDHARTHA MUKHERJEE:

Well that's partly because prostate cancer's a very unique form of cancer in which there are very many-- very different variants. Some of them are very aggressive and some of them are very slow moving or we call them indolent. And so you know five-year survival can become a little bit of a mistake statistically because you might be only looking or primarily looking at the indolent versions of that cancer.

 

JIM GLASSMAN:

Now you say that genetic-- the genetic predisposition to cancer is really-- is not all that important in most kinds of cancers. Is that right?

 

DR. SIDDHARTHA MUKHERJEE:

Well what I do say is that we know very little about the genetic predisposition. We do know-- what we do know very well is there are multiple carcinogens in the environment, tobacco smoke being probably the most preeminent example of that-- that affects our capacity of the development of cancer. I think the genetic predispositions are--  we're just starting to scratch the surface. I believe in the next decade we'll discover much much more about that.

 

JIM GLASSMAN:

But basically you think that prevention is the cure. Or a big part of the cure.

 

DR. SIDDHARTHA MUKHERJEE:

I think that prevention is a big part of the cure absolutely. I think that prevention is a big part of the message but I think that one of the things that's happening-- and this is one of the things we discuss is very uniquely happening in cancer biology is that the lines between prevention and therapy are blurring. So as cancer medicine is moving, understanding what it is that makes the cancer cell tick, as it were, we're beginning to discover that in fact that understanding is equally impacting the way we think about prevention as with-- as it's impacting treatment. So in the future we'll break open this black box of prevention and break open the silos that separate prevention and treatment they'll become actually very much a part of each other.

 

JIM GLASSMAN:

So what can people do? Besides stopping smoking, we all know about that. But what can people do to make themselves less likely to get cancer?

 

DR. SIDDHARTHA MUKHERJEE:

Well the list is not-- the list unfortunately-- and this gets back to the idea of the infancy of prevention research, the number of carcinogens that we've identified is large, but the exposure risk-- that you know the things that are common in the environment that we've identified are not so large anymore because we've effectively removed many of them; asbestos is one of them, radon is another one of them, and you know cigarette smoke we talked about. So what we can do right now is be really vigilant when new chemicals enter our environment, be really vigilant and really test them using the best possible tests to find out if these are truly carcinogens or not.

 

JIM GLASSMAN:

So can we expect to see cancer death rates decline because of-- not just because people have stopped smoking but also because we removed asbestos and some of these other things?

 

DR. SIDDHARTHA MUKHERJEE:

Well cancer death rates have already started to decline and they have been doing so for 10 years, actually probably a little bit longer than ten years, and that's a significant victory in the war on cancer. Now people have gone back to analyze what's driven that decline in death rate and the answer is very satisfying; the answer is everything has helped. Prevention has helped, stopping smoking has helped, but also treatment has helped, treatment for breast cancer in particular has helped that decline. Even chemotherapy has helped-- has helped drive that decline.

 

JIM GLASSMAN:

You know I was struck by the decline in the death rates from colon cancer. Why is that?

 

DR. SIDDHARTHA MUKHERJEE:

Yes well a large part of that has to do with screening so colonoscopy-- screening colonoscopy has driven a large part of that. So again, it's part of that puzzle. There is no universal solution that will attack every form of cancer, this is a patchwork quilt that has to be put together piece by piece. And the puzzle is so deep and so elemental that we have to do it-- we have to put together prevention with screening with treatment and only by mixing and matching appropriately we'll be able to get the full picture.

 

JIM GLASSMAN:

What about gene therapy and stem cell treatment? Is there much hope here?

 

DR. SIDDHARTHA MUKHERJEE:

Well I think these fields are very much in their infancy and whether these turn out to be new beacons of hope or whether they repeat the cycles of hubris that have furrowed through this history remains to be seen.

 

JIM GLASSMAN:

Now you're an oncologist.

 

DR. SIDDHARTHA MUKHERJEE:

I am.

 

JIM GLASSMAN:

Do you feel that doctors are well trained to handle the kind of human aspects of cancer? You know somebody learning that he or she is suffering from cancer is-- are doctors humane enough I guess is the question.

 

DR. SIDDHARTHA MUKHERJEE:

That's a tough question. I certainly think they are becoming trained-- it has become part of our consciousness in medicine to train them-- to train doctors in the more humanistic and humane aspects of medicine. You know this was not easy going. The book tells a story of Cecily Saunders, a nurse who retrained as a doctor in England, who had to essentially-- who invented-- or launched the palliative care movement. And what was amazing about Cecily Saunders was that she had to go out and tell people you well know palliative care is not the anti matter of treatment.

 

JIM GLASSMAN:

Palliative care means basically well we're kind of giving up on you, we're not going to make historic-- or heroic efforts to save your life.

 

DR. SIDDHARTHA MUKHERJEE:

Yes but it absolutely does not mean giving up on someone it means-- it means maximizing their capacity to live their lives with dignity and as Cecily Saunders points out it is exactly the opposite of giving up on someone. It is in fact taking that-- taking the patient to their fullest extent and treating them like a human being.

 

JIM GLASSMAN:

But just as a specific-- somebody has let's say brain cancer and there is some kind of treatment although it doesn't work very often, do you as a doctor say to that person, 'well you have a 5 percent chance of living, or 10 percent chance but if we treat you it's going to be pretty horrible for you for the next year or two.' Is that their decision? Is it your decision? How-- what do you see as your role?

 

DR. SIDDHARTHA MUKHERJEE:

It's absolutely their decision but one of the things that happens very quickly these days I think and very advisedly is that we bring that conversation up very-- up front. This is not a conversation to be having when a patient it-- when a man or woman is-- having troubles.

 

JIM GLASSMAN:

Don't some doctors want to be kind of heroes? I mean you sort of hear about surgeons for example pushing cancer patients to have surgery because they-- because you know out of I guess humane instincts the I mean surgeon wants to save this person's life but it could be the chances are kind of small or it could be some terrible consequences from the surgery.

 

DR. SIDDHARTHA MUKHERJEE:

One of the most moving stories in my own practice-- and I write a little bit about this book is I was rounding-- as a medical student I was rounding with one of the senior most surgeons at Mass General Hospital, a man named Arlan Fuller, and he would start rounds-- he would start rounds around 5:30 in the morning and he would go to every bed and the first question he would ask was, 'how was your night and can I help you with my-- with your pillow?' I have never met a surgeon who falls into this mythology of the hero, the bully, the cowboy. I find them-- I find surgeons incredibly thoughtful about their discipline, particularly cancer surgeons.

 

JIM GLASSMAN:

Let's talk about policy. Is there-- what should the government be doing, if anything, to fight cancer?

 

DR. SIDDHARTHA MUKHERJEE:

Well I think one of the things that we should be doing is we should be reviving the importance-- important legacy of the National Cancer Institute, we should be pouring more resources into clinical trials and we should be asking patients to become our allies in finding out more about cancer. One of the things that's in crisis in this country is the clinical trial system because not enough people are enrolling. There's a glut of new cancer drugs that are coming out on one hand, and bizarrely an absence of patients who are willing to-- who are willing to you know sort of engage in these trials. This needs to be rectified as soon as possible.

 

JIM GLASSMAN:

And so why is that?

 

DR. SIDDHARTHA MUKHERJEE:

Well part of the reason is that there are so many-- there are so many difficulties in getting a good trial launched, there are bureaucratic difficulties, there are so many difficulties in getting good trials launched that at the end of it it becomes an exhausting process. We need to find a system by which this becomes streamlined so that patients get access to new medicines and that researchers can test these new medicines in a completely safe environment such that everyone has the same goal and which is to convert cancer into a chronic disease.

 

JIM GLASSMAN:

Because you would certainly think that if you have cancer and especially if you had a terrible kind of cancer that you would want to participate in a trial. Sometimes people don't even know about the trials.

 

DR. SIDDHARTHA MUKHERJEE:

It's exactly that. Part of it is that the information systems that are out there are not as sophisticated as they could be in terms of informing patients about clinical trials and what the outcomes might be and what the best possible solutions for that particular patient might be.

 

JIM GLASSMAN:

There was some money for cancer research in the stimulus package, is that useful?

 

DR. SIDDHARTHA MUKHERJEE:

Absolutely it's useful. I mean, you know, every penny is useful so absolutely it's been useful.

 

JIM GLASSMAN:

What about drug companies? Do they need more of an incentive to search for new drugs or do they have enough now?

 

DR. SIDDHARTHA MUKHERJEE:

Well the question of drug companies comes up and I often think-- I often think that there's a kind of a schizophrenia or split personality within every drug company; so there's one pharmaceutical industry that is peddling to us false products, hiding data, and making it impossible for us to build a trust with pharmaceutical indus-- with the pharmaceutical industry. But then there is another pharmaceutical industry as it were, which was an incredibly important partner in the development of Gleevec and Herceptin, every single major drug.

 

JIM GLASSMAN:

You know one issue I know for drug companies is off label uses of drugs so a drug will be developed, as you said Gleevec is an example, for one purpose and if-- you know you find out hey this works on cancer as well. And yet the drug company is not allowed to publicize that fact. Is that harming cancer treatment?

 

DR. SIDDHARTHA MUKHERJEE:

Well I think that the channels by which a drug company is allowed to publicize that are appropriate which is that there needs to be an appropriately run clinical trial which demonstrates the use of this off label use of this compound in the appropriate setting. And that clinical trial needs to occur in the most rigorous manner possible and once that's performed then everyone is better for it. The drug company can now say that this is a drug that truly works in this setting and patients can say we're now safe; it is appropriately safe to take this drug for this kind of cancer. I mean I can give you a quick example of this; you know Gleevec was originally approved for leukemia and in fact it works on about 20 other forms of diseases including some very lethal kinds of cancer. Discovering all of these uses was done by performing very rigorous clinical trials and that's the exact appropriate way to do this.

 

JIM GLASSMAN:

Is the profit incentive though important-- important character in this story of cancer.

 

DR. SIDDHARTHA MUKHERJEE:

It is.

 

JIM GLASSMAN:

You mean in a positive way or a negative way.

 

DR. SIDDHARTHA MUKHERJEE:

I think it is so in a positive way as I said you know if that profit incentive was harnessed in the appropriate manner, it can be. But we tell the story you know many of the pharmaceutical companies including Novartis and including Genentech whose stories-- I mean the stories of whose heroic research scientists are told in this book became resistant to the development of million and or billion dollar drugs. And so there needs to be a process, and they were resistant by the way because they thought they would never get enough market for these drugs, so there needs to be a process by which we can-- by that we I mean academics, scientists, researchers, the NCI can communicate to pharmaceutic-- the pharmaceutical industry that this-- we're in it together and that the best goal here is to get patients you know cured or at least free of cancer or at least treat their cancer and convert it into a chronic disease and if we reach that goal everyone will benefit including the pharmaceutical industry.

 

JIM GLASSMAN:

What advances are you most optimistic about?

 

DR. SIDDHARTHA MUKHERJEE:

Well the-- the two areas that I think are-- you know bring the most optimism to my mind; number one is targeted therapies. This idea that you can exquisitely, specifically target a cancer cell while sparing the rest of the body, and of which Gleevec is the first example.

 

JIM GLASSMAN:

Will that help with all cancers?

 

DR. SIDDHARTHA MUKHERJEE:

No absolutely not. So each cancer has its own unique spectrum of targets and every ca-- basically often a targeted therapy has to be developed for every single form of cancer.

 

JIM GLASSMAN:

But I mean every single kind of cancer could benefit from some sort of targeted therapy.

 

DR. SIDDHARTHA MUKHERJEE:

In principle. You know this is a proof of principle that's out there, we don't know if pancreatic cancer for instance will benefit from a targeted therapy. Some cancers may be so complex that we-- that these simpler targeted therapies might not work, maybe combinations need to be used, maybe a new kind of chemical needs to attack those kinds of cancers. But targeted therapy being one direction. The other direction of course is-- a revamping, a revivification of prevention. So the idea that we were talking about this before instead of running large epidemiological studies which have been very important in early prevention research, is to find out enough about what makes a cancer cell tick so that you can in the laboratory find out a chemical before it's released to the public, whether it's a carcinogen or not.

 

JIM GLASSMAN:

Thank you Sid Mukherjee.

 

DR. SIDDHARTHA MUKHERJEE:

Thank you so much, thank you for having me.

 

JIM GLASSMAN:

Before we go I want to remind viewers that you can catch Ideas in Action whenever and wherever you choose. To watch complete shows just go to our website ideasinactiontv.com or download a podcast from the iTunes store. That's it for this week's Ideas in Action; I'm Jim Glassman thanks for watching.

 

ANNOUNCER:

For more information visit us at ideasinactiontv.com. Funding for Ideas in Action is provided by Investor's Business Daily. Every stock market cycle is led by America's never ending stream of innovative new companies and inventions. Investor's Business Daily helps investors find these new leaders as they emerge. More information is available at Investors.com.

This program is a production of Grace Creek Media and the George W. Bush Institute, which are solely responsible for its content.

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Siddhartha Mukherjee, M.D., Ph.D.

Author, The Emperor of All Maladies: A Biography of Cancer

Siddhartha Mukherjee, M.D., Ph.D., is a leading cancer physician and researcher. He is an assistant professor of medicine at Columbia University and a cancer physician at the CU/NYU Presbyterian Hospital. Ten years in the making, his first book, The Emperor Of All Maladies: A Biography Of Cancer is a magnificent “biography” of this shape-shifting and formidable disease that has plagued and riddled humanity for thousands of years.

A Rhodes Scholar, Mukherjee graduated from Stanford University, University of Oxford, and Harvard Medical School and was a Fellow at the Dana Farber Cancer Institute and an attending physician at Massachusetts General Hospital and Harvard Medical School.

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