Tavis: Dr. Siddhartha Mukherjee is a cancer physician at the Columbia University Medical Center and an assistant professor of medicine at Columbia. His text on cancer has become one of the most talked-about books on the subject in recent memory.
The “New York Times” best seller is called “The Emperor of All Maladies: A Biography of Cancer.” Dr. Mukherjee, first of all, thank you for your work, and an honor, sir, to have you on this program.
Dr. Siddhartha Mukherjee: Thank you for having me. I’m a big fan of the show.
Tavis: Oh, I’m a big fan of your work and glad to have you on. I look forward to the day when your work will be irrelevant or unnecessary.
Mukherjee: (Laughs) I do, too. I sometimes say to people, “I want to be out of a job.”
Tavis: Yeah, yeah, but that’s not going to happen any time soon, though, unfortunately.
Mukherjee: No, no, no, unfortunately.
Tavis: And why not?
Mukherjee: Well, part of the reason is that cancer’s not one disease but many diseases, and we’re just beginning to understand what drives this family of diseases. The second reason is that for many forms of cancer, not all forms of cancer, the problem lies in the vulnerability in our cells themselves.
So in other words, even if we, in an ideal world, were to get rid of every known carcinogen, there still would be the prevalence of cancer driven by accidental causes inside each one of our cells.
Tavis: So that when we say we’re fighting cancer, we’re really then fighting ourselves.
Mukherjee: Well, exactly. It’s a complex story. It turns out that the very genes that turn on in cancer cells perform vital functions in normal cells. In other words, the very genes that allow our embryos to grow or our brains to grow, our bodies to grow, if you mutate them, if you distort them, then you unleash cancer.
Now, of course, carcinogens do this, and there’s a lot to be done still in the world to remove agents that make these mutations happen, but these mutations are also happening accidentally in our bodies. So in some sense, cancer is part of our inheritance.
Tavis: But these numbers are so startling. In our lifetimes, in our lifetimes, one in two men – one in two – will contract some kind of cancer. In our lifetimes, one in three women will contract some kind of cancer. That’s just – those numbers are arresting and unsettling.
Mukherjee: Absolutely. Cancer is going to be, if it already is not, it is the defining disease of our generation.
Tavis: Mm. This book, “The Emperor of All Maladies,” as I said, it is the book that everybody’s talking about who cares anything about, has lost anyone to or is curious about this thing called cancer. You dedicate the book to someone named Robert Sandler. I noticed this the minute I picked it up. Robert Sandler, who was born in 1945, and unless there is a misprint here, died in 1948.
Mukherjee: That’s not a misprint.
Tavis: So Robert Sandler was dead at the age of three and you dedicate the book to Robert Sandler and “to those who came before and after him.” So who is Robert Sandler?
Mukherjee: Robert Sandler is a child who died when he was three years old, and he is a child who was the first child that we know of to be treated with chemotherapy. He was part of a cohort of children, about 12 children, in Boston, who Sidney Farber treated with the first-ever invented chemotherapies, and he had a very brief remission from his leukemia – he was a child with leukemia – and then relapsed and died soon after.
When I was writing this book, I think the biggest challenge in this book is how do you take a topic like cancer and bring it down to a human level, to a readable level? Because we all need to read about it, but how do you convert that? And the answer, as I wrote the book, which became very obvious, was that you have to tell human stories.
So the story, chemotherapy is something we encounter in the abstract. How do you tell a story of that history? So I had to find this child. I ultimately found him through a complicated serious of accidents, found him actually not far from my parents’ house in India.
Someone had kept a photograph, a cutting, and I found his photograph and cutting there, and thereby discovered his name and dedicated the book to him, because he’s a reminder of the human face behind this history.
Tavis: To your point about the human face behind the history, and I ask this, of course, respectfully, why do we care about the history? Why does the history matter? What we care about, I suspect, most, is finding a cure and saving lives that are at risk, or saving lives that have obviously not yet been lost. Why is the history, the biography, so important, of cancer?
Mukherjee: The history is important because science is a discipline deeply immersed in history. In other words, every time you perform an experiment in science or in medicine, what you’re actually doing is you’re answering someone, answering a question raised by someone in the past.
It’s amazing – I’ll give you one example of this. The drug Tamoxifen, used for estrogen receptor positive breast cancer, a billion dollar drug that’s saved hundreds of thousands of lives. The reason that Tamoxifen was discovered was because a Scottish surgeon, George Beatson, was walking through the Highlands of Scotland and he overheard a shepherd saying that if you take out the ovaries of sheep and cows, you change the way their breasts behave. This was a time in the 1890s when no one knew the connection between ovaries and estrogen and breasts and breast cancer.
So it was through a series of such accidents that Beatson eventually figured out that there was a link between ovaries and breast cancer, and through that link it was ultimately discovered that estrogen was linked to breast cancer. From there on, an anti-estrogen, Tamoxifen, was used.
Now, the story reminds us that such accidents, such serendipitous pieces of history, are still happening all the time. In fact, the most modern drugs in cancer, like Gleevec or Herceptin are also products that come up from a long history – 10 years, 15, 20 years – so we really have to remember the past in order to understand the future.
Tavis: Your story makes me remember something a friend said to me years ago when I was struggling with the loss of a loved one, going through this process, and there is a point, I think even you’ll admit, where medicine stop. There’s only so much that we can do, so much that we know; hence, our wrestling with this thing called cancer.
Tavis: So my friend said to me, “There’s a reason why they call it the practice of medicine.”
Tavis: There’s a reason why it’s called the practice of medicine. How much do we really know? How much of this is really shooting in the dark when you have stats like the ones that we’ve been talking about so far?
Mukherjee: Well, I think some of it is shooting in the dark, but some of it is not, and I think that spectrum is changing. There were diseases like chronic myelogenous leukemia, a disease that was uniformly fatal, was a chronic disease, but in the end, patients died of it in two to five years. That disease has been converted into a disease which patients take a single medicine and their lifespans may extend to 25 or 30 years.
Breast cancer is a great example as well. For certain variants of breast cancer, not triple-negative breast cancer but estrogen receptor positive breast cancer, many patients are living 10, 15, 20 years with that disease.
So I think we have already seen a transformation in our landscape of cancer, and that’s why, again, we come back to this book. We need to know that history. We need to know why that happened and what happens next.
Tavis: What got you – everybody appreciates what you have done here, and that’s why everybody’s talking about it, that’s why “The New York Times” has listed this as one of the 10 best books of last year.
I wrote this down, as a matter of fact, speaking of that “Times” piece. This really caught me as a great description of the book. The “Times” referred to you as a “passionate young priest attempting a biography of Satan.”
Tavis: That’s a cold piece, right there – “A passionate young priest attempting a biography of Satan.” What is it that gets Siddhartha Mukherjee interested in wanting to dig into this?
Mukherjee: Well, the book was inspired by a question that a patient asked me, and actually several patients have asked me since then, and that is patients want to know what it is that they’re facing. What’s astonishing to me and what remains astonishing to me is that this is a part of our lives, and yet it’s not a part of our history in the sense that you can go to a bookstore and you can see a thousand books on cancer, and yet there are very, very few attempts to write the history of cancer.
When did it first arise? What is its story? How did we develop our understanding of it? So the book grew out of kind of an urgency to try to understand a patient’s question, which is what am I battling, and what happens next?
Tavis: As a physician, how do you process that? How do you go about telling a patient what he or she might not want to know when they ask you that question?
Mukherjee: Well, one of the things that you realize through training is that everything in medicine has nuance, and every conversation has meaning and it can be approached through a variety of different ways.
There’s no one right solution. Every patient requires information in different manners. Some people want it up front. So part of learning medicine, the art of medicine, the practice of medicine, as you were pointing out, really involves finding out the psyche of the patient beforehand, before you break the news, before you tell them something, and figuring out what kinds of information will be relevant.
Eventually, you’re going to tell them the truth, but there are a hundred different ways of arriving at the truth, and that’s something you really learn. It’s a learned method, and you learn from the master. The master clinicians teach you how to do this in the most masterful way.
Tavis: In each of our lives we have to wrestle, it seems to me, with how to navigate losing versus winning.
Tavis: We’re not always going to win. There are going to be losses that are going to come in our lives. But that seems to me to be a bit different, Dr. Mukherjee, than the situation that so often you are in, which is that you’re losing, oftentimes, more than you’re winning, depending on the patients, obviously, but oftentimes you’re losing more than winning.
How does one stay motivated to do the work, whatever his or her calling is in life, whatever your vocation is? How do you stay motivated to do the work when oftentimes you are losing more than you’re winning?
Mukherjee: Well, part of the answer lies in rephrasing the understanding of losing and winning, of victory and loss. One of the things that I talk about in the book, and I trace its history, is the word “cure,” the word “win,” the word “war” are deeply loaded words. They’re punitive words, almost, and patients, when you don’t win against cancer, you therefore become a “loser.”
These are punitive words for patients, so I think one of the things we need to do is get away from this vocabulary. Harold Varmus, who’s the current head of the NCI, actually proposed a very beautiful metaphor. He said, “Well, instead of thinking about the war on cancer in terms of winning and losing, we should really be thinking about cancer in terms of a puzzle. You don’t win or lose a puzzle, you solve a puzzle.”
So that’s the scientific end of things. The last point I would make is that even when patients are not getting the benefits of chemotherapy, there is not necessarily a loss in that for the doctor or the patient. There are many things you can do.
You can assuage the psyche; you can take care of patients. There’s palliative care, there’s hospice. So there are many, many things that can be done, again, to get away from this vocabulary of losing and winning, and I think that’s important.
Tavis: It is important, and I’m glad you answered that question that way. That said, though, there have to be days, because you’re human; you’re not human and divine, you’re just human. You get connected to these patients and their families and their lives, and you process, navigate through those deaths how?
Mukherjee: Well, I come back, I think about my own loved ones. I grieve. I’m human. There are days that are certainly much tougher than others. My fellowship years, when actually we would often, there were patients who would be lost – in the span of a week, sometimes, we would lose four, five, six, seven patients, people who I’d known intimately.
You understand how to grieve, how to give solace. I’m human, we all are – all doctors are – and grieving is a natural part of medicine. As a doctor, grieving is a natural part of medicine. If you deny that, again, you’d get into this trap of curing and victory. I think grief is very important.
Tavis: Let me offer this, then, as – I could do this for hours, this is such a fascinating text, but let me offer this as the exit question. Does the history make you hopeful about the future?
Mukherjee: The history makes me absolutely hopeful about the future. The way that – and the one thing that makes me most hopeful is that the history is threaded through with the stories of patients. You discover, in the book, you discover the stories of patients, and the stories of patients are incredibly inspiring.
Whenever the field of oncology got into a position where it sort of fell into a trap, it was patients and patient advocates working with doctors and scientists who resurrected it, and that makes me incredibly hopeful about the future.
Tavis: It is, as I said three times already, one of the most-talked-about books of the year, you have to get it. It’s called “The Emperor of All Maladies: A Biography of Cancer,” written by this brilliant genius, Siddhartha Mukherjee. Doc, good to have you on the program. Thanks for your insights.
Mukherjee: Thank you so much.
Tavis: And for your work.
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