Mercedes Tatum

Cancer Biology
“The Emperor of all Maladies” Summary #1

 Part One: “OF BLACKE CHOLOR WITHOUT BOYLING”

 “A suppuration of Blood”
 The book starts out with a doctor named Sidney Farber who is a pathologist that
worked in the basement of an All Children’s Hospital in Boston.
 Farber had worked closely with children who had leukemia cancer, which was an
extremely difficult cancer to beat especially for children.
 Farber’s job never really involved working with patients and he mostly did
autopsies; he identified cells, and diagnosed diseases.
 Farber began to get really depressed because he wasn’t working with live patients
so he moved to a clinic in the upper area of the Children’s hospital where he
would be able to work with the children with Leukemia directly.
 Farber’s goal was to use all of his experience in pathology to develop treatments
and therapies for children in the hospital that were suffering from Leukemia.
 Most physicians during the early 20th century saw leukemia as a lost cause
because no one was able to develop a treatment to fix it.
 Dr. John Bennett described a case about a man who had a mysterious swelling in
his spleen.
 The man had an extremely high white blood cell count and Dr. Bennett said this
mans blood was “spoiled”.
 A German researcher Rudolf Virchow had a very similar case to Bennett with a
patient that had an extremely large white blood cell count and described these
cells as having some kind of mysterious drive to continue to grow uncontrollably.
 At first, cancer was seen as a disease in the blood because of the leukemia patients
but it become very clear in the early 1900s that there were many forms of this
disease.
 Towards the end of this section, Mukherjee discusses how fascinated Farber is
about Leukemia and how he was determined to work to find a therapy to help
children with this disease.
 “A monster more insatiable than the guillotine”
 Antibiotics became a big attention grabber in the early 1900s.
 This attracted a lot of attention because many people were dying of sicknesses
like small pox, typhoid fever, tuberculosis, and poliovirus.
 Antibiotics like penicillin began to be mass-produced so that virtually these
common sicknesses could be wiped out from America.
 This drew attention away from cancer studies let alone any kind of cancer
research.
 So far, the only “cure” for cancer was to remove and destroy diseased tissue.
There was no kind of “anti-cancer” drug available like there was for the other
common sicknesses of the time
 The government wasn’t concerned about funding the research for new
advancements for a cure for cancer.

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  In 1899, Rosewell Park had said that cancer would someday overtake the leading
cause of death in America over the smallpox, typhoid fever, and tuberculosis.
 As the antibiotics for the other sicknesses grew, Parks prophecy was becoming
more and more real as cancer deaths were increasing a significant amount every
year.
 Because this was happening, in 1900, there was a proposal set out to fund cancer
research but nothing was done until Matthew Neely asked congress it advertises
an award for 5 million dollars to whoever had information to “arrest human
cancer”.
 The advertisement got such a huge response that congress passed a bill for 50
thousand dollars called Neely’s Cancer Control Bill.
 This created further advancements as the National Cancer Institute was created
through President Roosevelt.
 However, the cancer research was set back yet again because of world war two
and the area where the national cancer institute was doing its work was turned
into a civil war hospital.
 Farber was working with Leukemia in an all children’s hospital.
 Farber believed that the key to figuring out how to cure leukemia was to study the
blood in normal circumstances.
 He studied two types of anemia on that were due to lack of vitamin b12 and the
other that was due to the lack of folic acid.
 Farber was so fascinated by the folic acid that he attempted to treat some children
leukemia patients with folic acid and was saddened to see that this treatment
actually made the leukemia worse and accelerated the process.
 Now Farber was looking to find an antifolic drug and collaborated with his friend
Yella who has synthetically with a group of scientist figured out how to make the
drug.
 Yella agreed to help Farber and sent him a package of antifolate drug and Farber
was very excited about what was to come.
 Farber’s Gauntlet
 Farber then had received his first patient able to take the new antifolate drug that
was sent from Yella’s lab. It was a man named Robert Sandler who was a toddler
experiencing the symptom’s of Leukemia.
 Farber started to inject Sandler with pteroylaspartic acid or PAA, which was an
antifolate.
 Surprisingly, doctors during this time didn’t need any consent from the parents or
the child to do experimental procedures.
 The PAA drug showed little affect in the toddler and the leukemia actually started
to get worse and the case started to seem hopeless.
 A month later, Farber received a new antifolate drug called aminopterin, which
was a different form of PAA.
 Farber began to inject the little boy with this drug and it miraculously start to halt
the growth of the leukemia cells. The growth of the cells even started to go down
after the injection.
 However, this miracle only lasted for a while as the cancer came back and
eventually killed Robert Sandler.

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  Farber publish a paper in the New England Journal of Medicine that got a lot of
attention, this was the first step in finding a cure.
 A Private Plague
 The book referred to cancer as being more adapted to life than we are.
 This portion of the novel strives to determine when cancer was born and how long
it has been around for.
 Edwin Smith identified many cases in the ancient Imhotep civilization that had to
do with bulging masses in the breasts.
 The treatment for these bulging masses was that “There is none”.
 Overall cancer was not documented as main disease in ancient civilization.
 Hereodutus story of Atossa was another rare ancient story of cancer where Atossa,
queen of Persia had a bleeding lump in her breast.
 She allowed a slave to remove the tumor from her breast but she later died from
the cancer all together. The removal of the tumor provided temporary relief.
 Another ancient bone cancer was found in Peru on a thousand-year-old mummy.
 The oldest form of cancer that has been discovered was a tumor that was invading
the pelvic bone found on an Egyptian mummy.
 Onkos
 In 450BC the word for cancer first arose from the word karkinos from the Greek
word for crab and these were cancers that were easily visible.
 Hippocrates thought that cancer reminded him of a crab with its legs spread out in
a circle.
 Onkos is known as a word to describe a tumor and would become the basis for the
oncology practice.
 Onkos is described as a mass or burden, which is basically what cancer, is to the
human body.
 Vanishing Humors
 This sections starts out with talking about how a med school student named
Andreas Vesalius was frustrated about the fact that in order to study the body, the
students needed to find a cadaver and cut it open to study it.
 During this time there was no charts or diagrams of how and what the body
looked like so this med school student decided to do this.
 This chart was a very important factor in medicine during the time period around
1555.
 Mukherjee discussed that during this time physicians decided that in order to cure
cancer, bleeding needed to take place at the site of the tumor.
 Remote Sympathy
 Morbid Anatomy is what had originally laid out the instructions on how to extract
a tumor from a human.
 The discovery of anesthesia was discussed in this section and was a huge step
forward in the field of surgery because now surgery was painless.
 The discovery of antisepsis was also discussed in this section, which was
important in surgery because it prevented infection from happening due to
surgery.
 With these two techniques, surgeries could now be used to remove cancer tumors
much easier that before.

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  The problem with cancer was that some cancers, even after the tumor was
removed, would continue to relapse.
 A Radical Idea
 This section discusses William Halsted who is known as the founder of radical
surgery, which is very applicable when it comes to cancer patients.
 Halsted developed the pain-relieving drug of morphine through injecting cocaine
and using it as an anesthetic.
 Halsted moved to work at John Hopkins and dedicated his life with working with
cancer patients and doing surgery on these patients.
 Halsted was a very significant doctor because he preformed the first radical
surgery during the late 19th century.
 The radical surgery that Halsted preformed was a mastectomy.
 Sadly, only some cancers could be cured this way because if the cancer was
metastasized, it was very hard to get rid of it all.
 The Hard Tube and the Weak Light
 This section discusses the invention of x-rays and how they could be used in
medical advances.
 The accidental inventor of the x-ray was William Rontgen who only discovered x-
rays because an electron tube in his lab had leaked.
 X-rays were found to actually penetrate human flesh and eventually bind to cells
and alter them.
 This section was a precursor on the early developments of radiation treatments for
cancer patients because this type of therapy could target the cancerous cells, bind
to them, and destroy them.
 However, x-rays and radiation were also said to cause cancer by altering normal
cells so this type of therapy was not perfect.
 Dyeing and Dying
 The start to this section discusses the true challenges that researchers and
physicians face when treating cancer patients everyday.
 Mukherjee brings up the excellent point that anyone could kill a cancer cell in a
test tube which is why developing therapies to fight cancer isn’t very easy.
 The biggest trouble in cancer therapies is finding a selective “poison” that will
only kill and damage the cancer cells and leave the patient unharmed.
 There was a chemical that some chemist had believed that might be the answer
that physicians and researchers were looking for and it was found in dyeing
fabric.
 However, while this chemical had the poisoning effects to the cancer, it was not
good for the patient who had the cancer because the chemical had burned flesh,
gave blisters, and also was very harmful to the bone marrow.
 Poisoning the Atmosphere
 This sections opens with a very practical statement that says, “Every drug is a
poison in disguise”.
 Chemotherapy, although it kills the cancer cells, is poison to all of the other body
cells.

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  During the year 1943, it was discovered that mustard gas had targeted bone
marrow. This discovery was made when allied forces blew up a man named John
Harvey.
 This gas interested researchers because it had the ability to remove or get rid off
white blood cells.
 The gas was injected into a patient with a lymphoma and the swollen glands had
disappeared.
 The MP-6 chemical was also produced during this time but only provided
temporary relief of the cancer symptoms.
 The Goodness of Show Business
 These discoveries of the MP-6 chemical and mustard gas really inspired Farber
that there was some sort of chemical that could indeed cure lymphoblastic
leukemia.
 This section talks about a fund that Farber and a man named Bill Koster put
together that was strictly for the fight against pediatric cancers.
 Originally, Koster had an organization that had a lot of attention because of a girl
named Catherine Sheridan who was abandoned outside of the Sheridan Square
Film theatre.
 Catherine was taken care of by Koster’s organization and Koster went to Farbers
hospital one day trying to look for other ways that his organization could help
other children.
 Farber and Koster’s organization was called Children’s cancer research fund.
 This funding was very successful and brought in many patients to be treated at the
hospital by Farber.
 Another fund was made called the Jimmy Fund which was named after a boy who
had cancer who got a lot of attention because he was on the Ralph Edwards radio
show Truth or Consequences.
 This fund made a lot of money and made a huge response.
 The House that Jimmy Built
 Because of all of the funding and attention to cancer, Farber’s work had started to
grow exponentially as he was constantly being flooded with patients suffering
with leukemia.
 Farber moved to a new clinic to be able to continue to keep up with the demands
for treating his patients but he soon even moved out of this one and then in 1953
had his own building to treat patients.
 Although Farber was able to treat many more patients and give them hope, he was
still on the hunt for another drug that would give his patients more time to live.
 Part Two: AN IMPATIENT WAR
 They form a society
 Farber was extremely interested in funding cancer research nationally so that he
could figure out a way to develop a more aggressive drug selectively targeted to
the cancer cells.
 Farber knew that the only way to achieve this goal was to get more funding and
he was able to make a partnership with Mary and Albert Lasker.
 Albert was very good at advertising and with his work; he was able to campaign
very hard for funds to help fund cancer research.

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  In this campaign Farber focused on advertising his antifolate therapies but really
focused on telling people that there needs to be a cure.
 These New Friends of Chemotherapy
 Albert Lasker was diagnosed with colon cancer while he was trying to fight so
hard to end cancer.
 Albert Lasker died of the cancer and because of his death; his wife Mary took an
even more aggressive approach to fight cancer.
 Farber had his scare with cancer when in the late 1940s he developed a chronic
inflammatory disease in his intestines.
 Farber chose to keep his surgery very secret and away from the public.
 Pre-cancer was discovered upon Farber’s surgery.
 During this time WWII was happening and a lot of focus turned onto the war
instead of cancer.
 Mary said that they needed a “Manhattan Project” for cancer just like they had for
the war.
 In 1955, the senate had authorized the NCI to build a program to fight cancer by
finding chemotherapeutic drugs that were more targeted and selective toward
cancer cells.
 A new antibiotic actinomycin D was used to treat cancer and worked only on
certain types of cancer especially Wilms’ tumor which is a rare form of kidney
cancer.
 Actinomycin D along with x-rays seemed to by the patients the most time and
seemed to be the most effective treatment at the time.
 The butcher shop
 Gordon Zubrod was the new director of the NCI clinical center and wanted to
ensure that leukemia research was kept out of trouble.
 He wanted to ensure that the main goal for doctors and researcher was to fight
cancer and not just to see patients and follow normal protocols.
 This helped further cancer research and cancer trails started on patients using a
few different combinations of cancer drugs to fight the cancer cells.
 With these new trials many rumors started to go around that said the leukemia
ward was a butcher shop because doctors were treating patients with cytotoxic
drugs.
 An Early Victory
 This section talk about the victories that came from the cancer trials.
 Two researchers Min Chui Li and Roy Hertz studied a rare form of leukemia that
was formed in the placenta called choriocarcinoma.
 They transfused a patient’s blood with this cancer back into her body, which to
most people seemed crazy but actually ended up eliminating all of the tumor
masses in the patient’s body.
 Li realized that this cancer secretes a hormone that could be detected early on so
that treatment could start as soon as it was detected.
 Continuing Li’s treatment with methotrexate was able to stop the growth of the
choriocarcinoma cancer without relapse, which was the first chemotherapeutic
cure of cancer in adults.
 Mice and Men

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  Friereich described clinical research as a “matter or urgency”.
 A new anticancer drug was developed during this time called Vincristine, which
was seen to kill leukemia cells.
 Researchers wanted to find a way to tie in methotrexate, prednisone, 6-MP, and
vincristine together to make a very efficient cancer-fighting drug.
 A scientist named Howard Skipper called the “mouse doctor” was helping cancer
research with injecting leukemia cells into mice.
 Skipper found that combining different drugs together and administering them to
the mice was a very effective way of killing off the cells.
 This lead to the conclusion that children that had leukemia needed to be treated
with multiple different types of drugs.
 VAMP
 The remedy that was developed for leukemia was called VAMP and contained
four drugs in it.
 This drug was developed by Skipper, Frei and Friereich and presented the drug to
Zubrod who was very surprised at how powerful this drug could be.
 The VAMP drug was not taken well by members at the national meeting of blood
cancers.
 At first VAMP was actually making patients feel worse than before they took the
drug.
 After the suffering patients went through VAMP, somehow some of the patients
pulled through and normal bone marrow cells began to recover gradually.
 VAMP, although it worked in some patients, took a very long time to work and
caused a lot of pain to some people even causing them to be addicted to morphine.
 An Anatomist’s Tumor
 This sections start off with talking about a man named Ben Orman who was an
athlete that had a lump on his neck that originally, he didn’t think was any kind of
a big deal.
 It turned out to be a tumor on the lymph nodes known as lymphoma and the
author Mukherjee is the doctor who would start to treat him.
 Henry Kaplan began to become interested with the fact that X-rays/ radiation
could be used to treat solid cancers like lymphomas, breast cancers, and lung
cancers.
 The radiation treatment was seen to decrease relapse rates in the lymphoma
cancers but it wasn’t a cure for the cancer.
 An Army on the March
 Researchers George Canellas and Tom Frei worked to determine which cancer
drugs would best with which specific type of cancer.
 These researchers were focused on treating solid cancers with the drugs Cytoxan,
vincristine, procarbazine and methotrexate.
 All of these drugs had a common similarity that they all worked to stop the
growth of cells, which is a major problem in cancer.
 The first test of intensive combination chemotherapy for advanced lymphoma
cancer was called MOMP and combined the drugs nitrogen mustard,
methotrexate, vincristine and prednisone.
 MOMP was an extremely toxic drug that caused devastating nausea.

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  Carla Reed was brought back up and Mukherjee talks about how the leukemia
became personalized in her which effective her mood and personality a lot.
 The Cart and the Horse
 Farber was celebrating the 21st anniversary of the Jimmy fund.
 Jimmy, the child who originally had the cancer, was alive and well of off
chemotherapy and spent 21 years cancer free.
 DeVita said that cancer would be cured with high dose chemotherapies with the
right combinations of drugs in them.
 Peyton Rous had discovered in the 1920s that the only causes of cancers were not
just environmental carcinogens.
 The somatic mutation hypothesis of cancer was developed which said that these
environmental carcinogens caused permanent changes and slowly altered the form
of normal cells.
 This started the thought that cancer could be transferable if cancerous cells were
transferred from one organism to another.
 Rous discovered this ability through viruses that could transmit cancer into
chickens meaning that viruses could transmit cancer to different organisms.
 The drive for funding for cancer research continued with the Laskerites.
 A moon shot for cancer
 This section starts out with a letter that the New York Times published to
President Nixon asking for more funding on cancer research.
 This was at the time that man had so called traveled to the moon so if we were
able to do that then we should be able to cure cancer.
 This publishing put the idea funding cancer into a huge spotlight and brought a lot
of attention to the cause.
 People started to actually fear the idea of cancer because of the publication and it
became a huge idea that everyone feared and that was on everyone’s mind.
 President Nixon did resist funding the research because of his lack of beliefs in
scientists.
 Finally after a panel, a government agency was formed to focus on developing
drugs and treatments to battle cancer.
 Ann Lander brought up the point that cancer was not only a medical cure but also
a political cure.
 Every year that this organization existed, more and more funding went into it.
 Farber ended up dying in 1973 from a heart attack after all of these bills were
passed and there was officially a government agency funding cancer research.
 At the end of this section, Mukherjee goes back to talking about his patient Carla
Reed and says that the bone marrow was starting to be housed with normal cells
rather than cancerous ones. She was in full remission.

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