The Emperor of All Maladies

by Siddhartha Mukherjee

  The choice between the two paths is instinctual. Some of us inherently perceive ourselves as clinicians; others primarily as scientists. My own inclinations have changed little since the first day of my internship. Clinical medicine moves me viscerally. But I am a lab rat, a nocturnal, peripatetic creature drawn to the basic biology of cancer. I mull over the type of cancer to study in the laboratory, and I find myself gravitating toward leukemia. I may be choosing the laboratory, but my subject of research is governed by a patient. Carla’s disease has left its mark on my life.

  Even so, in the fading twilight of my full-time immersion in the hospital, there are disquieting moments that remind me how deeply clinical medicine can surprise and engage me. It is late one evening in the fellows’ room, and the hospital around us has fallen silent save for the metallic clink of cutlery being brought up for meals. The air outside is heavy with impending rain. The seven of us, close friends by now, are compiling lists of patients to pass on to the next class of fellows when Lauren begins to read her list aloud, calling out the names of those in her care who have died over our two-year fellowship. Suddenly inspired, she pauses and adds a sentence to each name as a sort of epitaph.

  It is an impromptu memorial service, and it stirs something in the room. I join in, calling out names of my patients who have died and appending a sentence or two in memory.

  Kenneth Armor, sixty-two, an internist with stomach cancer. In his final days, all he wished for was a vacation with his wife and time to play with his cats.

  Oscar Fisher, thirty-eight, had small-cell lung cancer. Cognitively impaired since birth, he was his mother’s favorite child. When he died, she was threading rosaries through his fingers.

  That night I sit alone with my list, remembering the names and faces late into the evening. How does one memorialize a patient? These men and women have been my friends, my interlocutors, my teachers—a surrogate family. I stand up at my desk, as if at a funeral, my ears hot with emotion, my eyes full of tears. I look around the room at the empty desks and note how swiftly the last two years have reshaped all seven of us. Eric, cocksure, ambitious, and smart, is humbler and more introspective. Edwin, preternaturally cheerful and optimistic in his first month, talks openly about resignation and grief. Rick, an organic chemist by training, has become so infatuated with clinical medicine that he doubts that he will return to the laboratory. Lauren, guarded and mature, enlivens her astute assessments with jokes about oncology. Our encounter with cancer has rounded us off; it has smoothed and polished us like river rocks.

  A few days later, I meet Carla in the infusion room. She is casually chatting with the nurses, as if catching up with old friends. From a distance, she is barely recognizable. The sheet-white complexion I recall from her first visit to the hospital has warmed up several degrees of red. The bruises in her arm from repeated infusions have vanished. Her children are back in their routine, her husband has returned to work, her mother is home in Florida. Carla’s life is nearly normal. She tells me that her daughter occasionally wakes up crying from a nightmare. When I ask her if this reflects some remnant trauma from Carla’s yearlong ordeal with illness, she shakes her head assertively: “No. It’s just monsters in the dark.”

  It has been a little more than a year since her original diagnosis. She is still taking pills of 6-mercaptopurine and methotrexate—Burchenal’s drug and Farber’s drug, a combination intended to block the growth of any remnant cancer cells. When she recalls the lowest points of her illness, she shudders in disgust. But something is normalizing and healing inside her. Her own monsters are vanishing, like old bruises.

  When her blood counts return from the lab, they are stone-cold normal. Her remission continues. I am astonished and exalted by the news, but I bring it to her cautiously, as neutrally as I can. Like all patients, Carla smells overenthusiasm with deep suspicion: a doctor who raves disproportionately about small victories is the same doctor who might be preparing his patient for some ultimate defeat. But this time there is no reason to be suspicious. I tell her that her counts look perfect, and that no more tests are required today. In leukemia, she knows, no news is the best kind of news.

  Late that evening, having finished my notes, I return to the laboratory. It is a beehive of activity. Postdocs and graduate students hover around the microscopes and centrifuges. Medical words and phrases are occasionally recognizable here, but the dialect of the lab bears little resemblance to the dialect of medicine. It is like traveling to a neighboring country—one that has similar mannerisms but speaks a different language:

  “But the PCR on the leukemia cells should pick up the band.”

  “What conditions did you use to run this gel?”

  “Agarose, four percent.”

  “Was the RNA degraded in the centrifugation step?”

  I retrieve a plate of cells from the incubator. The plate has 384 tiny wells, each barely large enough to hold two grains of rice. In each well, I have placed two hundred human leukemia cells, then added a unique chemical from a large collection of untested chemicals. In parallel, I have its “twin” plate—containing two hundred normal human blood-forming stem cells, with the same panel of chemicals added to every well.

  Several times each day, an automated microscopic camera will photograph each well in the two plates, and a computerized program will calculate the number of leukemia cells and normal stem cells. The experiment is seeking a chemical that can kill leukemia cells but spare normal stem cells—a specifically targeted therapy against leukemia.

  I aspirate a few microliters containing the leukemia cells from one well and look at them under the microscope. The cells look bloated and grotesque, with a dilated nucleus and a thin rim of cytoplasm, the sign of a cell whose very soul has been co-opted to divide and to keep dividing with pathological, monomaniacal purpose. These leukemia cells have come into my laboratory from the National Cancer Institute, where they were grown and studied for nearly three decades. That these cells are still growing with obscene fecundity is a testament to the terrifying power of this disease.

  The cells, technically speaking, are immortal. The woman from whose body they were once taken has been dead for thirty years.

  As early as 1858, Virchow recognized this power of proliferation. Looking at cancer specimens under the microscope, Virchow understood that cancer was cellular hyperplasia, the disturbed, pathological growth of cells. But although Virchow recognized and described the core abnormality, he could not fathom its cause. He argued that inflammation—the body’s reaction to a harmful injury, characterized by redness, swelling, and immune-system activation—caused cells to proliferate, leading to the outgrowth of malignant cells. He was almost right: chronic inflammation, smoldering over decades, does cause cancer (chronic hepatitis virus infection in the liver precipitates liver cancer), but Virchow missed the essence of the cause. Inflammation makes cells divide in response to injury, but this cell division is driven as a reaction to an external agent such as a bacteria or a wound. In cancer, the cell acquires autonomous proliferation; it is driven to divide by an internal signal. Virchow attributed cancer to the disturbed physiological milieu around the cell. He failed to fathom that the true disturbance lay within the cancer cell itself.

  Two hundred miles south of Virchow’s Berlin laboratory, Walther Flemming, a biologist working in Prague, tried to uncover the cause of abnormal cell division, although using salamander eggs rather than human cells as his subject. To understand cell division, Flemming had to visualize the inner anatomy of the cell. In 1879, Flemming thus stained dividing salamander cells with aniline, the all-purpose chemical dye used by Paul Ehrlich. The stain highlighted a blue, threadlike substance located deep within the cell’s nucleus that condensed and brightened to a cerulean shade just before cell division. Flemming called his blue-stained structures chromosomes—“colored bodies.” He realized that cells from every species had a distinct number of chromosomes (humans have forty-six; salamanders have fourteen). Chromosomes were dupl
icated during cell division and divided equally between the two daughter cells, thus keeping the chromosome number constant from generation to generation of cell division. But Flemming could not assign any further function to these mysterious blue “colored bodies” in the cell.

  Had Flemming moved his lens from salamander eggs to Virchow’s human specimens, he might have made the next crucial conceptual leap in understanding the root abnormality in cancer cells. It was Virchow’s former assistant David Paul von Hansemann, following Flemming’s and Virchow’s trails, who made a logical leap between the two. Examining cancer cells stained with aniline dyes with a microscope, von Hansemann noticed that Flemming’s chromosomes were markedly abnormal in cancer. The cells had split, frayed, disjointed chromosomes, chromosomes broken and rejoined, chromosomes in triplets and quadruplets.

  Von Hansemann’s observation had a profound corollary. Most scientists continued to hunt for parasites in cancer cells. (Bennett’s theory of spontaneous suppuration still held a macabre fascination for some pathologists.) But von Hansemann proposed that the real abnormality lay in the structure of these bodies internal to cancer cells—in chromosomes—and therefore in the cancer cell itself.

  But was it cause or effect? Had cancer altered the structure of chromosomes? Or had chromosomal changes precipitated cancer? Von Hansemann had observed a correlation between chromosomal change and cancer. What he needed was an experiment to causally connect the two.

  The missing experimental link emerged from the lab of Theodor Boveri, yet another former assistant of Virchow’s. Like Flemming, who worked with salamander cells, Boveri chose to study simple cells in simple organisms, eggs from sea urchins, which he collected on the windswept beaches near Naples. Urchin eggs, like most eggs in the animal kingdom, are strictly monogamous; once a single sperm has entered the egg, the egg puts up an instant barrier to prevent others from entering. After fertilization, the egg divides, giving rise to two, then four cells—each time duplicating the chromosomes and splitting them equally between the two daughter cells. To understand this natural chromosomal separation, Boveri devised a highly unnatural experiment. Rather than allowing the urchin egg to be fertilized by just one sperm, he stripped the outer membrane of the egg with chemicals and forcibly fertilized the egg with two sperms.

  The multiple fertilization, Boveri found, precipitated chromosomal chaos. Two sperms fertilizing an egg results in three of each chromosome—a number impossible to divide evenly. The urchin egg, unable to divide the number of chromosomes appropriately among its daughter cells, was thrown into frantic internal disarray. The rare cell that got the right combination of all thirty-six sea urchin chromosomes developed normally. Cells that got the wrong combinations of chromosomes failed to develop or aborted development and involuted and died. Chromosomes, Boveri concluded, must carry information vital for the proper development and growth of cells.

  This conclusion allowed Boveri to make a bold, if far-fetched, conjecture about the core abnormality in cancer cells. Since cancer cells possessed striking aberrations in chromosomes, Boveri argued that these chromosomal abnormalities might be the cause of the pathological growth characteristic of cancer.

  Boveri found himself circling back to Galen—to the age-old notion that all cancers were connected by a common abnormality—the “unitary cause of carcinoma,” as Boveri called it. Cancer was not “an unnatural group of different maladies,” Boveri wrote. Instead, a common feature lurked behind all cancers, a uniform abnormality that emanated from abnormal chromosomes—and was therefore internal to the cancer cell. Boveri could not put his finger on the nature of this deeper internal abnormality. But the “unitary cause” of carcinoma lay in this disarray—not a chaos of black bile, but a chaos of blue chromosomes.

  Boveri published his chromosomal theory of cancer in an elegant scientific pamphlet entitled “Concerning the Origin of Malignant Tumors” in 1914. It was a marvel of fact, fantasy, and inspired guesswork that stitched sea urchins and malignancy into the same fabric. But Boveri’s theory ran into an unanticipated problem, a hard contradictory fact that it could not explain away. In 1910, four years before Boveri had published his theory, Peyton Rous, working at the Rockefeller Institute, had demonstrated that cancer in chickens could be caused by a virus, soon to be named the Rous sarcoma virus, or RSV.

  The central problem was this: as causal agents, Rous’s virus and Boveri’s chromosomes were incompatible. A virus is a pathogen, an external agent, an invader exogenous to the cell. A chromosome is an internal entity, an endogenous structure buried deep inside the cell. The two opposites could not both claim to be the “unitary cause” of the same disease. How could an internal structure, a chromosome, and an external infectious agent, a virus, both create cancer?

  In the absence of concrete proof for either theory, a viral cause for cancer seemed far more attractive and believable. Viruses, initially isolated in 1898 as minuscule infectious microbes that caused plant diseases, were becoming increasingly recognized as causes for a variety of animal and human diseases. In 1909, a year before Rous isolated his cancer-causing virus, Karl Landsteiner implicated a virus as the cause for polio. By the early 1920s, viruses that caused cowpox and human herpes infections had been isolated and grown in laboratories, further cementing the connection between viruses and human and animal diseases.

  Undeniably, the belief in cause was admixed with the hope for a cure. If the causal agent was exogenous and infectious, then a cure for cancer seemed more likely. Vaccination with cowpox, as Jenner had shown, prevented the much more lethal smallpox infection, and Rous’s discovery of a cancer-causing virus (albeit in chickens) had immediately provoked the idea of a therapeutic cancer vaccine. In contrast, Boveri’s theory that cancer was caused by a mysterious problem lurking in the threadlike chromosomes, stood on thin experimental evidence and offered no prospect for a cure.

  While the mechanistic understanding of the cancer cell remained suspended in limbo between viruses and chromosomes, a revolution in the understanding of normal cells was sweeping through biology in the early twentieth century. The seeds of this revolution were planted by a retiring, nearsighted monk in the isolated hamlet of Brno, Austria, who bred pea plants as a hobby. In the early 1860s, working alone, Gregor Mendel had identified a few characteristics in his purebred plants that were inherited from one generation to the next—the color of the pea flower, the texture of the pea seed, the height of the pea plant. When Mendel intercrossed short and tall, or blue-flowering and green-flowering, plants using a pair of minute forceps, he stumbled on a startling phenomenon. Short plants bred with tall plants did not produce plants of intermediate height; they produced tall plants. Wrinkle-seeded peas crossed with smooth-seeded peas produced only wrinkled peas.

  The implication of Mendel’s experiment was far-reaching: inherited traits, Mendel proposed, are transmitted in discrete, indivisible packets. Biological organisms transmit “instructions” from one cell to its progeny by transferring these packets of information.

  Mendel could only visualize these traits or properties in a descriptive sense—as colors, texture, or height moving from generation to generation; he could not see or fathom what conveyed this information from one plant to its progeny. His primitive lamplit microscope, with which he could barely peer into the interior of cells, had no power to reveal the mechanism of inheritance. Mendel did not even have the name for this unit of inheritance; decades later, in 1909, botanists would christen it a gene. But the name was still just a name; it offered no further explanation about a gene’s structure or function. Mendel’s studies left a provocative question hanging over biology for half a century: in what corporal, physical form was a “gene”—the particle of inheritance—carried inside the cell?

  In 1910, Thomas Hunt Morgan, an embryologist at Columbia University in New York, discovered the answer. Like Mendel, Morgan was a compulsive breeder, but of fruit flies, which he raised by the thousands on rotting bananas in the Fly Room on the far edge of the C
olumbia campus. Again, like Mendel, Morgan discovered heritable traits moving indivisibly through his fruit flies generation upon generation—eye colors and wing patterns that were conveyed from parents to offspring without blending.

  Morgan made another observation. He noted that an occasional rare trait, such as white eye color, was intrinsically linked to the gender of the fly: white eyes were found only in male flies. But “maleness”—the inheritance of sex—Morgan knew, was linked to chromosomes. So genes had to be carried on chromosomes—the threadlike structures identified by Flemming three decades earlier. Indeed, a number of Flemming’s initial observations on the properties of chromosomes began to make sense to Morgan. Chromosomes were duplicated during cell division, and genes were duplicated as well and thus transmitted from one cell to the next, and from one organism to the next. Chromosomal abnormalities precipitated abnormalities in the growth and development of sea urchins, and so abnormal genes must have been responsible for this dysfunction. In 1915, Morgan proposed a crucial advance to Mendel’s theory of inheritance: genes were borne on chromosomes. It was the transmission of chromosomes during cell division that allowed genes to move from a cell to its progeny.

  The third vision of the “gene” emerged from the work of Oswald Avery, a bacteriologist at the Rockefeller University in New York. Mendel had found that genes could move from one generation to the next; Morgan had proved that they did so by being carried on chromosomes. In 1926, Avery found that in certain species of bacteria, genes could also be transmitted laterally between two organisms—from one bacterium to its neighbor. Even dead, inert bacteria—no more than a conglomeration of chemicals—could transmit genetic information to live bacteria. This implied that an inert chemical was responsible for carrying genes. Avery separated heat-killed bacteria into their chemical components. And by testing each chemical component for its capacity to transmit genes, Avery and his colleagues reported in 1944 that genes were carried by one chemical, deoxyribonucleic acid, or DNA. What scientists had formerly disregarded as a form of cellular stuffing with no real function—a “stupid molecule,” as the biologist Max Delbruck once called it dismissively—turned out to be the central conveyor of genetic information between cells, the least stupid of all molecules in the chemical world.