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Susan Sontag: "The Emperor of All Maladies" was written as an answer to her book, "Illness as Metaphor"

ILLNESS AS METAPHOR By Susan Sontag (1978)

Although Susan Sontag's book is not about cancer per se, it is a profound study about how we imagine illness. Sontag raises a crucial question: How does metaphorical thinking affect our experience of a disease? When we talk about "fighting" an illness, or cast patients as "soldiers," do we trap ourselves in those words and images?

Sontag pays particular attention to cancer, in part because this disease has always been wrapped in metaphor. The word "cancer" arrives through the Greeks, who imagined a solid tumour as a crab crawling under the skin, its claws represented by blood vessels spread out around it. And generations of scientists, doctors and patients have embellished this vivid image. For some, the constant, slippery mobility of cancer - metastasis - was reminiscent of the crab's sideways, unnatural movement. For others, the pain produced by cancer carried a memory of being caught in a creature's claws.

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Sontag argues that these metaphors can become punitive: If fighting cancer is a "war," the body becomes a battlefield, often pitted against itself. Yet, as an oncologist, I find that metaphors of cancer can be both punitive and redemptive. For some patients, fighting is what defines their experience of cancer, and to deny them that metaphor is to deny their reality. For others, the notion of battling one's own body becomes a horror in its own right. In a sense, then, The Emperor of All Maladies was written as an answer to Sontag's book, both as homage and challenge.


This quirky, deftly written book describes an incredible scientific journey. In the late 1960s, many scientists believed that viruses - particularly retroviruses - were the root cause of all cancer. In part, this belief was admixed with a hope for a cure. Several viral diseases, including polio and smallpox, had been controlled through vaccination, and the notion that cancer, too, would become curable or preventable was too seductive to resist. Indeed, a retrovirus, the Rous sarcoma virus (or RSV), was found to cause cancer in chickens, nearly sealing the virus-cancer connection. Many virologists argued that viruses caused cancer by introducing viral genes into cells, thereby forcing cells to divide uncontrollably.

In 1976, however, Harold Varmus and J. Michael Bishop turned the viral theory on its head. They found that cancer arises from the activation of genes that are endogenous to all cells. RSV, it turned out, was merely a carrier for such an endogenous gene. The implication of this experiment was enormous: The genes that cause cancer, Varmus and Bishop argued, were inherently present in the human genome, awaiting activation. These cancer-causing genes were termed oncogenes.

Weinberg is a prominent cancer researcher at the Massachusetts Institute of Technology and a central player in this story. He tells it with the vividness of an insider, bringing the laboratory and its strange rituals to life. Here is Weinberg describing the moment he learned about the Varmus and Bishop results: "We had little advance notice of the storm that would hit us in 1976. … We were wandering about in a fog. Then, almost without warning, a strong wind swept in, and for the first time a solution appeared in front of us."

AND THE BAND PLAYED ON By Randy Shilts (1987)

The story of the early days of the AIDS epidemic - a step-by-step account of the arrival of a mysterious, lethal epidemic that seemed to form out of thin air in New York and San Francisco in 1982. The suspense and pace make this read like a thriller. Shilts traces "Patient Zero" - a young Air Canada steward whom, he believes, was partly responsible for the coast-to-coast spread of the virus. He moves us from location to location - laboratories, bathhouses and clubs - to illustrate the dynamic movement of a global epidemic in its infancy.

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Why might a book about AIDS be required reading for those interested in cancer? In part, because Shilts blends the political and biological realms of illness so effortlessly, and demonstrates how quickly a disease can grip public imagination. He brings in memorable characters and locations, and propels us forward with his narrative strength. This is a "biography" of the AIDS epidemic in its earliest stages. Shilts himself would later die of AIDS.

CANCER WARD By Alexander Solzhenitsyn (1967)

This is a book about imprisonment. A young Russian, Pavel Nikolayevich Rusanov, is diagnosed with cancer and whisked off to a nameless hospital in the frigid north. He knows little about what will happen next; when he questions his future - treatment, prognosis, survival, release - he is silenced. The diagnosis of cancer - not the disease, but the mere stigma of its presence - becomes a death sentence for Rusanov. The illness strips him of his identity. It dresses him in a patient's smock (a tragicomically cruel costume, no less blighted than a prisoner's jumpsuit) and assumes absolute control of his actions.

To be diagnosed with cancer, Rusanov discovers, is to enter a borderless medical gulag, a state even more invasive and paralyzing than the one that he has left behind. Solzhenitsyn may have intended his absurdly totalitarian cancer hospital to parallel the absurdly totalitarian state outside it, yet when I once asked a woman with invasive cervical cancer about the parallel, she said sardonically: "Unfortunately, I did not need any metaphors to read the book. The cancer ward was my confining state, my prison."

ANATOMY OF HOPE By Jerome Groopman (2004)

Groopman, an oncologist and writer, tackles important questions. What role, if any, does "hope" play in our capacity to confront cancer? How does one define "hope"? What are its biological origins? Using powerful stories from his own experiences, Groopman sets out to construct an "anatomy" of hope. He finds, however, that there is no simple, archetypal anatomy. Hope, instead, becomes something negotiated between doctor and patient over time, a moving target that appears to shift shape and form.

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One patient, a revered professor of pathology, can find solace only in aggressive surgery, chemotherapy and radiation. A quiet woman from New York City seeks hope by resisting therapy. Dan, an army veteran with a real chance, hesitates and nearly dies of a curable lymphoma. A feisty gambler called Eva thinks chemotherapy is merely a bluff - and then dies "at an advanced age" nearly 20 years later.

Through these stories, told with humanism and humility, Groopman informs us of the crucial role that hope plays in illness. "Hope" he writes, "is as vital to our lives as the very oxygen that we breathe." This is a moving testimony to the resilience and inventiveness of all patients.

Siddhartha Mukherjee is the author of The Emperor of All Maladies.

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