‘In writing this book, I started off by imagining my project as a history of cancer, but it felt inescapably as if I were writing not about something, but about someone. My subject daily morphed into something that resembled an individual, an enigmatic, if somewhat deranged image in a mirror. This was not so much a medical history of an illness, but something more personal, more visceral: its biography.’

That was an excerpt from The Emperor of All Maladies, A Biography of Cancer by Siddhartha Mukherjee.

(MUSIC)

Welcome to Apollo On Call, the podcast of MedHum.org. I’m your host, Dr. David Hsu. Hope you enjoy the show.

Alright, welcome everyone to the first episode of Apollo On Call. I’m Dr. David Hsu,(DH) a family doctor and your host for this episode, and I’m joined by my buddy, Mr. Luki Danukarjanto, (LD) my reading book buddy, and he’s going to be giving us the non-doctor viewpoint of all the things we talk about on MedHum.

LD: Thanks for having me, Dr. Hsu, and a pleasure to be on this podcast.

DH: As always, as always. People who don’t know us, we’ve been doing other podcasts where we talk about books on a regular basis. So this is kind of our wheelhouse, but we’re shifting gears and talking about medicine and the humanities for the sake of MedHum, and if people don’t know, MedHum.org, our organization, our mission, is to explore the human condition as expressed through medicine, literature, and the arts, which is why we’re calling this podcast Apollo On Call. Because most of you probably know that Apollo is the Greek God of the Sun, but you may not realize he’s also one of the gods of medicine, the arts, and healing. So it fits right into what we’re trying to talk about here today.

LD: Sounds like he’s the subject of the humanities part of it, for sure, and given the medical parts, he’s the patron god of MedHum.

DH: I guess so. We haven’t declared that officially, but I think that is actually what’s going to happen. Now, the quote that you guys heard me read was a quote from The Emperor of All Maladies, by Siddhartha Mukherjee. This is a book that was written about a decade ago, and it’s, as he calls it, the biography of cancer. And I thought this would be a good book for us to pick as we go on our MedHum journey, because this book really encompasses a lot of information about the history of cancer and the history of medicine through that, and so maybe Luki can give us a breakdown of what this book is about. You’ve got two minutes to summarize 478 pages.

LD: Well, let’s start a little bit with the author. So, Siddhartha Mukherjee. He’s a doctor, he’s kind of every Asian parents’ dream. He’s done so much. He’s a trained hematologist and has discovered a whole bunch of different things. He was actually named one of Time’s 100 Most Influential People, and he’s the author of plenty of books. This one is probably the most famous one that he’s responsible for, and a bunch of other ones where he’s had some notable entries. But in terms of the story, it’s basically a biography of cancer, as the subtitle says. So it’s a journey into how cancer, I guess, was put into the normal zeitgeist, and people are aware of it, even all the way from the Egyptians to the Greeks, and as we evolved in our medical training and understanding, how that moved from the black bile in someone, all the way to this evolution in terms of different radiation therapies, chemotherapy, and understanding of how cancer evolved and the treatments as a result of it. So, it’s also view into the medical establishment and how medicine has evolved, how pharmaceuticals have evolved, and how our care of patients has evolved too well, not ‘our’ because I don’t care for patients, but Dave and his crew and how they take care of it. So it’s an interesting view of cancer and an interesting view of how people might see cancer being discovered over the ages.

DH: You mentioned that it traces it all the way back to ancient times, right? So there are reports of people discovering a mass growing on their chest, sticking out of the skin, but not really understanding exactly what’s causing it. But the book does make the point that cancer is a very modern thing, right? That there are mentions of it in these historical documents, but to be sure that what they’re talking about is cancer, we’re only going back a few hundred years. So it was only in the last few hundred years that we start to really categorize these things, and we’re sure that, oh, that mass that was growing is actually a tumor, and not say an abscess or an infection. Not to say that it didn’t exist before that time, but at least that’s now when we recognize it. But then it goes on to talk about the modern history of how modern medicine evolves over the last hundred, hundred and fifty years, and that’s where a lot of interesting things happen, because you start to realize that, oh, cancer is a modern illness. It’s not something that’s exactly a prehistoric illness. It isn’t something we read about in the Bible, right, or in ancient Rome much. It’s something that’s very, you know, 18th century, 19th century, 20th century, especially, right? And it coincides with the rise of certain factors that are also part of modern life, like cigarettes. And so this book goes through this whole biography, beginning to end. Well, maybe not end. There’s no obvious end in sight for cancer. So it’s an unusual biography in that sense. But that’s the basic lay of the book.

Is it because we’re detecting it more and able to do so that we have more instances of it, or did it always exist? But it seems to be that with certain environmental, certain lifestyle and chemical changes, that there is an epidemic of cancer that’s growing, and it’s kind of those leading causes of death that people seem to not know why, but there’s so many signs pointing to potential causes, and the book outlines some of them, and also some of the factors why it’s the case, and sometimes even what we can do about it to some extent, and also how our understanding is actually evolving over time as well, because it’s quite interesting to see how we used to think cancer was this type of thing, and now it’s something totally different.

Alright, so what do you want to talk about first? Do you want to talk about the patient’s viewpoint of cancer, or the doctor’s viewpoint? Who wants to step up to the plate first? You or me?

LD: I’ll take a second round and just let you take the lead of it. So, and to be truthful, I’m not a patient of it, so I don’t have any firsthand knowledge of cancer, but I am taking the viewpoint of the layperson, so the non-medical practitioner here, just kind of adding my two cents for some color commentaries.

DH: Which is actually a very valid viewpoint, right? We didn’t actually pick Luki out of nowhere for no reason, right, because, in fact, in medicine, every patient-doctor interaction, the patient is exactly 50% of that interaction, right? And most doctors have more than one patient. So actually, patients make up the vast majority of medicine stories. And I feel like sometimes medicine gets written by doctors, which is something that we need to reverse a little bit here.

LD: And just in case people who are listening that know me, know I’m not aware that I have cancer. So when you say patient, it’s from that viewpoint of non-medical professional in there, but you’re absolutely right where I think part of the whole mission of MedHum is to humanize medicine where it is that patient experience that is really lacking. And actually, that’s one really interesting part of the book that I noticed was the whole concept of palliative care, which I thought was just a normal part of medicine, but apparently it’s relatively recent. But we can go through some of our other discoveries as we chat a little bit more.

DH: Alright, so what do you want to know? You wanted me to step up first, so you want to hear the middle-aged doctor’s viewpoint about cancer in this book?

LD: Well, as a medically trained professional, what of this did you know and were aware of, and it was kind of like the normal teachings of a medical professional versus like, that’s news to me too, I had no idea and you’re listening to it for the first time, along with me. So that’s what I was a little bit curious about because doctors are very learned professionals. They know a lot, but at the same time they often don’t know what they don’t know too, right? It’s one of those things that the medical establishment is so vast that there’s so much that nobody knows, or nobody can know about many different areas. So unless you’re really trained in a particular area, what of it do you know? What didn’t you know? So I’m curious, Dr. Hsu.

DH: Okay, so the book is written in the general form. I mean, I know it calls itself a biography, but it is really a history book, right? It’s the history of medicine, talking about our understanding of cancer over a few hundred years. I have to say that I didn’t know that much about it. I’m practicing medicine these days, my patients come to see me. Some of them, you know, we find out on a mammogram that they have breast cancer, or we find on a colonoscopy they have colon cancer. A few times, I’ve noticed someone has, like, a lump growing on their neck, and it turns out to be cancer. So, this is something that I’m interacting with on a fairly regular basis. But just like you, I’ve kind of taken for granted that certain structures exist, and in my head, I’ve sometimes realized they didn’t always exist, but I think of them as if they always existed, right? I think that, oh, everyone probably did mammograms. I mean, obviously we know that’s not true, and at some point a program for screening mammograms must have started. So when did that start? How did it get implemented? These are things that we never really get taught in medicine. And to actually peel back the cover for a lot of these things that I do on a regular basis and see that, oh, so these were the dudes who thought of the idea that everyone should get a mammogram, and then how they were racing around trying to enroll as many women as they could to do it. And it wasn’t really that long ago. Like, I think that particular example was from the 60s, right? Whereas, I’m in my mid 40s now, to me, I feel like, oh, mammogram screening must have been around forever, but really not that old of a thing. All these things are very, very new and I didn’t know a ton about it. Some of it I knew a little bit about. To be honest, when we’re going through medical school, there’s just so much information that’s thrown at you that we only have a few lectures here and there to talk about the history of medicine, a few lectures to talk about ethics. There isn’t time to discuss it. And a lot of times in medicine, we have this idea that the science takes precedence. So we need to understand how the science works today. You know, if you have extra time, yeah, sure, go read about the past. But that’s not as important, right? This book is trying to give us a fuller picture of it, which I really appreciate, because I learned a lot. So a lot of the history of how things came to be was fascinating, and a lot of things about how everything ties together. This book isn’t just about cancer, right? As I read it, I realized this is about the history of all of medicine, right? That without radiology, right, without this ability to take a picture of an x-ray of your bones, we wouldn’t be able to take a picture of a patient’s tumor, right? And without the knowledge that we developed to have surgery, to be able to cut someone open reliably and not kill them, then there’s no treatment for cancer. And all of these things are intertwined. And it keeps going, like these advances even into the 80s, right? Like AIDS gets discovered, and they sort of start to figure out that, oh, it’s caused by a virus, and then that understanding of how the virus works affects the understanding of how people are researching different types of cancer. Everything is tied together in this giant web. It is fascinating to see how it evolves, and it’s crazy to realize how new all of this is. So there’s this element of technology that gets thrown into modern medicine, which is probably different than like, you know, if you and I were sitting there having a podcast 500 years ago, right, or we’re telling oral story traditions about the history of medicine up to that point, there wouldn’t be that element This thing turns into a race, right? And things are happening really quickly and within a person’s lifetime, you know, paradigms are getting shifted and thrown on their heads repeatedly.

LD: I’d be curious to hear about what happened since the publishing of this book, because if you trace back all of the advancements that happened, well, did they come up with a cure for cancer, like yesterday or something, who knows? Or are they really close to it, on the verge of it, any day now?
.
DH: The other thing I will say is that, as a medical student, we have some time to talk about basic sciences, so there’s some understanding of how genes work. So, as Mukherjee starts talking about, you know, proto-oncogenes and, you know, reverse transcriptase, little bells are going off in my head. I don’t know where, like, I’m looking around trying to figure out, okay, I think I knew a little bit about that, or this gene, but a lot of that stuff also, like when we’re in medical school, we’re just trying, we’re scrambling to just understand the basics, right, to be able to interview a patient, figure out basically why the patient’s here, where they need to go, and sometimes the nuts-and-bolts science of it gets lost, right? We’re in over our heads. We don’t have time to master that. So this book actually, not only is it trying to present the details of the history and the past and the humanities aspect, it’s also presenting a very detailed description of science, right, of the new scientific innovations that are happening and trying to present that to the layperson, which is a really impressive, ambitious thing that it’s trying to do. Difficult to read at times, I have to admit, but very ambitious.

LD: For sure, yeah, I would echo that sentiment, where sometimes it’s like, what is this and what is this acronym, or our concept of this and that? But at some point it’s like, okay, I’ll just kind of get through this point. But I’d love if you could comment a little bit where the way that I start the discussion is thinking about how doctors are even engaged in the first place, right? So they’re always these learned folks put on a pedestal, like they know so much, they can help save me, heal me, prolong my life, that sort of thing. And then you have a cancer diagnosis, and they start cutting off all sorts of pieces or giving you these experimental drugs, and you’re just like, okay, the doctor is doing it to the best of their ability, to the best their knowledge, and all of it is going to heal me, and I, through my full being, trust this person, right? So trying to think about doctors in the concept of the whole, world establishment, societal establishment, where they’re all at the top of the knowledge pyramid, and the openness for everybody to take in some of these procedures and just say, okay, my doctor said I’ll do it, so I’ll do it. Wondering if you have any thoughts around that, you being that person who can prescribe and thou shalt whatever.

DH: I’m glad that you think of me as being at the pinnacle of human knowledge. But no,

LD: Always, Dave, always.

DH: I think in this book, a lot of what’s happening in the background is it speaks to the desperation of everything that’s happening. Because, this isn’t a book about, you know, hip fractures. This is a book about death, right? And cancer is something that historically, even now, it’s a very scary word, right? And I don’t think that’s changed Even though I’ve read about all these protein kinases and all these inhibitors and all this progress, none of us wants to hear that word when we go to see the doctor, right? And that didn’t change at all. And I feel like the doctors in this book, who are fighting against cancer, they’re fighting against death all the time, and so they’re willing to do craziness to achieve it. And I think that point gets underscored many times in this narrative. The most interesting I found was in the earliest days, I’m talking turn of the 20th century, you know, early 1900s, very primitive surgical techniques exist. The concept that we can remove a tumor that might buy the person a little bit more time, so maybe we should remove the area around the tumor. So for breast cancer, we’ll remove the entire chest wall. Well, maybe we’ll get into the neck, we’ll just start removing organs in the neck, like these massive surgeries, because people are just desperate. They want to live a little bit longer. They already see that the writing’s on the wall that if you get one of these diagnoses, you’re finished. So the doctors are trying everything. And, as time passes, it gets a little bit more rigorous. It gets a lot more rigorous, and where we become a lot more careful, but the basic premise is still the same. We’re up against death. And I feel like that’s why people are willing to, for the most part, try what the doctors are selling, right? And sometimes it works, and a lot of times it doesn’t. And in the later part of the book, actually, he does this throughout the book, he sprinkles a bit of his own patient narratives into the book, right, of patients that he saw when he was a fellow in oncology. And so we kind of see how some modern-day patients handle this. And it’s sort of the same, you know, people are out there trying everything. They’re on blogs, they’re on message boards, they’re probably on Reddit trying to figure out what the newest options are for their diagnosis. When the metastatic cancer comes back, they’re trying to figure out what to do. It’s the weapons and the tools are a little bit different, but the idea is the same. They’re up against death.

LD: Yeah, and I think they mentioned it in some of the later stories, where there were these groups of patients that were sometimes gathering together and telling their doctors, hey, can you get me on this one because they heard it from another patient somewhere else, right? And it becomes that information exchange at a different level, because historically, it was the doctors, the medical establishment, that knew all this stuff. But now, with the internet and forums and stuff, everybody’s got information and everybody’s got an opinion. So, right, it’s interesting.

DH: I feel like you were asking me, how much of it did I know, much of I don’t know. I came away from this book feeling like we do know a lot about cancer in some ways, but in some other ways, we still don’t know that much at all. I felt like, if we really understood it well, we wouldn’t be so scared of it, but it is still a pretty daunting thing, right? For only a few specific types of cancer, there are some treatments that work really well, and sometimes there are treatments that work well, that prolong mortality for a few years. And with that itself, we call that working really, really well, right? So we’re making some small progress, but there’s still so much we don’t know. That seems to be my takeaway point from this book.

LD: For sure, it’s like a lot of things with the human body or the human condition that we’re only kind of scratching the surface, but I think we’re making good progress, and hopefully we’ll be able to save a lot more people as a result. But if I were to take a stab at saying like, well, how do I understand cancer based on this, if I can make some presumptions. I mean, I have very little experience, right? I might have some friends whose relatives may have had a cancer diagnosis, but I don’t have anybody close to me that has gone through it. So this is coming from almost like a fresh set of eyes, learning about cancer, its history, and all that sort of thing..

DH: Okay, from that vantage point, fresh set of eyes, before you read the book, if you heard the word cancer, what would you presume? What was your understanding of it going into the book?

LD: Well, I was always interested in, like peak performance, and part of it is medicine, right? So I have listened to podcasts and watched some YouTube videos on cancer, just because it’s one of those pervasive diseases that you should probably know about, more on the prevention side, versus what to do when you have it. And we hear the word like, carcinogens, right? We recently figured out what these things are and, well, that makes sense, because they didn’t always, or we didn’t know they existed, right? Someone had to have figured it out. So thinking about what those are, and you mentioning that this is a very like modern-day disease, where a lot of it is, call it the conveniences, like the coal, the energy, all these chemicals that are in our homes to make it more comfortable to live in. A lot of that becomes the cause of cancer. And I mean the way that I understood it, it’s just
cells that don’t want to die, and they pervasively grow much more than others. Now what causes that is probably those carcinogens. This is one case, and then there’s a bit of genetics thrown into it, and the combination of those two, and probably some other factors that we don’t yet know about is what causes it, but those types of things where, to be honest, I didn’t know too much about it, and I’m kind of learning a little bit more. I can’t say I know a lot about it now, but I am a little bit more familiar with it, at least to talk to my fellow lay person.

DH: So coming from that angle, which I think is what most people’s view on cancer is, like a lot of us don’t even realize that cancer isn’t one disease, it’s sort of a term that encompasses anything with unregulated cell growth, right, and so coming from that angle, what are the things from this book that you would take away that were meaningful to you?

LD: I liked one of the sections where it said prevention is the cure.

DH: I knew you would like that, actually,

LD: That’s one of those things where, when you have cancer, it’s, I don’t call it’s too late, but the way that I’ve understood is like our bodies have abnormal growth all the time, but our natural immune systems are able to get rid of it, and it’s this some sort of trigger, some sort of threshold that’s crossed that makes it overwhelming to the body, so that it can’t take over these. Now again, whether it’s genetics and or some environmental factors or lifestyle or whatever it is, that’s still not 100% known, because for people that live in a certain environment with certain genetics, the person right beside them, like their identical twin or whatever, might not ever develop it. So we still don’t know so much about it, but the fact that you can kind of live a good lifestyle and still get cancer and live a bad lifestyle, I think they had people who like smoked till whatever, and they were fine, versus people who get second hand smoke who aren’t so fortunate. Those are kind of the interesting parts of it, and just the genetic progression of it, where you can have, I guess, multiple different contributing factors that will lead to it?. So I don’t know, there’s so many more questions, I guess, as a result of this. But I think one of my curiosities was, to your point, this is really a story of like, death, where they’re given this prognosis, you have cancer, so you need to, and are willing to do pretty much anything and everything in order to avert that prognosis, because you might have months, you might be lucky to have years there, but you’re basically gonna die, right? So how are you gonna arrange your affairs? How are you going to live it to the best of your ability? So things like the concept of radical surgery, where you cut off everything, and cancer might not be here there, but let’s cut it off anyway, just in case. So it’s kind of like, yes, you want to live, but like, at what cost, and people looking like they’re skeletons as they’re going through chemotherapy and all that stuff. And again, at what cost? That’s the interesting thing. But again, this comes from someone who has not gone through it and if I was faced with death, maybe I’ll be like, yeah, bring on any new, novel thing, just test me. Guinea pig, patient number zero, go ahead, because what else do I have to lose?

DH: Desperate times call for desperate measures, that is one of the themes of this story.

LD: Yeah, for sure.

DH: Okay, one question I have for you is, you weren’t really a biology science guy from what I remember.

LD: No.

DH: So what about reading this book? It’s almost 500 pages, and there’s probably a good 250 pages that’s dedicated to, like a hardcore scientific explanation of this stuff. I have to admit that this isn’t my cup of tea. This is the stuff I would have tuned out when I was a student. I tried my best here to plow through this. What did you think of it?

LD: It could have probably been about 200 pages shorter. But a lot of that is somewhat interesting, where, minus some of the super specifics of, like the different chemicals, and genome components and stuff like that, the fundamental components of cell replication, the fact that chromosome breakage probably leads to the activation of certain tumors, and out of control growth and things like that, right? I don’t know that they really talked about it, but the study of epigenetics, I’m familiar with that, where it leads to all the outside conditions, is really what influences your genes, right? Because your genes are your genes, but that doesn’t mean they’re your destiny. It’s one of those things where, with certain lifestyle changes, you can potentially avert cancer, but sometimes it’s just written in the stars, that sort of thing, right?

DH: What I thought was interesting was that he was able, in the narrative, to weave the science with the history of how the science evolved. There’s this whole component of how this research happens, there’s all these scientists in labs around the world, but a lot of is American. So actually, this was one thing I was going to say, is that this is a biography of an American disease, almost, because most of the research is happening in America, and the viewpoint, the perspective of everything seems to be fairly American centric. But I really enjoyed how he was able to tie our understanding of the science with some of these bigger picture, social things that were happening at the same time, right? And for example, cancer research doesn’t happen without fundraising, and that wasn’t the thing, if you go back 200 years ago, people weren’t stumping on hotlines to raise money for your local hospital. We kind of take it for granted that this is a thing now, but this is a thing now because of cancer, right? So this is a part of the story of cancer is that it spun off these industries on the side, so fundraising becomes a thing, or this whole business of pharmaceutical companies now are trying to figure out, well, what should we spend our money on? We can spend research on this disease or that disease. How do we pick the one that we’re going to spend on? Obviously, it’s the one that’s going to make them more money, right? So certain promising research for cancers that aren’t as prevalent maybe doesn’t happen, right? So a lot of weird and interesting little issues arise in this whole narrative, which I thought, that stuff actually, to me, was much more interesting than the cellular level. But I guess the cellular level has to be there.

LD: You can’t extract it if you’re going to call it a true biography of cancer, but I think you alluded to in the introduction, where one area of interest was the whole concept of like cigarettes, how recent they are, and how they came bursting onto the scene and how they’re still around, even though everybody knows that they’re not good for you, but people still smoke.
DH: We were just on a trip in the Caribbean, and I was walking by, like a shop that puts the cigarettes right in the window, and they have these giant boxes, right? The box has a little white box on it, I mean, we’ve all seen those labels. Cigarette smoking can kill you. It’s these block letters. People don’t care. They’re still doing good business. It’s really crazy. I was shocked to learn – this is probably out of this whole book – the thing that shocked me the most that I after I read it, I started messaging people, I started quizzing my kids, when did cigarettes become a thing? And I just assumed that cigarettes were something from medieval times, and has been going on for hundreds and hundreds of years, but it’s really just from around 1850. We created this monster, and we can’t put it back in the box.

LD: You don’t see, like, all the knights in the round table smoking some cigarettes.

DH: I assumed that it was old, because I always had this idea that Sherlock Holmes was smoking all the time with a pipe, but he really is just from the 1800s.This is a really new thing, and it speaks to if, whichever dude it was that rolled that tobacco a new piece of paper and smoked, if he doesn’t do that, maybe we don’t go down this road. But anyways, that was shocking to me. You’ve mentioned that the palliative care bit was kind of shocking to you. So that was also interesting in the sense that so many of these structures that we have in medicine now that we kind of take for granted that this exists, didn’t exist very long ago at all. Our grandparents generation, probably they grew up and got into old age without realizing that palliative care was a thing.

LD: One of the quotes in the book was that death meant failure to any of these doctors. So they would not allow you to say, oh, yeah, just, just die in comfort, die peacefully. It’s like, no, we’re gonna go down trying, and we’re gonna cut more, we’re gonna give you more chemicals, we’re gonna give you more this and that, whatever, and we’re gonna save you, gosh darn it, that sort of thing, right? And to realize that you know what, it’s a terminal disease, and you’re only going to have a few months and let’s make it comfortable. That’s new.

DH: It’s crazy, because I have a feeling that if I was a medical student 40 years earlier, I could very well be one of these cutting guys, right? I’d be like, no, no, we got to keep fighting. And it makes you wonder, like, 50 years from now, when people look back to today, they’re like, you guys were barbarians back there. You did that ? You gave people chemotherapy. You crazy, right? But things change, and I think this book does touch on that, and the speed, and, the scope of all these changes, it’s quite, quite incredible,

LD: One curiosity that I have is recently is AI has jumped on the scene. So how much of this new cutting-edge technology could help? Because a lot of what they mentioned is they find one chemical that will help with this type of cancer, but then it mutates, and now they have to adjust it to this one. It’s well, now can AI build a protein for that and make it so that you can almost have like a custom-developed cancer treatment for you and your particular instance and all through the push of a button. And we’re not there yet, but I think it’s just a matter of time until they really isolate all these things, assuming cancer is what the book is kind of alluding to, because it could be elusive where it actually is something totally different, and what we think it is right now is something totally different, and there’s another plot twist in the book that they don’t consider until the next edition is out, or whatever.

DH: Did you did you feel that cancer sounds more scary to you or less scary to you after reading this thing, given that you didn’t know a lot about it before?

LD: I don’t know if it’s one of those things where, when you read about it you’re like, I have those symptoms, those types of things, where I was like feeling different parts of my body.

DH: Oh, that’s like, a medical student thing. When you’re going through med school, everyone thinks they whatever unit you’re on, you have that symptom for a few days.

LD: So I was cognizant of that because I was, wait, make sure you’re not believing that you’re having these symptoms. Dave, I’m gonna kill you for suggesting this book. At the end of it, I was like, do I think have cancer or maybe I have cancer? But no, to your question, I think towards the end, it actually gave me quite a bit of hope in the sense that they’re starting to understand it. And it’s just a matter of time where, again, they can create that right formula, that right system, where this cocktail of chemicals can be done for a particular one, because they have it for some, and there’s a huge increase in life as a result of and I think they distinguish between life and health, where health span versus life span, where you don’t want to be, like, living to an extra 20 years like an invalid, that sort of thing, you’d rather be living that actually out and about. So it’s given me hope. And it’s one of those things where, I mean, if someone said, hey, I have, I got cancer, it’s like, well, let me pull out the book and see what I can do to help. No, I don’t think it really has answers, but it will be one where you can start looking a little bit more and you’ll have more things to take a look at. I’m a little bit more positive as a result of this book. But how about you as the doctor, knowing more has it made you feel better or feel a little bit more challenged?

DH: I don’t think it changes. I’m still pretty darn afraid of it.

LD: Don’t get me wrong. I’m still afraid of it.

DH: I do think that I understand a little bit better why patients would be super afraid of it because I interact with it tangentially on a regular, semi regular basis. But a lot of patients probably have heard stories, you know, horror stories from their parents, 60s, 70s, right? Or from their grandparents, right? And so, I have seen some of these changes seep down into even like a family doctor’s office in 2024. It’s nice to know that, you know, there is targeted therapy for certain tumors. And not everyone needs chemotherapy.. And it’s changed even from the time I was a student till now. So it’s nice to see that these advances are coming along. And I’m really happy to be living in 2024. I’d rather be here than in 1924 that’s for sure. And so I think this book did present that hope, and I think I think that’s what you’re alluding to.

LD: Yeah, and it’s one where taking a look at little nuggets, that whole chapter on prevention is a cure. One of the things that I thought was interesting was even social networks as strategy for cancer prevention. So the more people and this might be bad, but the likelihood of cancer increases or decreases depending on who’s around you. It’s that notion of you are the average of the five people that you spend the most time with. So if you’re spending time with smokers, right, who end up with cancer, guess what? You’ll probably have it. The scary part to me is that you could be like the healthiest person in the world, but still end up with cancer too. So it’s not necessarily that it’s 100% under your control. There are other factors that could have you go one way or the other. But I did find it interesting how there were kind of nuggets of hope and this is what you can do about it, because you’re not predestined for cancer or whatever your genes or whatever your environment or whatever is laid out in front of you.

DH: Now, before we go, there are a lot of little fun nuggets in this book. Maybe we can just touch on a couple other ones to give people a taste of what they’re in for, if they read this thing. Give me some nuggets that you really enjoyed.

LD: I actually liked the way they created Jimmy.

DH: I didn’t know that story, I didn’t know that either. The notion is to start with the fundraising in order to get monies for the cancer treatment or the research. Then they pretty much invented this character name.

LD: Which is real, he was a guy.

DH: He was real, but his, he wasn’t named Jimmy.

LD: That’s true, he was a kid.

He was a kid, and he was around, but he wasn’t Jimmy. And I think he had a fairly ethnic name, and they made it Jimmy, just to make it so that everybody could relate. And you’d have Jimmy updates and things like that, and Jimmy was a celebrity. I thought that was an interesting bit. What’s one that you well remember?

HD: In line with the Jimmy story, there’s this whole story about Mary Lasker, the fundraising lady. Yes, this lady is just a philanthropist who decides to make cancer her pet cause and donates a ton of money, energy, time, her whole life, to fighting cancer. And you don’t think about philanthropists a lot in terms of when you think about the war on cancer. The first people that pop to mind are probably doctors, these old surgeons. You think about the patient suffering, but there are people in the background doing incredible things. And I’m glad that this gets touched on in the book. It really rounds out the story fuller because it’s showing cancer’s place in the world and how so many of us, in different ways, can do our part to help fight it. That’s cool, I like that part.

LD: Another part which we sort of touched on is all these experimental drug treatments and people who have tried everything. They’re willing to be those guinea pigs. And not only willing, they’re, like, demanding to be part of these trials where it’s experimental, it’s like, yes, sign me up. I found that quite interesting, where they’d get to the point where they would sue people to say, you didn’t open up these trials for us so we couldn’t get access to the latest cutting-edge experimental medicine and all that. And it goes back to the discussion of being close to death and trying anything. I found that interesting where you demand the drug companies to, who cares about all your double-blind, placebo controlled, whatever. Just give me it, if it works, it works, right, just give it to me.

DH: Well, in keeping with that, the other story that I enjoyed in a couple of these stories, was the examples of physicians or scientists doing research on themselves in some wacky way, right? They couldn’t get approval to do the study, and no one else was willing to take the medicine. The one I’m thinking of is the guy who figured out that stomach ulcers and stomach cancer is caused by the H. pylori bacteria. He just got fed up with waiting and just drank the bacteria himself. That was cool. I was like, wow, this guy’s a real martyr for their cause. He deserves, like, a special place in doctor heaven. And then there’s Marie Curie, like those early people who were working with imaging, and the radioactive material that allowed them to be able to see their bones and then would kill them a few years later. Pretty incredible that people were willing to, I mean, they didn’t know it, maybe in the example of the radiologist, but people are putting their lives at risk to advance science. We sometimes lose sight of that in modern times when we think about scientists. But these, these old school people, they were really pushing the boundaries.

LD: And one of the interesting things I found was all of the different like trials of testing where they had conscripted some people, but in some of the earlier ones are just like they put them in the trials. They didn’t really sign up, or the patients, as far as I could understand, they didn’t really sign up for it. They were just given this, and the other group was given that. So were they even consulted? Were they even aware? Did they even know there were options to do this?

DH: The book talks about this. At some point, they started randomizing the groups and trying to figure out statistics. The book even talks about the history of how medical statistics and biostatistics becomes a thing. All of this stuff is so new. It’s all stuff we take for granted. That is, ultimately, what I think is the coolest part of this book. So we’ve read the book, we’ve talked about the book. Do we recommend this book to people who are interested in medical humanities, and if so, who are those people that should read this thing?

LD: Anybody who’s scared of cancer, I think should take a read.

HD: That’s pretty much everyone. That’s a broad net that you’re casting. See, I don’t know if everybody’s afraid of cancer, because it’s one of those things that if it doesn’t really affect you, I don’t know if they’re truly aware. I think it’s one where you hear of one person, you’re like, okay. Then you hear of 2, 3, 4, and then you’re like, oh, okay. And then a little bit more, you’re like, it’s coming for me, I should read this book. It’s probably where I would suggest, because it does have that history and anyone interested in, I guess, medical humanities, because it is that link between the medical establishment and kind of the rest of society, where it’s even turning common assumptions on their head to say, like, this stuff wasn’t common knowledge, like, only a couple of decades ago. And now all of us are, of course, you don’t smoke a cigarette. Why would you want to do that, right? And even still, some people haven’t got the message. I think he does a good job of weaving the science and the humanities together. And that makes it a good read. When you’re in medicine as a physician, and probably when you’re in it as a patient, there aren’t a lot of things that weave these two things together. A lot of times these two things get siloed off, You’re either dealing with the touchy-feely art of everything, or you’re dealing with the numbers. And this book actually brings the two together in an interesting way. I think it’s a good introductory podcast for MedHum, for sure. It is a good read for people, but it is long and it’s not easy. This was what my oncology friend warned me when I said, this is the book we’re gonna do first. And she’s like, you sure? This is not easy to read.

LD: If someone could create a version that’s kind of half the size, then I think it would get way more readers and a lot more adoption. Maybe, but then you would drop the science part, right? You drop a lot of science and keep the funny stories about the fundraising and, you know, a very bare-bones science. But I feel like the book needs that detail, that heft.

HD: I think you could whittle down the science details, but still keep the science behind it, right. So I’m reminded there’s this anime that we were watching, and it’s called Cells At Work, where it basically personifies and like you have this, the main character is like a red blood cell, but it’s basically a character with red hair, and they carry these boxes of oxygen to different parts.

LD: He does this type of thing in this book. I’m just saying, if he had a little bit more of that, I think it would be more. So just maybe turn this into an anime and get the Japanese folks to make it epic, you’ll definitely have an award winner. But I do sense that there was definitely some of that. And I think just for the true lay person like versus the invested person who really wants to do it. I think some of that would help more. But yeah, a lot of great information, a lot of great insights on this, for sure. And he did a good job.

DH: Excellent. So we learned something, which is our goal here. Our goal, every month, we’ll learn a little bit of something on Apollo On Call. So, there you have it. The first episode of Apollo On Call is in the books. I hope Apollo, wherever you are, you’re happy with this podcast. We did our best. We tried to find a book that was dense but entertaining, and tries to tether medicine and the humanities together. I think we did an okay job with it.

LD: Yeah, I think so.

HD: Alright, and if not, we’re gonna keep working on it. So come back in a month, we’ll have some other content just hit us up about once a month. We’re gonna be producing some different types of material on this show. Sometimes it’ll be books, might be films. Sometimes we’ll be interviewing people who work in medical humanities, all of it. The idea is to bring the world of medicine and humanities a little bit closer together to people.

‘Taken to its logical extreme, the cancer cell’s capacity to consistently imitate, corrupt, and pervert normal physiology thus raises the ominous question of what “normalcy” is. ‘Cancer,’ Carla said, ‘is my new normal,’ and quite possibly cancer is our normalcy as well, that we are inherently destined to slouch towards a malignant end. Indeed, as the fraction of those affected by cancer creeps inexorably in some nations from one in four to one in three to one in two, cancer will, indeed, be the new normal. The question then will not be if we will encounter this immortal illness in our lives, but when.’

Apollo On Call is produced by MedHum.org.

Special thanks to my co-host today, Mr. Luki Danukarjanto. The theme song is Un Sospiro by Franz Liszt and is performed by my wife, Dr. Justina Sam. Thank you all for listening.