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Author Archive: "Siddhartha Mukherjee"

Stress and Cancer

A 46-year-old woman diagnosed with breast cancer had one burning question at the beginning of our meeting : is stress related to cancer? She was in the midst of a gut-wrenching separation from her husband. She was juggling work, finances, responsibilities, child care, and in the midst of all this, had been struck by breast cancer. Had she unleashed her tumor through stress?

The quick, if unsatisfying, answer is that we don't know. Five years ago, I would have been less agnostic. Most likely, I would have said: "stress certainly can exacerbate the psychic symptoms that accompany cancer — anxiety, fear, depression, guilt. But to blame cancer on stress is to enter a cycle of blame and victimhood that can be debilitating. Cancer patients often need to summon incredible reservoirs of resilience, and stress can deplete that reservoir in some and activate it in others. And stress, of course, can enable behaviors that are cancer-linked, such as smoking. But the role of stress in directly causing cancer remains speculative.

Recently, I've begun to change the way that I think — in part, because of an astonishing experiment performed recently ...


Winning or Losing?

Patients often ask me, are we winning or losing the War on Cancer? It is a worthy question, but notoriously difficult to answer. To start with, the very definition of "winning" comes into question. How does one measure victory, or defeat?

Take, for instance, a seemingly obvious proposal about the measurement of progress. What if we created a catalog of all major forms of cancer — lung, breast, prostate, colon, and so forth — and measured the fraction of patients who survive five years, or one year, after being diagnosed with each form. Has that fraction changed between 1970, say, and 2010? If only 5% of patients were surviving at 5 years in 1970, and that number is now 20%, can we legitimately use that change as a measure of victory?

No — because using survival rate as a guide for progress is inherently sensitive to biases.

To understand these biases, imagine identical twins living in neighboring houses — call them Hope and Prudence. Now imagine that a new diagnostic test is introduced that detects early breast cancer. Hope chooses to be screened by the test. Prudence, suspicious of medicine, chooses ...


Awakening the Sleeping Giant

In 2009, a Maryland woman in perfect health discovered a solid, matted lymph node under her left arm. It was biopsied and found to be a malignant melanoma. It had evidently metastasized from a primary tumor somewhere else in her body (melanomas grow from skin cells, and they don't grow directly in lymph nodes). When she underwent scans to appropriately stage her disease, metastatic masses were found everywhere: in lungs, liver, and abdomen. Yet surprisingly, the primary cancer — the origin of her diffuse disease — was never found.

Cases such as hers are relatively rare in oncology. They are called "carcinomas of unknown primary" or CUP. And they usually present a particular thorny therapeutic problem. A major emerging theme in cancer medicine is that every tumor-type is treated differently. Breast, prostate, lung, and uterine cancer are attacked with vastly different regimens of chemicals, and they respond very differently. So how on earth do you treat a cancer of unknown primary?

In this particular case, the woman's tumor cells bore a distinct biological mark indicating their origin in the skin, thereby classifying this as a melanoma. But although ...


To Push or to Pull

For my week-long blog for Powell's.com, I'll be attempting something novel. Every day, I will pick a single recent case from my files that highlights a major new discovery in cancer science or cancer medicine. As always, the names and dates will be scrambled to protect the identities of patients. And I will provide a link to the major medical or scientific study that lies behind the case. My goal here is to demonstrate how every case in medicine is a story in its own right — and how grand ideas are inevitably concealed within the homunculus of each story.

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Robert Bernard was a 77-year old advertising executive diagnosed with advancing leukemia who came to the clinic seeking advice. Bernard came from a large, voluble French-Canadian family — and much of that family, as it turned out, was also in the room with him. His wife, two sons, and a daughter had flown into New York from various parts of the planet. They were a tight-knit group, talking each other in an internal language that needed few words. The father, children, and even their mother ...


The Hottest Trial in Lung Cancer

For my week-long blog for Powell's, I'll be attempting something novel. Every day, I will pick a single recent case from my files that highlights a major new discovery in cancer science or cancer medicine. As always, the names and dates will be scrambled to protect the identities of patients. And I will provide a link to the major medical or scientific study that lies behind the case. My goal here is to demonstrate how every case in medicine is a story in its own right — and grand ideas are also concealed within each story.

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In the summer of 2009, a friend of mine awoke one night as if from a nightmare — flushed, hot, and short of breath, with a powerful fluttering in his chest. He thought he was having a heart attack. He was 43, an acclaimed writer about cities and urbanism, and in otherwise excellent health. That evening, he had made himself a particularly high-voltage version of the chili that he loved, spiced with the hottest Indian peppers in the world (in large part, our friendship is based on the ...


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