13. The 1980 Canadian mammography trial (see pages 298–300) was possibly flawed because technicians disproportionately steered women with suspected breast cancer to get mammograms, likely out of compassion. Put yourself in the technicians' shoes. Would you have allocated your friend to the mammogram group? If so, how can trials ever be randomized? Should a trial with a promising new drug be randomized—even if it means forcing some patients to be in the non-treatment group? What if a new treatment emerges for a deadly form of cancer? Should half the enrollees in the trial be forced to take sugar-pills to document the efficacy of the treatment?
14. On page 316, Mukherjee argues that "the trajectories of AIDS and cancer were destined to crisscross and intersect at many levels." Do you agree with Mukherjee's comparison? What did Susan Sontag mean when she said AIDS and cancer had both become "not just a biological disease but something much larger—a social and political category replete with its own punitive metaphors?"
15. Review the case of Nelene Fox (pages 322–324), whose HMO, Health Net, refused in 1991 to pay for an expensive bone marrow transplant to treat her diagnosis of advanced breast cancer, citing the procedure as "investigational." In your view, was it appropriate for Health Net to refuse reimbursement? Should patients pay for expensive experimental treatments out of their own pocket? What if these experimental treatments turn out not to extend survival—as with Fox's transplant?
16. The author says that he was motivated to write this book after a patient asked him, "What is cancer?" Mukherjee could not think of a book that would answer her question. So he wrote it. Does "knowing your enemy"—knowing cancer—bring some kind of comfort?
17. On page 459, Mukherjee writes, "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 normal—an inevitability." Mukherjee makes this assessment despite the approval of oncogene-targeting drugs like Herceptin, which have given new hope to cancer patients, as well as promising efforts to sequence the cancer genome. At the end of The Emperor of All Maladies, do you come away with optimism about science's efforts to combat cancer? Why or why not?
18. In the final chapter of the book, Mukherjee creates a fictional journey for Queen Atossa through time to demonstrate how cancer treatment has changed over the centuries. How might you have summarized this book? What image, or metaphor, emerges most powerfully at the end of this book?
19. Germaine Berne's story, which ends the book, is not superficially a story of hope, since she ultimately dies from relapsed cancer. Yet Mukherjee portrays her as a symbol of our war on cancer. In what sense does Germaine epitomize the battle against cancer? How is her story a story of hope?
20. Mukherjee calls this book a "biography." Can a "biography" be written of an illness? How might such a biography differ from the traditional biography of an individual? Are there other diseases that demand biographies, or is this project unique to cancer?
21. In what sense does history "repeat itself" in cancer research? In science, where new discoveries keep altering the landscape, what is the worth of reliving the past?
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