Siddhartha Mukherjee, M.D., D.Phil.: ‘The Experience of Cancer Has Changed’

Siddhartha Mukherjee, M.D., D.Phil., has devoted his career as a physician, a researcher, and an author to cancer. An associate professor of medicine at Columbia University and a staff oncologist at Columbia’s medical center, he received the Pulitzer Prize for his bestselling book “The Emperor of All Maladies: A Biography of Cancer,” which was followed by “The Gene: An Intimate History” and “The Song of the Cell: An Exploration of Medicine and the New Human.”

Yesterday, he delivered the William C. Menninger Memorial Lecture. Here are five takeaways from his remarks, edited for length and clarity:

1. The psychology of cancer: Right from the very beginning, the connection between cancer and the mind was noted. This is not to say that cancer has any causal connection with the mind, but it’s to say that the experience of cancer has changed and continues to change culturally, socially, and, most importantly for this audience, psychologically—the way we perceive ourselves as individuals at risk.

This is a very storied past. Galen was a Roman physician who practiced among the Greeks and was one of the first people to create this theory of humors—black bile, blood, phlegm. Most importantly, it assigned an excess of black bile to a disease, and that was cancer. “Melancholia” literally means black bile, so this idea of cancer being an accumulation of melancholy has a very interesting and very tragic history but is now coming out in very different ways as we imagine both patients who unfortunately get cancer but also patients who are at risk of getting cancer.

2. The anxiety of previvors: There’s a new word that’s come upon our lexicon, which is the word “previvor.” A previvor is someone who’s not yet had cancer but lives in the anxiety or the shadow of having cancer. These patients—and I hesitate to call them patients—are increasingly appearing in my clinic, often carrying diagnoses of family histories of cancer, often carrying family histories of anxieties that are associated with cancer. Mothers with breast cancer, aunts with ovarian cancer. There’s a lot of anxiety about exposure to carcinogens such as secondhand smoke.

This is the paradox, I think, that we’re facing today—that on one hand, while we fight battles in early detection, in classification of risk, in making patients really understand how to manage their own risk, what should they be doing? What behaviors, what changes should they be undergoing? We’re also manufacturing the anxiety and often depression around the diagnosis, not only for patients who have cancer but people who imagine themselves as survivors or people who imagine themselves as having cancer in the future.

In that case, we have to ask: What is risk? How do you quantify it? Can we change risk? But, most importantly for this audience, can we change the anxiety of risk? How do we manage the anxiety of risk? How do we manage the depression of risk?

3. An interdisciplinary approach: Just about four or five weeks ago, I met a woman who’s 21 years old. She wanted to have children and has a very strong family history [of breast cancer]. We quantified her risk, and she did in fact inherit that same degree of risk. And now her question is: What should she do?

Healing that patient in terms of their understanding of their body—the body that has betrayed them, the body that has now set them up for risk—is something that is done in an interdisciplinary manner. We do this with the help of genetic counselors, with the help of psychologists and psychiatrists. [Patients] may come to a decision that is extremely complex, such as, they might want to preserve their eggs and have an aggressive surgical procedure that will really change their body and their conception of self. And then, how they communicate that [genetic] risk to their children if they were to have children is something that requires a level of nuanced care that only an interdisciplinary team can provide.

4. Priors and posteriors: Many of you are familiar with the idea of Bayesian statistics. Bayesian statistics is the idea that prior probabilities modify posterior probabilities. In some cases where you don’t have an equation or a certainty about something, you use wisdom and you use your understanding of what a person has in their priors to understand their posteriors. How does that help us as oncologists? How does that help you as psychiatrists?

Well, the principal way that helps is that we try to understand the person before they were transformed into the diagnosis of cancer. We try to understand who they were, what their priors were, and what it is about them that has changed. That’s very important, because understanding the prior person gives us insight into who that person was or could be, and how we can restore the idea of the prior personhood to this human being who is being transformed, either by the diagnosis or by the actuality of cancer appearing in their body.

5. Navel-gazing and psycho-oncology: I recently had a patient who, as a consequence of their severe and, for a long time untreated, bipolar disease, had comorbid substance abuse and a variety of other high-risk behaviors. This person had therefore become totally estranged from their family and now had a diagnosis of cancer.

One of the things about healing this man that I realized, being a holistic physician, was to have family counseling in addition to chemotherapy. And I can assure you that while the chemotherapy helped a little bit, the family counseling helped vastly more because they were able to reconnect with the family that they had lost as a consequence of their organic mental illness. [We had an opportunity] to explain to the family that that organic mental illness was the cause of this high-risk behavior.

We’ve been looking for too long at the idea of healing in very limited ways. We have a capacity to navel-gaze and not think about a patient in whole terms. That has to change. And, if it doesn’t change, it will only lead to worse outcomes for everyone. The discipline of psycho-oncology is not new, but it’s been desperately unused. As people enter the world of cancer more and more, as there become more and more survivors, we will need your help as much as we can get in comanaging these very complex patients who may have organic mental illness, or may develop anxiety as a consequence of diagnosis or being a previvor.