These 250 pages on the many ways that cancer care in America is broken should be read by everyone with even a passing interest in oncology, and must be read by every heme/onc fellow or fellow-to-be. Malignant reminded me of the best days of my own fellowship, when the then-program director Tito Fojo would eviscerate an article — these tended to be poorly thought out phase 3 trials of one TKI or another that somehow made it to the New England Journal — with a few slides made at the last minute.1 But this is not just a rehash of those lectures, nor is it the best of Prasad’s prolific Twitter feed, nor an overview of his billion meta-science articles and editorials. It is instead a series of lectures — enough to fill a semester — that takes bits and pieces of the above and adds quite a bit of new to make something better.

It is not the easiest of narratives to follow. This is understandable: cancer research, policy, and outcomes are as intertwined as the molecular pathways Prasad valiantly tried to avoid, and mapping their connections will inevitably result in a crazy wall. There are nominally four parts to the book with four chapters each, because you had to put it together somehow, and the parts make sense. Even so, more than once I was wondering what exactly a particular vignette had to do with where it was in the book, and wanted to put it somewhere else. But the feeling goes away quickly — Prasad’s style is entertaining, the puns are clever2, and there isn’t a superfluous paragraph in site.

To that last point — if anything, the book is too short. My pet cancer peeve, the disconnect between bioplausability and reality, and the many misuses of animal models to inform clinical trials, was barely mentioned when it could’ve easily made a whole chapter. Same for grant mechanisms, which did get a page and a half — that one half is a figure — but left too many things unexplained and uncovered, particularly for the lay audience. And as to Prasad’s big advice that the federal government should take over running clinical trials from private companies, well, it’s nice to put some pie-in-the-sky proposals out there, but something that is so against the grain should be more fleshed out.3 Or maybe mention some more feasible proposals, in the line of Vincent Rajkumar’s plea to cut down the number of people with veto power over a randomized controlled trial. I could go on, but I’d rather not spend too much time on what can be refuted by a single sentence: “Write your own damn book”.

Written by Vinay Prasad, 2020

  1. And I mean this quite literally: you could see him cropping screenshots two minutes before journal club. 

  2. My favorite involves a marinating chicken and curry. 

  3. There is, of course, the argument that someone who’s never run a clinical trial has no right to comment on the quality of those that are out there, nor to propose how they should be done. Rather than resorting to modern arguments against gatekeeping, I will echo my grandmother: I don’t have to lay eggs to know when there’s a rotten. 

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