the international agreement that limits iran's nuclear ambitions, ignoring the wishes of his european allies. he claimed it was a horrible deal that should never have been done. he is also reimposing the highest possible level of sanctions against tehran. an angry response from the iranian president, hassan rouhani, who has ordered his officials to be ready to restart the enrichment of uranium at industrial levels. but he says he is reaching out to the other world powers who signed the deal to see if they can keep it in place. efforts are underway to strike a different nuclear deal, this time with north korea. after meeting china's president, kim jong—un is set for more talks with the us secretary of state. mike pompeo has arrived in pyongyang to prepare for the release of three american prisoners and prepare for a summit with president trump. now on bbc news, hardtalk. welcome to hardtalk.

i'm stephen sackur. hundreds of billions of dollars are poured into cancer treatment and research every year. we understand it better and have more effective tools to combat it than ever before, and yet it kills close to ten million of us every year. my guest is one of america's leading cancer specialists, siddhartha mukherjee. his book, the emperor of maladies, a self—styled biography of cancer, painted a unique picture of the disease, mixing memoir, science, and a writer's sensibility. eight years on from publication, is cancer any less of a curse? siddhartha mukherjee, welcome to hardtalk.

thank you. you are a reknowned oncologist, you're also now a feted writer. now, do you regard those two activities as entirely separate, or is the writing a way of you following your calling as a doctor? for me, i mean, like many other people, i write to think. you know, in order to figure out the questions that we, that you might find interesting, where are we in cancer? the only way for me to answer that question is to write, and sometimes, it might be writing a big book of facts, a 600 page book. sometimes the questions can be answered through a smaller article, sometimes they need to be scientific articles,

but the writing is just a method for me to think. you've obviously thought about, worked on cancer for most of your professional life. at what point did you think to yourself, you know what, there might be a book in this that the general public would like to read? because cancer, let's face it, isn't necessarily a natural subject for a big selling book. well, the first time i put together a book proposal, someone said there'll be two readers, you and your mother will read the book, and... in fact, when we printed the book the first time round, we ran out of copies, because of the nature of the topic. so the quick answer's i didn't think about that, that is not what drove me to write the emperor, and not what drove me to write the recent book. these are complex topics and i feel that if you, if — if there are such intrinsic interest, people are so... i was so intrinsically interested in where and why we ended up today with cancer or with genetics, that i thought that if i could, you know, anyone would be

interested in reading it. if they didn't, that would be... well, and it proved to be true. but did you also think that cancer had been misunderstood and perhaps misrepresented to a certain extent? i think that there was a wealth of new information that was emerging in the early 2000s about the mechanisms by which cancer‘s caused, about what we're doing to combat the many diseases — it's not one disease but the family of diseases — that it felt as if you were reading from the standpoint of a lay public or even a patient, that you needed a kind of roadmap. where are we? where are we going? why did we end up here? and you couldn't find one. you know, there was lots of self—help hooks, sort of, you know, a lot of feel good, this is my struggle kind of book. all of which are maybe important, but this was not my book. but i suppose my question about the misrepresentation of cancer and the misunderstanding of it is partly premised on something you do that i can't think of anybody else doing in quite

the same way, and that is you sort of give cancer a character, almost a human character, which sounds completely bizarre but when one reads the book, sort of makes sense. well, what i tried to do... you know, itried not to anthropomorphise, make cancer a human being. but what i try to do is to try to understand what is the — what drives this illness or this family of illnesses? what drives the — what's the animus behind it? what kind of mechanism drives it? and what's interesting about it, once you get into that idea of what's driving something, what is the — what are the molecular, the genetic forces that are driving it, it's almost as if you can imagine it as a tangible thing, and that's why it seems... and you give it the attributes of person... you say you don't anthropomorphise, but you do write sentences like this one. you know, what you say is, "i'm making an attempt to enter the mind of this mortal illness, to understand its personality." yeah. "to demystify its behaviour."

yeah. i mean, these are terms that one would normally apply to a person. that's right but — there's no but about this, the important feature is that cancers do have behaviours. there are, in fact, despite the fact that it's a family of illnesses, you can ascribe fundamental behavioural characteristics because it's a cellular disease and it picks up behaviours from the world of malignant cells, the abnormal metabolism, the drive to proliferate, the capacity to evade immune responses. you know, there's something, there is a real behaviour in there and in fact, this behaviour stretches across multiple forms of cancer. you sort of give it a sense in which the cancer cells are almost a mirror of us and our darwinian unconscious, but nonetheless, ever present darwinian desire to replicate, to sort of adapt and survive. absolutely they're mirror images, because they borrow, cancer cells are, in fact,

they derive from normal cells. from us. that's right. cancer is us in a way. that's right. they borrow from normal cellular material, from normal cellular genetic material, the codes that allow these cells to ultimately survive and grow. can i ask you — i don't normally do this on hardtalk, but because i think this is such an important part of your work — can i ask you just to read a short passage from your own book? yes. i know i haven't given you much of a chance to see this beforehand, but this is a passage from the emperor of maladies and it, i think it gets to the heart of the way you mix science with a sort of literary sensibility, so... um, so here i'm writing about cancer. "cancer is an expansionist disease, it invades through tissues, sets up colonies in hostile landscapes, seeking sanctuary in one organ and then immigrating to another. it lives desperately, inventively, fiercely, territorially, cannily and defensively, at times as if teaching us how to survive.

to confront cancer then is to encounter a parallel species, one perhaps more adapted to survival than even we are. if we seek immortality, then so too, in a rather perverse sense, does a cancer cell." that's very interesting. and deep in there is this notion of us, we, the human species, confronting cancer but, you know, we've all become familiar with various politicians and medical practitioners who've used the phrase a war on cancer. do you, looking as you have done at the history of human effort to combat the disease, do you think this notion of a war on cancer is useful? i think it's useful in some ways and historically, it was useful and remains useful. the idea of the word historically, the war on cancer batted away, did away with the kind of nihilism around cancer. that there's nothing we could do. that there was nothing you could do, but like every metaphor it came loaded with its own problems. it created the idea that, you know, we are soldiers in the battle, that patients are somehow collateral

damage, the loss of lives is somehow collateral damage as we move forward, ecetera. and that those who don't succeed in the battle, on a personal level, have failed. have failed, exactly. so, so like all metaphors, it had some powerful things about it, but even so, had created among people also a kind of a damaging sense of loss, which still lives today actually. some people say — some patients of mine say "well, i don't want to think of this as a war. you're an oncologist, you go fight the battle. let me heal, let me recover." so it works in some ways, it doesn't work in others. perhaps the most famous use of it was during the nixon administration... absolutely, yes. when nixon himself talked about a war on cancer and actually suggested that within five to six years, he hoped that cancer could pretty much be eradicated as a threat to human health. well, of course, all these years later, we know that was very much misguided. but if you look at

the situation today — and i said in the introduction, you know, roughly ten million people a year dying of cancer, it's one of — i think in the united states, it's, after heart disease, the single biggest killer. in fact, it'll probably cross over and become the biggest killer. yeah. so, looking from where we are today, what have we achieved over the last 50 years? well, 50 years is a long time, but we've achieved, we've made fundamental leaps both in understanding cancer and treating cancer. i'll give you some highlights, but it's a big, long list because it's been an intense 50 years. we understand now the cause of cancer. we know that cancer is ultimately caused by mutations in dna, these mutations can arise because of errors in dna, you can call them, these mutations can arise because you can inherit the errant gene, because the mutation can be caused by a carcinogen, like x—rays or by smoking, the mutations can be caused or brought into cells through viruses, and they can occur because of random chance, when cells replicate themselves, like any copying machine, they can make errors. this we didn't know 50 years ago.

this is since the 1970s and 1980s. we now know that on occasion, if you find an achilles heel in a cancer cell, a genetic liability, something that the cancer cell depends on very acutely for its survival, you can actually get profound remissions and sometimes cures. we now know that early therapy, the detection of cancer early for many cancers, not all, for many cancers, can actually be very helpful. in fact, if you treat cancers early and follow that up with some kind of achilles heel therapy, you can help. we know that there are many virally caused cancers and those virally caused cancers can be, can be — their life cycle can be changed as it were, through vaccination against viruses, such as the human papilloma virus that causes cervical cancer. so there's a whole host from prevention, early detection, treatment and cure, that we've

understood in the last 50 years. it's... given that understanding, do you think we've got the balance right at the moment between the resources and the prioritisation we put into preventive action, and the resources and priority we put into treatment? so the answer, the quick answer to the question is we would like to — we would like to prevent cancers, period, and therefore, ultimately the resources, i think should be directed towards prevention. the problem with prevention is that although we've identified several carcinogens such as viral carcinogens, smoking, etc, it's often not clear whether many of the cancers today, we don't have obvious carcinogens that are implicated in some of those cancers. some we do, we've identified many new ones, in fact, we've identified them in the world, but some we are still scratching our heads about and saying well, why did this woman who never smoked,

who doesn't seem to have an obvious exposure to one of the many known carcinogens, why did she get lung cancer? why is there a 30—year—old woman with no history of breast cancer in herfamily, and again, no obvious carcinogenic exposure, get breast cancer? is it bad luck? is it something we're missing? and that remains a challenge. i said, you know, and it's very easy for me to say it, that with hindsight, the optimism in 1971 about victory in the war on cancer was deeply misplaced, but there are people today, respected scientists, who are saying that here in 2018 because of the knowledge we now have of immunotherapy and genetics, they are saying yes — and i'm going to quote a couple to you. one in australia, dr leanna read, she's a leading immunotherapy doctor. she says it's a huge, hot area of medicine with the potential, she says, to cure cancer. and then we could look at the geneticist james watson —

now, genetics something you've been working on a great deal — he says, "beating cancer now is a realistic ambition because at long last, we largely know its true genetic and chemical characteristics. we may finally be ready for that war." do you think that level of optimism is more justifiable today? well, i remain a sort of — i remain a middle optimist. i absolutely think that important strides have ben made in the last five years, even the last three years, including things like understanding the genetics and the chemical nature of cancer and also, as the — as your other respondent pointed out, not only understanding the cancer cell but the environment, the home it builds around itself, the immune attack on the cancer cell, we're understanding this as a seed and soil idea. we still have to develop fundamentally new cancer therapies. if you take immunological therapy as one example, very widely celebrated, lots of hot news around it, and absolutely, there are many cancers that are being cured or at least treated and put into remission through immunological therapy. but we still don't understand why,

for instance, pancreatic cancer remains cold to immunological therapy. why does breast cancer, for the most part, remain cold to immunological therapy? why, in the same cancer, within colon cancer, do some people respond beautifully and strongly to immunological therapy and others don't? you know the questions to ask, but you just can't find the answers. well, what's important is in science questions are answered through tools. without tools you cannot even answer the questions. so about five to ten years ago began to reformulate the questions, what were the questions? in that time we invented important tools that will allow was to ask the questions. important strides against many cancers, but remaining questions are still unsolved. let me ask you a personal question. you say that, yes. the toolkit is expanding, but it is still clearly not sufficient, you work, currently, i believe in colombia

in columbia university hospital in new york, you work with cancer patients every day. yes. so dying and death are realities you live with every day. absolutely every day. what impact has that had on your life? it changes and it changed who i am. i actually can't think of myself as someone who hasn't encountered a death a week. that person that i must‘ve been at some point of time before i became an oncologist, has vanished for me, that person... that person who was under your care. this is someone that is under my care, is a friend, or someone i've been referred to, essentially, the familiarity with someone dying, as i said, one person in the large ecosystem of my life dying once a week is the new normal for me and is the new normal for most oncologists.

you're quite frank about it. you say that at times you walked down the corridors of your hospital after a particularly gruelling shift and you struggle to find the sympathy that you feel you should have for some of the patients in your care. i think for myself, i can answer for myself, that's the time i go to the laboratory. to go back and realise... to give meaning to what i do, which is to try to find new treatments and new ways of thinking about cancer. and i think this is one of the discoveries, i would say one of the illuminating things about what has happened in the last a0 years, is that we've encouraged a certain kind of doctor to become also, to put on at the same time their medical hat, and his or her research at and ask the question how can i take what i learnt from the clinic, bring it back into the laboratory, a cell, a way of thinking, a genetic propensity,

and then transform that into a way of preventing or treating 01’ curing cancer. i can see that the lab and the microscope are important features of your research life. but in the end, you know, being the kind of doctor you are, is an incredibly human thing as well. and i wonder how you way up some of the very difficult ethical questions that cancer care does raise about the merit of giving people the latest treatment at a point in their disease where it might extend life by a maximum of three or six months at great expense and also probably with great suffering and hardship as well. how do you balance out what extra life is worth? i think the first important thing to realise is that as an oncologist, as a doctor, you are not the arbiter, you have to listen to the goals of patients and then be

realistic about those goals. you mean you're guided by the patient? i try to be. in fact, i think that's one of the cardinal principles of medicine, which went somewhat wrong in the 1970s in oncology when it was all war all the time, is that we forgot to listen to the goals of patients. what kind of life did they want and not kind of take my ventilator off or do this, allow this kind of procedure, give me that kind of chemotherapy, i mean a much, much more prima facie question about where do you want to be, what kind of life do you want to have? if i were to extend your life, a life on average by three months, but if that involved being in hospital most of the time, suffering through some procedure or chemotherapy, is that the life you want? some people want to take that sort of bargain on hope.

some people don't want it. and i think there's a kind of lucidity or clarity that went missing that i hope, i can only say hope, we are trying to get back. it is interesting the way you talk about it. if you don't mind, i'm going to make it very personal. because you wrote recently about dealing with the death of your own father. right. now, it wasn't a cancer death. he had long—term dementia, i know. he was back in india, you were with him. and you say when you were trying to figure out with him and your mother the best way for his end of life to come. yes. you found it profoundly difficult. you talk about "the amount of dread it brought on me when it was my turn to have the conversation as a son, not a doctor". and, ah, infact, it was... when my father died i sort of relived every such conversation that i had had in the life that preceded, in the 20 odd years that

preceded it and in reliving those conversations, i suddenly found that as a child, as a son, it was as if i was also starting afresh. it was as if it was first time i had ever had a conversation, because i had never been that person, the recipient of that wisdom. it's different. it's totally different. i had never been the recipient of that conversation, of that wisdom. and it took me some time to figure out who i was. what was i trying... what was going on in my own brain? what was trying to battle... do you think you got it right in terms of the help and support and advice you offered to him and your mother? my father was unconscious through most of this. we had reached a state of, he had reached a kind of coma. i think what helped, what helped enormously, again, was that his goals had been clear while he had been alive. his goals were, he had a kind of if then else kind of and idea about his dying.

if i'm not able to be sentient, if i can't do these things that i love to do, then i'm done. i've had enough. that helped. because i could keep that as a kind of moral compass or a guide as i moved forward in trying to get his care sorted out. before we end, i want to bring it back to the big picture. i just wonder if you, as a world—renowned cancer specialist, live in dread of what comes next, not because advances aren't being made and we're learning more about cancer all the time, but because the world's population is ageing dramatically and with greater age and longevity comes more cancer, itjust seems that is a consequential relationship, and how on earth are we going to afford to care, to treat all of the new... you're not talking about personal dread, you're talking about the dread of... it's a systemic problem. the systemic dread. i lean back on an old idea, which is death in old age

is inevitable. it is premature death, death in young age that we are mainly trying to prevent. so you are not so concerned about cancer in old people. what i am trying to say is the definition of old keeps switching. old was 60 in 1960, 70 in 1970, old is 2000 in 2018. but the point is, again, the goals are that we want to maintain function and not exacerbate or compromise dignity. those are changing terms. people are now functional at 80, people are functional at 85. it becomes somewhat of a personal decision. but the person who is at the other end of that telescope of medicine, the patient, as long as they are understanding of what is happening, they are functional, they have dignity, they have autonomy, i think we try to cure and treat them. irrespective of age. in terms of the language of cancer, do you look to a day

when we have beaten cancer? absolutely. you do? you think that's a concept we should aspire toward? because, in some ways, from your writing i get the feeling that you think cancer is so much a part of us, so integral to what makes us us physiologically that we will never beat it. right, so. but to push farther and farther away the kind of suffering, the premature termination of life, the assault on dignity, the assault on personhood, the assault on autonomy that such a terrifying disease brings, that itself is victory. you don't need to queue every cancer and have everyone live until they're methuselah, what we really need to do is to diminish the aggravation that this family of illnesses has had on our lives for centuries. that is a great way to end this interview. siddhartha mukherjee, thank you very much. thank you. hello.

wednesday gets off to a fine start for many of us but for some it's not going to last as we get rain heading in from the west. we saw a weather system move through on tuesday. this one here, the leading edge of cooler air so things cool down for many. not quite into east anglia and the south—east of england, but in the day ahead, that process is complete. low pressure to the north—west of us and that's feeding in cooler, fresher conditions across all parts, and a bit of rain, as i mentioned, coming into the west. although most will start fine and dry for the morning, single—figure temperatures under clear skies but some in east and south—east england still around

10 or possibly 11 degrees. your eyes will be drawn to this weather system that will soon in the morning turn things wetter into northern ireland, into western scotland, the wind picking up as well, quite gusty into the western isles but it's really coming in very slowly so a lot of cloud increases ahead of that. many will be staying dry even on into the afternoon, particularly across eastern parts of the uk, and still some sunny spells into east anglia and south—east england, but temperatures here down significantly compared with recent days. that's how we end the afternoon. going into the evening, some of us will be getting a wet evening rush—hour. some heavy bursts affecting western parts of scotland beginning to pull away from the western isles, patchy in nature to the east of scotland, not much into north—east england and clearing from northern ireland some will get

the sun coming back before the end of the day, but more of wales and western england starting to get outbreaks of rain pushing into parts of the midlands too. much of eastern england will be dry and once this weather system crosses all parts, wednesday night into thursday morning, there isn't a huge amount of rain left on it. after the heat of the recent days if you want something on the garden, i think you're going to be disappointed. dry weather on thursday. there'll be a few showers developing, though, particularly into scotland, maybe the odd heavy one with a rumble of thunder. northern ireland and northern england, the rest of england and for much of wales, it is looking dry, variable cloud and sunny spells. 0n the breezy side, if anything it's a little bit cooler still and some of us for the rest of the week towards in the north—west of the uk in particular will find temperatures below average for the time of year. another fine start for much of the uk on friday, but then we see another weather system gathering out to the west. the winds picking up ahead of that. while many on friday will stay dry, some will start to the outbreaks of rain. some uncertainty about the timing

of this and the progression north—eastwards, so we will keep you updated, and temperatures still none too special. that's it for now. goodbye. hello. this is the briefing. i'm sally bundock. our top stories: president trump pulls the us out of the iran nuclear deal, vowing to seek what he calls a "real" solution. after april's surprise meeting, us secretary of state mike pompeo is back in north korea for more talks with kim jong—un. and with just ten days before prince harry and meghan tie the knot, your guide to windsor and the royal wedding. in business briefing we focus on iran — what is the economic fall—out for the country and who are the winners and losers in business? also, back with the begging bowl: argentina looks to the imf forfinancial aid.