If there’s one thing about how cancer is discussed in the media that drives me absolutely bonkers, it’s how seemingly whenever a public figure announces that he has cancer information is rationed to the point where the announcement is basically meaningless. I can understand why someone might not want to disclose more about his disease than he has to, and maybe I’m just too nosy and curious about these stories. Being a cancer surgeon and all, though I find such stories an irresistible temptation to see if I can figure out what’s going on. Such skills were honed in my analysis of quack cancer cure testimonials, where I learned to tease out as much information as I can and make reasonable, evidence-informed inferences about what is probably really going on, as opposed to what the patient claims is going on. Such skills have served me particularly well in my analyses of cancer cure testimonials by patients of Stanislaw Burzynski, by patients who underwent surgery but claim alternative medicine is what cured them, and patients claiming marijuana cured them (or, as I like to call them, “cannabis cures cancer” testimonials). Such skills also allowed me to deduce, fairly accurately as it turns out, what really happened in Steve Job’s case.
So when it was announced yesterday that former President Jimmy Carter has “cancer,” it was very hard for me to turn off that skill set that drives me to delve into stories like this and try to figure out what’s going on. I’ll be the first to admit that Jimmy Carter wasn’t one of my favorite Presidents. Maybe it was because I was in high school most of his presidency, and the Iranian hostage crisis had a profound effect on my politics at an early age. As I’ve gotten older I’ve realized that perhaps I was too hard on Jimmy Carter. Whether I was too hard on him or not, though, I always rather agreed with the characterization of Carter as the “best ex-President we’ve ever had,” based on his charitable work and activism after leaving office. Regardless of my political opinion of him, I sincerely hope his cancer is treatable and that he does well. He might be 90 years old, but he’s still a force and could still do a lot more.
Here’s what we know:
Former President Jimmy Carter has cancer, and it has spread to other parts of his body, he announced Wednesday.
Carter, 90, had a “small mass” removed from his liver during surgery earlier this month. At the time, he received a prognosis for a full recovery.
But he said Wednesday in a brief statement that “recent liver surgery revealed that I have cancer that now is in other parts of my body.”
It was not clear where the cancer originated or where it had spread. Carter’s family, however, has a history of pancreatic cancer, which CNN correspondent Sanjay Gupta said could be afflicting the former president. Carter lost his father, brother and two sisters to the disease. His mother had breast cancer, which later moved to her pancreas.
“If you’ve got pancreatic cancer, you die. Absolutely,” Carter told CNN’s Larry King in 2008.
Personally, I think the pancreatic cancer reference is probably a red herring, despite all the attention news media medical correspondents are heaping on it. Yes, I know that for a time Carter was undergoing regular CT scans, but there’s not a lot of evidence that that approach is likely to prevent death, even in someone with a strong family history of pancreatic cancer. That being said, sure, it’s possible that Carter has pancreatic cancer. I hope that’s not what he has, though, because if he does have adenocarcinoma of the pancreas, it’s game over, particularly with liver metastases. Indeed, if I were counseling a 90 year old with stage IV pancreatic cancer, my recommendation would be palliative care and hospice. I know that, by all reports, Carter is one of the healthiest, most active 90 year olds you’ll ever see.
I lean towards thinking about Jimmy Carter’s case more this way. When we’re talking about a 90 year old, influence of family history and genetics are far less likely to be a cause of cancer than they are if the man develops cancer at age 40. Most likely, Carter developed one of the cancers of the elderly, cancers that increase in incidence as a man ages. Of course, the most common cancer in elderly men is prostate cancer, but this is not a typical presentation of prostate cancer; so I doubt that it’s that. Let’s look at the presentation. What do we know about Carter’s presentation.
For one thing, we do know that in May he had to cut short a visit to Guyana to monitor elections there because he was “unwell.” No details were given as to his symptoms. Now, four months later, he has announced that he has cancer. From the description, it sounds as though a small mass was found in his liver, and a surgeon removed it. Presumably, a medical workup for Carter’s symptoms led to a liver ultrasound or a CT of the abdomen that found the mass. We don’t know what his symptoms were, but presumably they were of a nature that pointed to an intraabdominal problem. Perhaps he had abnormalities in his liver function tests. We don’t know, but given what we do know these are reasonable speculations, educated guesses if you will.
Then there’s the issue of the surgery. This stuck out in the news stories I read because normally liver masses are biopsied using a large core needle under ultrasound or CT guidance, rather than surgery, particularly in a 90 year old. Here’s where it’s important to know the terminology. The statement says that the mass was “removed,” not biopsied; so the procedure done earlier this month must have been surgery, either laparoscopic or open, most likely a wedge resection of the liver, ± intraoperative ultrasound guidance. But why surgery? Most likely an ultrasound or CT-guided core needle biopsy was attempted. Either the mass was not amenable to it or the sample was nondiagnostic. Alternatively, the mass was in an anatomic location that was not amenable to percutaneous (through the skin) biopsy.
So now we know it’s cancer. What really will determine how well Carter can do is what kind of cancer it is. It’s improbable that this is a lymphoma or leukemia, because they usually don’t first manifest themselves as a liver mass. Also, I’d be willing to bet that if it were a lymphoma or leukemia, Carter would have revealed more because these are tumors that are (mostly, depending on the specific cancer) treatable for cure. True, they’re much less so in a 90 year old, but they’re still treatable.
That leaves solid tumors. We’ve already (mostly) ruled out prostate cancer. It could be pancreatic cancer, which would be very, very bad. But what’s the most likely diagnosis in an elderly man? There are two broad possibilities. Either this is liver cancer or this is a metastasis. Jimmy Carter didn’t have any risk factors for liver cancer (alcohol abuse, hepatitis B or C, etc.) that we know of; so a primary liver cancer is unlikely. Moreover, note how the tumor is described as a mass in the liver and that it is in “other parts” of Carter’s body. This suggests widely metastatic cancer, but Carter didn’t specify where the cancer had spread to. Think about it, though. Carter almost certainly had a chest x-ray and a CT scan of at least the abdomen. If the tumor was in the lungs or elsewhere outside of the abdomen, it was apparently not detected before surgery; otherwise the doctors would have known Carter probably had cancer before they operated.
Putting it all together, though, I conclude that the most likely culprit is a cancer arising in the bowel that has metastasized to the liver and elsewhere. It started when Carter became ill four months ago. His symptoms probably persisted after he arrived home from Guyana, and as a result he underwent a workup. Thinking about it more, I give you my best guess about what happened. Obviously, Carter’s workup must have found a liver mass. Most likely, it found nothing else. So a core biopsy was very likely done but was nondiagnostic. I briefly considered the possibility that the biopsy showed cancer and surgeons decided to try to remove the cancer because it was a solitary lesion but rejected that possibility based on the failure to announce that Carter had cancer in June or July, but admittedly I could be wrong about this (as I could be wrong about most of my speculation).
So next, to get a diagnosis, surgeons likely did a liver biopsy or wedge resection but were met with a nasty surprise, tumor deposits in the peritoneal cavity, a process known as carcinomatosis, where the tumor spreads along the surface of the peritoneal membrane. Carcinomatosis, when in its early stages, is often not picked up on abdominal CT scan, when the individual tumor deposits are still small, which is why I referred to it as a “surprise.” Basically, the overall story is consistent with what oncologists call adenocarcinoma of unknown primary, which is basically adenocarcinoma diagnosed as a metastasis without a primary site having been identified.
Assuming I’m correct (and I might well not be), the biggest question is: From where in the bowel did this cancer originate? It’s an important question because it will determine how well he might do and how long he might survive with this cancer, which sounds as though it’s stage IV. Moreover, unlike when I rotated on the oncology service many years ago, the tools of immunohistochemistry and various other tests have advanced to the point where it is often possible to identify with a high degree of probability where the cancer originated. Overall, the median survival of a diagnosis of carcinoma of unknown primary for all comers ranges from 6-18 months, but that can vary depending on the primary. Again, if Carter does have indeed pancreatic cancer, sadly, his prognosis is dismal. That’s the worst it could be. Second worst would be gastric cancer or esophageal cancer, which also portend dismal prognoses, but somewhat less dismal than pancreatic cancer. The best case scenario is that this is colorectal cancer, preferably colon cancer, metastatic to the liver. The reason is that, with newer chemotherapy regimens plus Avastin, survival in metastatic colon cancer has more than tripled.
As regular readers know (or at least as I hope they know), when indulging my penchant for analyzing news reports of famous people with cancer and analyzing alternative cancer cure testimonials, I never forget that the person with cancer is a person. I’m also very careful to try to be humble about my conclusions. For instance, in the case of Jimmy Carter, I know that I’m making some assumptions. If those assumptions are correct, very likely the conclusions derived from my speculation are correct. If my assumptions are not correct, then I could be way off base.
I must admit that, as a cancer surgeon and divorced from the knowledge of who was the subject of all the news stories, when I read stories that describe a 90 year old man with cancer in the liver and elsewhere, I cringed. It’s not a good scenario, no matter how you slice it. The Carter family has my sympathy—and my hope.
from ScienceBlogs http://ift.tt/1L7fadF
If there’s one thing about how cancer is discussed in the media that drives me absolutely bonkers, it’s how seemingly whenever a public figure announces that he has cancer information is rationed to the point where the announcement is basically meaningless. I can understand why someone might not want to disclose more about his disease than he has to, and maybe I’m just too nosy and curious about these stories. Being a cancer surgeon and all, though I find such stories an irresistible temptation to see if I can figure out what’s going on. Such skills were honed in my analysis of quack cancer cure testimonials, where I learned to tease out as much information as I can and make reasonable, evidence-informed inferences about what is probably really going on, as opposed to what the patient claims is going on. Such skills have served me particularly well in my analyses of cancer cure testimonials by patients of Stanislaw Burzynski, by patients who underwent surgery but claim alternative medicine is what cured them, and patients claiming marijuana cured them (or, as I like to call them, “cannabis cures cancer” testimonials). Such skills also allowed me to deduce, fairly accurately as it turns out, what really happened in Steve Job’s case.
So when it was announced yesterday that former President Jimmy Carter has “cancer,” it was very hard for me to turn off that skill set that drives me to delve into stories like this and try to figure out what’s going on. I’ll be the first to admit that Jimmy Carter wasn’t one of my favorite Presidents. Maybe it was because I was in high school most of his presidency, and the Iranian hostage crisis had a profound effect on my politics at an early age. As I’ve gotten older I’ve realized that perhaps I was too hard on Jimmy Carter. Whether I was too hard on him or not, though, I always rather agreed with the characterization of Carter as the “best ex-President we’ve ever had,” based on his charitable work and activism after leaving office. Regardless of my political opinion of him, I sincerely hope his cancer is treatable and that he does well. He might be 90 years old, but he’s still a force and could still do a lot more.
Here’s what we know:
Former President Jimmy Carter has cancer, and it has spread to other parts of his body, he announced Wednesday.
Carter, 90, had a “small mass” removed from his liver during surgery earlier this month. At the time, he received a prognosis for a full recovery.
But he said Wednesday in a brief statement that “recent liver surgery revealed that I have cancer that now is in other parts of my body.”
It was not clear where the cancer originated or where it had spread. Carter’s family, however, has a history of pancreatic cancer, which CNN correspondent Sanjay Gupta said could be afflicting the former president. Carter lost his father, brother and two sisters to the disease. His mother had breast cancer, which later moved to her pancreas.
“If you’ve got pancreatic cancer, you die. Absolutely,” Carter told CNN’s Larry King in 2008.
Personally, I think the pancreatic cancer reference is probably a red herring, despite all the attention news media medical correspondents are heaping on it. Yes, I know that for a time Carter was undergoing regular CT scans, but there’s not a lot of evidence that that approach is likely to prevent death, even in someone with a strong family history of pancreatic cancer. That being said, sure, it’s possible that Carter has pancreatic cancer. I hope that’s not what he has, though, because if he does have adenocarcinoma of the pancreas, it’s game over, particularly with liver metastases. Indeed, if I were counseling a 90 year old with stage IV pancreatic cancer, my recommendation would be palliative care and hospice. I know that, by all reports, Carter is one of the healthiest, most active 90 year olds you’ll ever see.
I lean towards thinking about Jimmy Carter’s case more this way. When we’re talking about a 90 year old, influence of family history and genetics are far less likely to be a cause of cancer than they are if the man develops cancer at age 40. Most likely, Carter developed one of the cancers of the elderly, cancers that increase in incidence as a man ages. Of course, the most common cancer in elderly men is prostate cancer, but this is not a typical presentation of prostate cancer; so I doubt that it’s that. Let’s look at the presentation. What do we know about Carter’s presentation.
For one thing, we do know that in May he had to cut short a visit to Guyana to monitor elections there because he was “unwell.” No details were given as to his symptoms. Now, four months later, he has announced that he has cancer. From the description, it sounds as though a small mass was found in his liver, and a surgeon removed it. Presumably, a medical workup for Carter’s symptoms led to a liver ultrasound or a CT of the abdomen that found the mass. We don’t know what his symptoms were, but presumably they were of a nature that pointed to an intraabdominal problem. Perhaps he had abnormalities in his liver function tests. We don’t know, but given what we do know these are reasonable speculations, educated guesses if you will.
Then there’s the issue of the surgery. This stuck out in the news stories I read because normally liver masses are biopsied using a large core needle under ultrasound or CT guidance, rather than surgery, particularly in a 90 year old. Here’s where it’s important to know the terminology. The statement says that the mass was “removed,” not biopsied; so the procedure done earlier this month must have been surgery, either laparoscopic or open, most likely a wedge resection of the liver, ± intraoperative ultrasound guidance. But why surgery? Most likely an ultrasound or CT-guided core needle biopsy was attempted. Either the mass was not amenable to it or the sample was nondiagnostic. Alternatively, the mass was in an anatomic location that was not amenable to percutaneous (through the skin) biopsy.
So now we know it’s cancer. What really will determine how well Carter can do is what kind of cancer it is. It’s improbable that this is a lymphoma or leukemia, because they usually don’t first manifest themselves as a liver mass. Also, I’d be willing to bet that if it were a lymphoma or leukemia, Carter would have revealed more because these are tumors that are (mostly, depending on the specific cancer) treatable for cure. True, they’re much less so in a 90 year old, but they’re still treatable.
That leaves solid tumors. We’ve already (mostly) ruled out prostate cancer. It could be pancreatic cancer, which would be very, very bad. But what’s the most likely diagnosis in an elderly man? There are two broad possibilities. Either this is liver cancer or this is a metastasis. Jimmy Carter didn’t have any risk factors for liver cancer (alcohol abuse, hepatitis B or C, etc.) that we know of; so a primary liver cancer is unlikely. Moreover, note how the tumor is described as a mass in the liver and that it is in “other parts” of Carter’s body. This suggests widely metastatic cancer, but Carter didn’t specify where the cancer had spread to. Think about it, though. Carter almost certainly had a chest x-ray and a CT scan of at least the abdomen. If the tumor was in the lungs or elsewhere outside of the abdomen, it was apparently not detected before surgery; otherwise the doctors would have known Carter probably had cancer before they operated.
Putting it all together, though, I conclude that the most likely culprit is a cancer arising in the bowel that has metastasized to the liver and elsewhere. It started when Carter became ill four months ago. His symptoms probably persisted after he arrived home from Guyana, and as a result he underwent a workup. Thinking about it more, I give you my best guess about what happened. Obviously, Carter’s workup must have found a liver mass. Most likely, it found nothing else. So a core biopsy was very likely done but was nondiagnostic. I briefly considered the possibility that the biopsy showed cancer and surgeons decided to try to remove the cancer because it was a solitary lesion but rejected that possibility based on the failure to announce that Carter had cancer in June or July, but admittedly I could be wrong about this (as I could be wrong about most of my speculation).
So next, to get a diagnosis, surgeons likely did a liver biopsy or wedge resection but were met with a nasty surprise, tumor deposits in the peritoneal cavity, a process known as carcinomatosis, where the tumor spreads along the surface of the peritoneal membrane. Carcinomatosis, when in its early stages, is often not picked up on abdominal CT scan, when the individual tumor deposits are still small, which is why I referred to it as a “surprise.” Basically, the overall story is consistent with what oncologists call adenocarcinoma of unknown primary, which is basically adenocarcinoma diagnosed as a metastasis without a primary site having been identified.
Assuming I’m correct (and I might well not be), the biggest question is: From where in the bowel did this cancer originate? It’s an important question because it will determine how well he might do and how long he might survive with this cancer, which sounds as though it’s stage IV. Moreover, unlike when I rotated on the oncology service many years ago, the tools of immunohistochemistry and various other tests have advanced to the point where it is often possible to identify with a high degree of probability where the cancer originated. Overall, the median survival of a diagnosis of carcinoma of unknown primary for all comers ranges from 6-18 months, but that can vary depending on the primary. Again, if Carter does have indeed pancreatic cancer, sadly, his prognosis is dismal. That’s the worst it could be. Second worst would be gastric cancer or esophageal cancer, which also portend dismal prognoses, but somewhat less dismal than pancreatic cancer. The best case scenario is that this is colorectal cancer, preferably colon cancer, metastatic to the liver. The reason is that, with newer chemotherapy regimens plus Avastin, survival in metastatic colon cancer has more than tripled.
As regular readers know (or at least as I hope they know), when indulging my penchant for analyzing news reports of famous people with cancer and analyzing alternative cancer cure testimonials, I never forget that the person with cancer is a person. I’m also very careful to try to be humble about my conclusions. For instance, in the case of Jimmy Carter, I know that I’m making some assumptions. If those assumptions are correct, very likely the conclusions derived from my speculation are correct. If my assumptions are not correct, then I could be way off base.
I must admit that, as a cancer surgeon and divorced from the knowledge of who was the subject of all the news stories, when I read stories that describe a 90 year old man with cancer in the liver and elsewhere, I cringed. It’s not a good scenario, no matter how you slice it. The Carter family has my sympathy—and my hope.
from ScienceBlogs http://ift.tt/1L7fadF
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