Respectful Insolence

It’s been a bad few days.

A mere four days after Elizabeth Edwards announced that her breast cancer had recurred in her rib, with an update the other day saying that the apparently was also another lesion in in her hip, I learn from a commenter and multiple other sources that White House Press Secretary Tony Snow has suffered a recurrence of his colon cancer. Apparently, it has spread to the liver:

CBS/AP) Presidential spokesman Tony Snow’s cancer has returned and spread to his liver and elsewhere in his body, shaken White House colleagues announced Tuesday. They said he told them he planned to fight the disease and return to work.

“He is not going to let this whip him, and he’s upbeat,” President Bush said of his press secretary. “And so my message to Tony is, ‘Stay strong; a lot of people love you and care for you and will pray for you.’”

Snow, 51, had his colon removed in 2005 and underwent six months of chemotherapy after being diagnosed with colon cancer. He underwent surgery on Monday to remove a growth in his abdominal area, near the site of the original cancer.

Doctors determined the growth was cancerous and the cancer had metastasized, or spread, to the liver.

The cancer has attached to the liver but is not in the liver, White House deputy press secretary Dana Perino said.


I’m not a big fan of Tony Snow, but I wouldn’t wish this on anyone. In marked contrast to Elizabeth Edwards, Snow’s prognosis is almost certainly not good. Unlike Elizabeth Edwards, who has, as far as anyone can tell, metastases to the bone only, a clinical situation where she has a good chance of living more than five years (as was pointed out to me as a mild retort that my original survival estimate for her was probably too pessimistic), Snow’s median expected survival is much shorter. Once again, before I start speculating, I have to throw in the usual disclaimer that I haven’t examined Tony Snow and my speculations are based solely on media reports of his condition and where the tumor was. Indeed, the reports were initially confusing, and that made a big difference. Original reports led me to believe that Snow’s tumor had recurred in the pelvis and metastasized to the liver itself, but the above report states that it had in the abdomen, attached to, but not in the liver.

You might ask why that makes a difference, and that’s a reasonable question. If, as I originally thought, he had had a recurrence in pelvis and metastasis to the liver, the cancer might still have been curable. One of the unusual things about colon cancer is that, in certain select cases, metastatic disease is still potentially curable. The “best” situation occurs when there is an isolated single metastasis to the liver that can be resected. In this clinical situation, liver resection can result in five year survival rates as high as 30-40% in some centers that do a lot of this surgery. Over the last decade or so, surgeons have been increasingly pushing the limit and resecting liver metastases in patients with larger lesions and even multiple lesions. The rule of thumb used to be that four metastases would be the limit for the number, and the size would be limited mainly by ability to take the tumor out by resecting one or two lobes of the liver. Disease in more than one lobe used to be a contraindication, but sometimes even now aggressive surgeons will go after multilobar disease. In the case of a pelvic recurrence, if the lesion could be completely resected, long term survival is still sometimes possible, although sometimes it requires a truly nasty operation known as a pelvic exenteration. In a pelvic exenteration, the entire pelvic contents are removed (rectum, bladder, and, if the patient is a woman, uterus and ovaries). That leaves the patient with a permanent colostomy or ileostomy and a pouch made of small bowel into which the urine drains (a “bag for urine and a bag for stool”), along with having the rectum sewn shut. It’s a nasty procedure and almost impossible to study in randomized trials, making it somewhat controversial among surgeons how useful this operation is, whether its relatively small benefit is worth the morbidity, and whether the apparent survival benefit is mostly due to selection bias, whereby only patients healthy enough to tolerate the surgery, who would presumably do better than average anyway, are selected for surgery. Even so, it is clear that some patients can have long term survival with this operation.

Surgeons tend to like colorectal cancer because it is one particular cancer that only surgery can cure. Chemotherapy alone won’t do it, nor will radiation. Only surgery. and if the tumor cannot be removed completely surgically, it is incurable. If the tumor cannot be resected, there are very close to zero survivors at five years. Sadly, that seems to be the case with Tony Snow, at least as far as I can tell from the media reports. Like the vast majority of colon cancer patients whose tumors recur, it appears that he is not a candidate for surgical resection. I will again admit that I’m speculating here, and perhaps reading between the lines a bit. For one thing, if Tony Snow had isolated liver metastases amenable to surgical removal, I would presume that it would have been reported that he was either going to undergo or had undergone a liver resection. No such report was made that I could find, and it was widely reported that Snow would be undergoing chemotherapy, which is usually reserved for unresectable disease, although it is also given after a successful liver resection for colon cancer metastases. Also remember, like Elizabeth Edwards, Tony Snow has access to the very best medical and surgical care in the world and would presumably have access to the very best liver and gastrointestinal surgeons if his tumor were resectable. In fact, I’m going to go out on a limb a little here and speculate that the “growth” that was found was probably carcinomatosis, which is the growth of tumor along the peritoneal lining that covers our abdominal organs and that a nodule was found on the surface of his liver. Carcinomatosis can range from a single nodule on the peritoneum only a few millimeters in diameter, to many small nodules (known as “peritoneal studding”), to golfball- or softball-sized tumors all over the abdomen, and it is usually unresectable and incurable, except in rare cases because the presence of one nodule usually indicates that there is disease elsewhere. True, there are very aggressive surgeons, such as Dr. Paul Sugarbaker, who does massive tour de force operations that strip as much of the cancer as possible from the peritoneum, after which the abdomen is bathed in hyperthermic chemotherapy. (Indeed I saw a presentation by Dr. Sugarbaker just a couple of weeks ago.) However, this procedure is still viewed by the vast majority of surgeons as experimental, and it’s fraught with the danger of complications. As with pelvic exenteration, it’s unclear whether its apparent value is due more to selection bias than anything else, and you can find surgeons arguing about this very issue at various surgical meetings. For liver-only disease, sometimes an infusion pump will be inserted to infuse chemotherapy directly into the liver; this method is being used less, though, because the newer chemotherapy regimens have much improved results. Other modalities for surgically unresectable liver disease include freezing the tumors or radiofrequency ablation.

So what is the expected survival? Well, it’s no longer quite as grim as what Sid Schwab has stated (six months). These days, using a combination of chemotherapy and antiangiogenic therapy (Bevicuzimab) results in a median survival of around 20 months, although five year survivors remain uncommon. Not fantastic, but considerably better than it used to be. It’s also considerably worse than what can be expected for breast cancer metastatic only to bone, where five year survival rates may approach 50%. It is true that long term survival is possible in patients with metastatic colorectal cancer, as Sid Schwab points out in an anecdote, but it is uncommon, with few surviving five or ten years.

I could be entirely wrong in my speculation, but I suspect not. At the very least, Snow appears to have a recurrence that is not surgically resectable. Of course, it’s possible that Snow has a better prognosis than that. If his disease volume is low, his prognosis might be somewhat better. If all grossly visible disease has been successfully resected, he would likely have a somewhat better prognosis. If his disease can be resected completely in a second operation, his prognosis would be better. But even the best prognosis he could possibly have is considerably worse than that of Mrs. Edwards.

It’s been a bad week for politicians with cancer. Two prominent politicians, one from each party, both of whom had cancer pretty close to the same time and both of whom thought they had beaten the disease, were rudely disabused of that notion by an implacable foe. As much as we have improved our treatments over the last three decades, to the point where for the first time we are seeing real improvements in survival in common tumors, there is still much to be done, much to be understood. Even for early stage cancer, there are still casualties.

Elizabeth Edwards and Tony Snow remind us of that.

ADDENDUM: I couldn’t find out earlier when I wrote this what stage Tony Snow was at when originally diagnosed. I heard over the radio this morning that it was stage III, which means lymph nodes were involved. Depending on whether he was stage IIIA, B, or C at the time of diagnosis, that could mean an expected five year survival anywhere between 30% (stage IIIC) and 50-60% (stage IIIA) so, unfortunately, Snow’s recurrence is not unusual in colon cancer patients.

ADDENDUM #2: The Cheerful Oncologist has more on this case. One thing I note from the story is how it was thought that this was a “benign growth” in Snow’s abdomen, something I’ve seen in multiple news reports now. I’m sorry, but any “growth” in the abdomen of a patient with a recent (less than five years ago) history of colon cancer has to be considered a recurrence of his cancer until proven otherwise. I’m guessing this is just more reporting weirdness, because I doubt his doctors told him it was probably benign without having biopsied it first. Again, I don’t have all the information, and making medical speculations based on news reports is a very perilous business indeed.

Comments

  1. #1 Mark
    March 28, 2007

    So, if I understand correctly (from your post), Snow’s original diagnosis was that lymph nodes were involved, and this occurred in 2005. And just now it was determined that he had an abdominal “growth.” I am particularly interested in cases like this because my wife had colon cancer surgery over five years ago and has been checking out clear since. Hearing about cases like this gives me chills.

  2. #2 Orac
    March 28, 2007

    One “good” thing about colon cancer (if there can be such a thing) is that, unlike breast cancer, which can recur as long as 10-20 years after original treatment or sometimes even longer, the vast majority of colon cancer recurrences happen within the first five years (actually, within the first three). So, to try to reassure you, if your wife has made it out past five years since her cancer, her chances of remaining colon cancer free for the rest of her life are quite good.

  3. #3 Amy Alkon
    March 28, 2007

    My friend Cathy Seipp, a nonsmoker who never worked with smokers, and did all the stuff you’re supposed to, just lost her battle with lung cancer:

    http://www.advicegoddess.com/archives/2007/03/cathy_seipp_2.html

    I’m wondering why we don’t detect more cancer early on than we do. (And P.S. with a cancer factory family, my [former!] primary care physician at Kaiser, my HMO, denied me anything more than a mammogram until I fought like hell, then she sent me to a breast surgeon at Kaiser to let him decide, and he heard my family history, scheduled me for regular ultrasounds, and decided I needed BRCA testing [negative!].) But, I’m an articulate, pushy broad — a newspaper columnist — what of the people who can’t push like I did? Do their cancers go undetected?

    As for so many cancers — can you talk about why they get as far as they do? Are there any advances being made in detection?

  4. #4 Mark
    March 28, 2007

    Thanks. I needed that.

  5. #5 Dianne
    March 28, 2007

    Surgeons tend to like colorectal cancer because it is one particular cancer that only surgery can cure. Chemotherapy alone won’t do it, nor will radiation

    I’d like to make a small addendum to this statement. Chemotherapy alone won’t cure colon cancer, but giving chemotherapy after surgery in moderately advanced (stage C) colon cancer signficantly reduces the chances that the cancer will recur. Furthermore, pre-operative radiation and chemotherapy can reduce the size of rectal cancer, changing it from not completely resectable to resectable in some cases and making the surgery needed less radical in others. I mention this just in case someone reading the post gets the wrong idea and thinks that chemo is not useful in colon cancer–not at all the message you want to send, I think. It is useful and sometimes even necessary, but it is not sufficient to cure colon cancer. For that surgery is needed.

  6. #6 dogscratcher
    March 28, 2007

    Kind quasi-off-topic, but thought you might find this interesting:

    http://www.newscientist.com/article.ns?id=mg19325973.800&feedId=online-news_rss20

  7. #7 Coin
    March 28, 2007

    Thanks for these informative writeups.

  8. #8 Graculus
    March 29, 2007

    Can I just point out that neither Tony Snow or Elizabeth Edwards are politicians (because I’m a pedantic SOB). Elizabeth Edwards is the wife of a politician, and Tony Snow is a shill for politicians. I despise him, but I would not wish this on him. The duck pit requires healthy inmates.

  9. #9 Claudia
    March 29, 2007

    My husband had colon rectal cancer 5 years ago and now he has a Grapefruit size tumor on the outside, leaning into, the liver. He doing chemo and will have surgery. We have been told it is from the orgional colon cancer.

    Why didn’t our doctors ask us to have yearly pet scans along with colonoscopy’s? Maybe this tumor could have been seen before it became so LARGE.

    Why don’t we have doctors that tell us of some “preventative” tests, cat scan, pet scan, ect. That would see these “tumors/spots”. Seems like that should be easy enough to advise their patients….

  10. #10 Amy Alkon
    March 29, 2007

    Claudia, the answer I’m sometimes given is that it would be “too expensive” (vis a vis caring for somebody on cancer? I wonder) and that there are too many false positives.

    My fight with Kaiser started when I asked my then-primary care physician for an MRI, due to my being up there in risk factors. (My best friend is an epidemiologist and public health researcher [who, among other things, teaches statistics to doctors in his professorial position]) and even pulled studies to support my position. Turns out I might’ve been right about needing an MRI, if you read the news this week, due to family history of cancers and breast composition.

  11. #11 Denny Read
    March 30, 2007

    I have been stage 4- twice now with metastatic colon cancer to my lung and to my liver.
    Doctors (especially Oncologists) have told me to keep up my chemo schedule and it may help to prolong my life. I had a spot on my lung (1 cm) and 5 spots on my liver (the largest being just over 5 cm). As you can imagine this news was devastating. I decided to not take these professionals opinion as the final word. I requested a second opinion at Mayo Clinic in Minnesota. I knew my chances and let the people at Mayo know I knew my chances. I realized they don’t usually do surgery on persons with more then three spots on their liver.
    This is where I got really lucky. I was given a surgeon that is by far the BEST and most aggressive Surgeon I have ever met ( Dr Que ).
    SHE advised me if I was willing to try the surgery, she was also willing. I was 56 years old at the time. Never have I received such care from a Surgeon. She is a small woman but a GIANT in the operating room.
    This all happened 3 years ago. They thought it had returned to my pancreas and I underwent another surgery last year with Dr. Que. She was prepared to do an even more risky procedure called ” The Whipple Method ” but luckily what they were seeing was my liver regenerating and it sent out an offshoot growth (new little liver) which protruded over my pancreas. Dr. Que CRIED with happiness for me.
    The multiple scans and tests that have been run since the liver surgery have all been negative for any cancer, ANYWHERE.

  12. #12 Theo Bromine
    March 31, 2007

    quoth Orac:
    Other modalities for surgically unresectable liver disease include freezing the tumors or radiofrequency ablation.

    Does that imply that resection is preferable and/or has a better outcome than RF ablation? I ask because a relative of mine recently (ie just over a week ago) had an RF ablation treatment, and, as I understand it, was presented with the following 3 scenarios in order of preference: 1) RF ablation followed by targeted chemo; 2) liver resection + chemo; 3) if the cancer was so advanced that neither (1) nor (2) were possible, close and provide comfort measures.

    The implication was that the RF ablation was preferable to the resection.

  13. #13 eve leavitt
    April 18, 2007

    my husband who is 42 just recieved the thumbs up from his first PET scan for post chemo/colon resection stage 3b colon cancer. He will have PET scans every 3 months for a year and colonoscopies every 4 months for a year.
    When I read the 5 year survival rates I am still freaked out…
    I don’t hear much about what can be done to prevent recurrance through diet…I heard cancer loves sugar ?…
    He needs to loose 40lbs but his oncologist hasn’t said anythig about his being over weight AND I don’t want to nag him. But if a low fat and low sugar diet will help….
    I’ll nag the heck out of him.
    His doctor did prescribe folic acid, asprin and calcium as a preventative therapy.
    I guess my real question is ..How can I help save my husbands life?….he is my hero, and an amazing man.

  14. #14 V Johnston
    May 19, 2007

    Denny Read,
    My father, like you, is also 56 and his colon cancer has metastasized to his lung (3 years after initial diagnosis). The spot on his lung has shrunk to 1.1 cm after 4 weeks of chemo. Several lymphnodes outside of the lung are also cancerous. He is scheduled to have his entire right lung removed. How large were your lung tumors and did you have a resection or complete removal of your lung? Did you have any follow-up chemo treatments post op?
    Thank you for the great post.