Respectful Insolence

Over the weekend, the Wall Street Journal reported that the reason for Apple CEO Steve Job’s five month medical leave of absence from Apple is that he needed a liver transplant, which, according to the story, he underwent a couple of months ago in Memphis. In my discussion, I assumed, for the most part, the most likely clinical scenario, namely that Steve Jobs’ insulinoma had metastasized to his liver and that the liver transplant had been done for that indication, but, as some pointed out, it was possible that Jobs had somehow fried his liver without his tumor having metastasized. Unlikely, true, but possible. Unfortunately, news coming out over the last couple of days, while confirming that Jobs did indeed undergo a liver transplant, only shed a little more light on what happened and still leave a lot of questions. For instance, late Tuesday Methodist University Hospital in Memphis issued a press release:

James D. Eason, M.D., program director at Methodist University Hospital Transplant Institute, chief of transplantation and professor of surgery at the University of Tennessee Health Science Center confirmed today, with the patient’s permission, that Steve Jobs received a liver transplant at Methodist University Hospital Transplant Institute in partnership with the University of Tennessee Health Science Center in Memphis.

Mr. Jobs underwent a complete transplant evaluation and was listed for transplantation for an approved indication in accordance with the Transplant Institute policies and United Network for Organ Sharing (UNOS) policies.

He received a liver transplant because he was the patient with the highest MELD score (Model for End-Stage Liver Disease) of his blood type and, therefore, the sickest patient on the waiting list at the time a donor organ became available. Mr. Jobs is now recovering well and has an excellent prognosis.

Unfortunately, this press release leaves as many questions unanswered as it answers.

So, first off, we know that Steve Jobs did undergo a liver transplant. However, the indication is still unclear. The near universal assumption among medical experts who have been interviewed about his case is that the transplant was done for multiple liver metastases that were either too numerous or encompassed too many lobes to be resected. However, this press release implies that Jobs was sick. Real sick. The implication is that he had end stage liver disease, and the hospital points out that he was the sickest patient on the list with his blood type at the time the organ became available. Certainly I did in my post on the subject. So does the expert that the New York Times interviewed:

“If you were to postulate why he did it, I think the most likely reason would be that he had liver metastasis,” said Dr. Richard M. Goldberg, an expert on pancreatic cancer at the University of North Carolina, Chapel Hill, who is not involved in Mr. Jobs’s treatment.

Though other, noncancerous types of liver disease could also have led to a transplant, experts say cancer is the most likely explanation.

The liver is the most common site for the spread of pancreatic cancer, especially the rare kind that Mr. Jobs had, known as a neuroendocrine tumor, Dr. Goldberg said. That type of tumor tends to be slow-growing and far more treatable than the more common type of pancreatic cancer, which can be fatal within months.

When neuroendocrine tumors do metastasize, Dr. Goldberg said, they often spread only to the liver, rather than all over the body, and a transplant may be recommended.

Often, though, when tumors spread to the liver, surgeons can treat them by removing just part of the liver. The fact that Mr. Jobs needed a transplant suggests that he might have had diffuse disease throughout his liver, something that does not bode well, Dr. Goldberg said.

“The prognosis for somebody with metastatic liver disease is not nearly as good as for somebody who has disease confined to the pancreas,” Dr. Goldberg said.

“I think this confirms the speculation that there was more going on than had been previously acknowledged,” he said, “but it still doesn’t really tell us where things are likely to go from here.”

Indeed. According to the New York Times report and an AP report, Jobs was the “sickest” patient on the list at the time. Specifically, he had the highest Model for End-Stage Liver Disease (MELD) score at the time of transplant. The MELD score is a liver failure scoring system implemented in 2002 and used to prioritize patients on the transplant list. Unlike the case for kidney transplants, which can be put off for a long time because a patient can always remain on dialysis even if his kidneys do not function at all, in the case of liver transplants, there are no ways to temporize very long. Consequently, unlike the case for kidney transplants, where first come first served is closer to the model used, for liver transplants severity of the patient’s liver failure . Enter the MELD score, which can be calculated using this online calculator. It’s a straightforward equation:

MELD Score = 0.957 x Loge(creatinine mg/dL) + 0.378 x Loge(bilirubin mg/dL) + 1.120 x Loge(INR) + 0.6431

Basically, this equation is like a lot of other disease severity scores in that it models mortality rates and fits them to an equation involving key parameters. This equation works out to an expected three month in-hospital survival by MELD score of:

  • 40 or more – 100% mortality
  • 30-39 – 83% mortality
  • 20-29 – 76% mortality
  • 10-19 – 27% mortality
  • <10 - 4% mortality

Now, I know what you’re thinking. There’s no spot for liver cancer. That’s where things get dicey. One of the criticisms of the original MELD score is that it penalizes patients with hepatocellular cancer, who may be doing fairly well and have, based on biochemical parameters alone, a low MELD score. The reason is that the MELD score was designed primarily to stratify patients with nonmalignant end stage liver disease. To get around this problem, various adjustments to the MELD score have been proposed. However, virtually all of them are based on data for hepatocellular carcinoma (HCC), for which liver transplantation can be curative if there is no disease anywhere but in the liver. The issues involved were actually fairly well discussed in this Medscape article. Here’s what it says about MELD scores and HCC:

Patients with hepatocellular carcinoma may initially have preserved synthetic liver function that will not be prioritized well by MELD score calculation, thus underestimating their urgency. Prior to implementation of the MELD score as the allocation method, there have been some attempts to mathematically calculate risk of HCC progression to estimate how this factor would contribute to the new allocation schema.[26] Previously HCC-adjusted MELD scheme stratified patients with T1 HCC (single lesion≤1.9 cm) with a MELD score equivalent to a 15% (most recently adjusted to 8%) 3-month mortality, and T2 HCC (one nodule 2-5 cm, or two to three nodules all ≤3 cm) with a score equivalent to a 30% (now adjusted to 15%) 3-month mortality. Additional points equivalent to a 10% increase in pretransplant mortality are also given every 3 months until the patient is transplanted or no longer suitable for transplant. T3 HCC (one nodule >5 cm or two to three nodules at least one >3 cm) and T4 HCC (four or more nodules of any size or gross vascular invasion) are not eligible for listing.[3] There is criticism that this schema was made without much prior data on the pattern and rate of dropouts, and that liver cancer patients may have been unfairly given an advantage. Efforts to verify the fairness of the scheme suggest that further refinement is still needed.[27,28]

The problem with applying this to Jobs’ case is that there is very little evidence to guide a valid method of estimating a MELD score for someone with metastases to the liver from a neuroendocrine tumor. It’s essentially flying blind; actually, it’s almost a pure guess. There is, of course, one case in which applying MELD to a patient like Steve Jobs, and that would be if his liver metastases were so widespread that they were causing liver failure severe enough to give him a moderate to high MELD score even without the correction for malignancy, which in the case of an insulinoma is nothing more than a guesstimate. Given that neuroendocrine tumors are usually fairly indolent and slow growing, it’s hard to see how one can even estimate three month mortality rates. In any case, if it is true that Jobs had a high MELD score without consideration of malignancy, then before his transplant Jobs was much, much sicker than anyone had let on. He could very well have been near death’s door. If this wasn’t the case, then I have a hard time understanding how Jobs’ doctors came up with a high MELD score for his neuroendocrine tumor. My guess is that Jobs really was in serious end stage liver disease, and, given the limited information, that’s all it is–a guess. If that is the case, and his end stage liver disease was due to his liver being chock full of insulinoma, then I’d be very worried that it won’t be long before it recurs in the new liver.

In the AP article, a surgeon whom I used to know (and wouldn’t he be surprised if he ever found out that he actually knew an obnoxious pseudonymous blogger?) speculates:

Patients in such bad shape would get priority on any organ transplant list, and if Jobs did have a recurrence of cancer, that would give him even higher preference, said Dr. Roderich Schwarz a pancreatic cancer specialist at the University of Texas-Southwestern Medical Center in Dallas.

Liver transplants in such cases can cure the cancer, although patients remain at risk for another recurrence, Schwarz said. In addition, the powerful immune-suppressing medicine they must take to keep the body from rejecting the transplanted liver also can increase their risks for recurrence.

Either way, it’s a bad situation. The best I can reconstruct it is that Jobs probably had bad end stage liver disease with liver metastases. His short-term prognosis after his liver transplant is most likely quite good. However, without knowing how extensive his liver metastases were, it’s almost impossible to speculate about his long term prognosis, especially in the absence of so little data for the efficacy of liver transplant in producing long term survival when used to treat liver metastases of a neuroendocrine tumor.

As for the ethical issues regarding this transplant that I expressed a bit of discomfort with, that blogging private surgeon from my old stomping grounds from residency, Buckeye Surgeon, takes issue with such complaints. He’s actually mostly right. Jobs did nothing illegal, even if he was listed for transplant in multiple states. Where Buckeye Surgeon goes a bit wrong is in asserting that it’s not possible to game the system. True, in most cases it’s not. The criteria are based on biochemical measures of liver failure; i.e., hard numbers. However, in the case of malignancy, physician judgment comes in as to how urgent the transplant is. For HCC, there are reasonable, albeit incomplete, guidelines. However, in the case of a neuroendocrine tumor, where there is so little data on whether or not transplantation can result in long term survival, whatever the surgeons decide upon for a MELD score is likely to be a guess more than anything else, especially if the transplant patient hasn’t yet developed severe biochemical derangements from his liver failure yet. I’m not saying that’s what happened in Jobs’ case. Indeed, i rather suspect that the real explanation for his undergoing transplant is that he was much, much sicker than advertised, with a much, much worse liver than anyone had let on. Be that as it may, none of this doesn’t change the fact that liver transplant for neuroendocrine tumors has relatively weak data to support it, all in the form of small case series. Indeed, the case series that Buckeye Surgeon cited even concluded:

OLT [orthotopic liver transplantation] can achieve control of hormonal symptoms and prolong survival in selected patients with liver metastasis of carcinoid tumors. It does not seem indicated for other NET [neuroendocrine tumors].

However, I also note that this study is 12 years old, and transplantation techniques have improved in the interim. In any case, though, any estimate for a MELD score for Jobs would have had huge error bars if it were primarily based on his neuroendocrine tumor metastases rather than cold, hard lab values indicating a dying liver.

There’s one thing that I would hope to see from Jobs’ case, and that’s a discussion of the importance of transplantation and organ donation. UNOS and various state and regional organ sharing organizations do try to work to minimize disparities in waiting time for organs based on geography, but there is only so much they can do. Part of the reason for the questions and criticisms of how Jobs managed to use his wealth and power to improve his odds as much as is legally possible is that there are such regional disparities in wait times. If there were not, neither Jobs nor anyone else would feel as compelled to do something like move to Memphis temporarily in order to take advantage of Tennessee’s shorter wait lists for liver transplant. The best way to overcome these disparities is to increase the number of organ donors. Far too many people still die waiting for organ transplants, and far too few people donate their organs. If the Steve Jobs case encourages more people to sign their donor cards, and, far more importantly given that the organ donor card does nothing except inform people of a person’s intent and that permission for organ harvest still has to be given by the family, to tell their family that they want to donate their organs, it will be a good thing indeed.

Comments

  1. #1 Windriven
    June 25, 2009

    Just a few questions:
    1. Does this fit into the broader discussion of woo in some way that has escaped me?
    2. If the patient’s name was Les Gurbleman would we be talking about this?
    3. Is anyone surprised that a high profile recipient got a liver?
    4. Granted the deficiencies of MELD, is there a rival method of ranking that is bullet-proof?

  2. #2 Pablo
    June 25, 2009

    Unrelated, but not completely: I heard on the radio this morning that the doctor who detected her breast cancer in the middle of winter at the south pole, and ended up treating herself with supplies brought by airdrop, died this week. I’m sure Orac has talked about her before, but I’m surprised nothing was mentioned here.

  3. #3 sophia8
    June 25, 2009

    1) Orac’s blog covers all aspects of medicine, not just woo;
    2) If the patient’s name was Les Gurbleman, he most likely wouldn’t have an agent sending out press releases about it.
    3) No – but if he needs the liver, why shouldn’t he get it?
    4) Dunno

    Just want to say that Orac manages to explain the inticacies of this particular subject very well.

  4. #4 Pablo
    June 25, 2009

    Wow, I never even read the first post. I will just note that Orac IS an oncologist, and so cancer cases are of specific interest to him.

    BTW, it’s Ned Gruberman.

    Boot to the head!

  5. #5 daedalus2u
    June 25, 2009

    What about the possibility of lab shopping to get high test numbers to fit into the formula?

  6. #6 Mystyk
    June 25, 2009

    Pablo:

    That story is confirmed. Dr. Jerri Nielsen died in the early morning this past Tuesday.

    http://www.cnn.com/2009/HEALTH/06/23/obit.jerri.nielsen/index.html

  7. #7 Orac
    June 25, 2009

    Just a few questions:
    1. Does this fit into the broader discussion of woo in some way that has escaped me?

    Who cares? I write about what interests me. This blog has never been about just woo.

    2. If the patient’s name was Les Gurbleman would we be talking about this?

    Probably not, but so what? If a famous person getting a liver for a questionable indication interests me, I’ll write about it. You don’t have to read it.

    3. Is anyone surprised that a high profile recipient got a liver?

    No. Should I be? The fact that Jobs did get the liver, though, provided a convenient jumping off point for me to discuss things that interest me.

    4. Granted the deficiencies of MELD, is there a rival method of ranking that is bullet-proof?

    Not that I’m aware of, but that’s the point. In a case like Steve Jobs, there is very little evidence to support a ranking one way or the other, and conflicting evidence whether liver transplant is curative.

  8. #8 Nan
    June 25, 2009

    As long as we’re talking about famous cancer victims, did you notice Farrah Fawcett died? Any idea what the “alternative” treatment she had in Germany that the NY Times mentions consisted of?

  9. #10 Michael Simpson
    June 25, 2009

    I think it’s time to move transplant lists from a state-level to national level. I know, I’ll hear that old “that’s socialism” canard, but this current system is flawed and irrational.

    I’m of two minds about whether wealth should allow one to obtain better healthcare. When resources aren’t limited (say an innovative method of treating a carcinoma is only available Mayo), I don’t care if Steve, Bill or Joan can pay the bill to be treated there. The healthcare system just can’t afford everyone being treated there, so it’s economically self limited to those who live in Minnesota or those wealthy enough to pay their way there and pay for the procedures.

    But transplants are a very limited resource, and no one should be able to “game the system” or, more bluntly, buy their way to receiving a transplant. That’s not right.

  10. #11 Nan
    June 25, 2009

    Thanks for the link, Mu, I missed that post in April.

  11. #12 Dave Undis
    June 25, 2009

    There’s one question that nobody seems to be asking about Steve Jobs and his liver transplant: is Steve Jobs a registered organ donor?

    It’s not fair to give an organ to a non-donor as long as there is a donor who needs it. But about 50% of the organs transplanted in the United States go to people who haven’t agreed to donate their own organs when they die. It’s no wonder there’s such a large organ shortage. If organs were allocated first to organ donors, more people would agree to donate and fewer people would die waiting for transplants.

    Anyone who would like to donate their organs to other organ donors can join LifeSharers at http://www.lifesharers.org or by calling 1-888-ORGAN88. Membership is free. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

  12. #13 marcia
    June 25, 2009

    As Jobs has not been forthcoming, it is up to the public, namely investors, to question the truth behind the health claims.

    Public Company notification guidelines:
    Listed entities should have an ongoing disclosure obligation requiring disclosure of all information
    that would be material to an investor’s investment decision.

    The comprehensive list of prescribed corporate events that are presumptively material and that must
    be disclosed, or will likely be required to be disclosed, with the U.S. SEC on Form 8-K ncludes

    * Changes in control of a company;
    * Events triggering a direct or contingent financial obligation that is material to the
    company

    Now, I know he hasn’t left. But. if there’s anyone who can be identified with a company in total, it is Jobs.

    Buffet agrees: transparency is necessary.
    http://features.csmonitor.com/economyrebuild/2009/06/25/jobss-illness-did-apple-shareholders-have-a-right-to-know/

    Orac speculates.
    I get an education.

  13. #14 Dr. Dredd
    June 25, 2009

    If the Steve Jobs case encourages more people to sign their donor cards, and, far more importantly given that the organ donor card does nothing except inform people of a person’s intent and that permission for organ harvest still has to be given by the family, to tell their family that they want to donate their organs, it will be a good thing indeed.

    Unfortunately, given the controversy and the distrust with which many people view organ transplantation, I’d say that the Steve Jobs case might be a disincentive for people to sign their donor cards.

    Sad.

  14. #15 daedalus2u
    June 25, 2009

    In my opinion, if you haven’t signed an organ donor card, you don’t get to bitch about how organs are allocated.

  15. #16 marie
    June 25, 2009

    @ Nan(#10): There is a distance aspect to organ transplant that makes it very difficult to have a nationwide donor list. The shorter the amount of time between organ in donor and organ in recipient, the better the subsequent prognosis is.

    @ Dave(#12): It’s not terribly ethical to discriminate based on whether or not someone is an organ donor; right to an organ should be solely on where the best potential patient outcome will be seen. And, even if Steve Jobs WAS an organ donor, it is rather unlikely that he can remain so now. Cancer patients (even if they die of something else) are frowned upon as donors because of the (very small) chance that the organs could give the recipients cancer.

  16. #17 BB
    June 26, 2009

    @Pablo, thank you for the news about Dr. Nielsen. So very sad to hear it.

  17. #18 Carlie
    June 26, 2009

    That doesn’t make much sense; people most likely to need organs are often also the ones who wouldn’t qualify to be organ donors. What we ought to have is an opt-out system rather than an opt-in. If you have good organs, they’re used unless you have specified otherwise. That would take care of the shortage as well as ease urban myths that “doctors kill people to get their organs”.

  18. #19 Carlie
    June 26, 2009

    There is a distance aspect to organ transplant that makes it very difficult to have a nationwide donor list. The shorter the amount of time between organ in donor and organ in recipient, the better the subsequent prognosis is.

    But what about near borders? Are there reciprocal agreements? You could have a nationwide list that preferences within 200 miles of the recipient in any direction. I think that they way it is now, you could have someone needing an organ who is 50 miles away but in a different state who gets passed over for someone in the same state who is 200 miles away.

  19. #20 Pablo
    June 26, 2009

    OK, so Orac posted about this a few days ago, and now a day has passed since his most recent, so I am now to the point where I am willing to say what I KNOW everyone is thinking:

    iLivers

    As you were…

  20. #22 Laura
    June 27, 2009

    David Undis, I’ve been told that cancer patients can’t be organ donors. They can’t donate blood either.

    Hey, do you believe that people who have never donated blood shouldn’t be eligible for transfusions? That makes about as much sense as your nonsensical post.

    Let me know if Lifesharers shares your beliefs. I’ll know to stay away from them.

  21. #23 Nostrum
    June 28, 2009

    I think it’s time to move toward an opt-out model where it’s assumed you are an organ donor unless you’ve specifically signed a card stating otherwise.

  22. #24 Windriven
    June 28, 2009

    Orac-
    No offense intended. Your blog is a source of information and opinion that often informs and always entertains. My point was simply that Jobs’ acquisition of a liver has attracted attention only because the acquirer was Jobs, that the issue of organ procurement is one of increasing importance as need outstrips supply, and that spotlighting inequities != pointing the way to a more equitable future. The fear of course is that once the Jobs transplant gives way to, say, the death of Michael Jackson the public discussion will end and nothing will change.

    Thanks to Paulo for the Ned Gruberman correction. That was, in fact, the allusion I was going for. I do find it interesting that so often celebrity is the catalyst for public debate about important issues. Ned Gruberman was probably a poor choice. But had the liver recipient in question been a successful but relatively unknown attorney in Kansas City, would the transplant have provoked any interest much less an examination of the way organs are alloted?

    While I recognize that responsibility for the future of the organ procurement program does not fall to you I do hope that you and your readers will explore these issues in some depth with the scientific detachment and rational argument that is hard to find in more mainstream venues.

  23. #25 boxed wine connoisseur
    June 29, 2009

    the whole point of MELD was to reduce the previous system of Child-Pugh scoring, which was loaded with subjective parameters like encephalopathy (and therefore subject to gaming).

    there will never be a “perfect” system of allocation, but two points to keep in mind
    1) transplant surgeons keep a box score, too – so they won’t blindly operate on a terminal patient, rich or not
    2) in this society, if you had two equally sick patients, the “have” will often win out over the “have not” – but don’t forget, they often donate $$ to help hospitals provide uninsured care, too

  24. #26 boxed wine connoisseur
    June 30, 2009

    the whole point of MELD was to reduce the previous system of Child-Pugh scoring, which was loaded with subjective parameters like encephalopathy (and therefore subject to gaming).

    there will never be a “perfect” system of allocation, but two points to keep in mind
    1) transplant surgeons keep a box score, too – so they won’t blindly operate on a terminal patient, rich or not
    2) in this society, if you had two equally sick patients, the “have” will often win out over the “have not” – but don’t forget, they often donate $$ to help hospitals provide uninsured care, too

  25. #27 mark
    January 17, 2011

    Great post, now, in light of the revelations of 1/17/11,What do you think now, about Jobs, did he have a recurrence of the liver mets, and is he surreptitiously having a 2d transplant?

  26. #28 iDECEPTION
    January 19, 2011

    Thanks for you work Orac, i too have been following Jobs + co “every little deceit along the way” minor( +ish later)hormone imbalance to liver transplant, perfectly ordinary medical protocol, happens every day, no suspicion at ALL there then :rolleyes:
    i don’t have your degree of knowledge but have found enough to catch the suspected + blatant deceptions (“Jobs got a little touch of the flu/cold” does Apple really things it customer base in that offensively stupid?)it obviously reassuring to hear the real experts having similar independently derived views.

    “When neuroendocrine tumours do metastasize, Dr. Goldberg said, they often spread only to the liver, rather than all over the body and a transplant may be recommended.”

    Is it a significant “often”, the further the progression of the illness the more chance outside the liver? i thought the point was a transplant is not a suitable treatment option for Jobs situation because the transplant process is itself favourable to making any cancer still around in the body outside the liver MORE aggressive and more likely re-metastasize the new Liver so quickly he could be back to why/where he wanted the transplant in the first place, when that Liver donated to someone else could offer them significantly more potential. It seems no matter how bad his cancer affected his liver functions, that only increases the chances of cancer recurrence in the new liver and the increased medical pointlessness of the transplant as an effective treatment in the first place? Old, outdated, irrelevant protocols over common sense?not accurate enough statical measures to have predicted the current outcome (i mean you don’t need to be a doctor to see how acutely bad he is now + the extraordinary rate of his deterioration over just the past few weeks)

    “and if Jobs did have a recurrence of cancer, that would give him even higher preference,”

    Is the above statement contradicted by the below one?

    “Liver transplants in such cases can cure the cancer, although patients remain at risk for another recurrence, Schwarz said. In addition, the powerful immune-suppressing medicine they must take to keep the body from rejecting the transplanted liver also can increase their risks for recurrence.”

    Mark – i can see your first qu’s as being rhetorical, not that there is the slightest surprise in the outcome despite an untruthful word NEVER once passing Apple’s “lips” before. Jobs and his Apple are a commercial outfit masters of/skilled to unequalled + endless repeated levels of (mass) deception + duplicity on which i imagine their degree of impact would be unrecognisable without AKA The Jobs “Reality distortion field” AKA “The Emperor’s New clothes”

    As for your 2rd qu interesting what will the experts say – i think his cancer is too advanced now that even $$$$ + ‘surreptitiously’, its too much a GLARING Medical No-No that careers won’t be risked for + now previously scrutinised + brought to the webs attention (thanks to Orac and the many other Professionals i’ve seen over the web who value fairness and integrity and the scientific method coming to the same conclusions despite and in contrast the irrationality of emotional intensity, the deranged fanatical hysteria of Jobs disciples/victims…RIP Jobs

  27. #29 mark
    January 19, 2011

    iDeception, so you think he is being made to wait for the 2d liver, because nobody can find a way around the ethical issues? interesting point..I’d like to know how he can keep all this so quiet…perhaps he is overseas, where there might not be such ethical/ protocol hindrances to getting his liver..I mean, I wish there was a way to monitor this.

  28. #30 iDeception
    January 22, 2011

    Mark, Jobs’ monstrous GOD complex has driven him to any ethically suspect degree to save his existence. so what you are suggesting ,inspired – at least not something i ever thought about, is entirely possible. I think one reason how he(as well as Apple) manages these endless SLY propaganda/deceptions/manipulation of the truth + keeps all the truth so hidden is the amount of media etc they have paid/onside (more platforms for their propaganda) – resulting in less journalistic investigation/digging into Job/Apple unethical/duplicitious activity (evidenced by Apple’s EXCEPTIONAL number of legal court cases) Just look at the overall resounding positive forecasts for Apple shares despite the potential devastating nature of Jobs announcement – EVERYDAY over the past 4 days DESPITE Apple reporting of exceptional profits AAPL value has slipped – this is an unheard of event in recent history flying in the face of all the positive undoubtedly on side/paid for(unsurprising give how rich Apple is in capital) analysts.

    http://gizmodo.com/5735916/this-is-why-apple-wont-be-fine-if-steve-doesnt-return

    As explained in the above gizmodo article,with all Jobs previous health leaves (which have been much more GRAVE + life threatening than Jobs/Apple has let on/blatantly duplicitous/manipulating the truth(as with their usual nature with just about everything they do) ) as you would expect with such an arrogant god complex, his statements have always said he WILL be back + a specified return contradiction. This time he has only expressed HOPE he will be back + without ANY stated time – clearly for such an ego as Jobs, considering the serious life threatening diagnosis + treatments he recently experienced, then his current diagnosis + chance of survival must be far more devastating than any previous ie TERMINAL not even another transplant could make any difference and medical theory supports this belief;

    From Orac’s previous blog on Jobs health (the relapse of his cancer AKA the CONTEMPTIBLE deceit “a Hormone imbalance”, which also relates to Jobs recent health announcement;

    http://scienceblogs.com/insolence/2009/06/whats_wrong_with_steve_jobs_revisited.php ;

    “If the patient already has metastatic disease in the liver )even in a slow growing tumor) wouldn’t a transplant 1. not necessarily cure the disease (other possible metastatic foci too small to evaluate at this time) 2. Leave the patient open to recurrence due to the immuno-suppression needed to accept the liver transplant and 3. Leave the patient open to a whole new series of tumors that come along with chronic immuno-suppression”

    That is the problem. However, in the case of hepatocellular cancer, for example, there is an indication for liver transplant.
    Posted by: Orac | June 22, 2009 8:23 PM”

    Just by comparing images of jobs appearance from the “hormone imbalance” time at the start of 2009 when the cancer was that severe + advanced(as seen by his appearance) his LIVER was in danger of failing, to the present he looks EVEN more sick/corpse like because as the above quote explains, given how advanced/ all over his body the cancer was already before the transplant, all the transplant did was make his aggressive relapsed cancer EVEN more SUPER aggressive in terms of rate of development + distribution throughout the body, basically EATING HIM alive, stealing the energy/energy resources from his body at an ever increasing exponential rate – ironically, the transplant may have significantly decreased his survival/made his death even more premature as the quote from Orac blog/WSJ Article suggests:

    “Getting a liver transplant to treat a metastasized neuroendocrine tumor is controversial because livers are scarce and the surgery’s efficacy as a cure hasn’t been proved, Dr. Hawkins added. He said that patients whose tumors have metastasized can live for as many as 10 years without any treatment so it is hard to determine how successful a transplant has been in curing the disease.”

    http://online.wsj.com/article/SB124546193182433491.html

    Given such a dire prognosis i question the decisions/motive of the transplant surgeon, his claim he would only operate on a patient who’s body was cancer free outside their liver yet their cancer come backs in force and kills them a couple of years later, his greed seems greater than his Hippocratic oath – i hope Jobs premature death initiates an investigation into this surgeon + the Hospital he worked at which has also used active deception instead of integrity to protects Jobs’ privacy – reported to a journalist with the deceptive “never been a patient” when he was!, instead of the conventional “no comment” as reported in the following article;

    http://www.forbes.com/2009/06/24/hospital-lies-about-jobs-technology-forbes.html