White House Press Secretary Tony Snow and liver metastases from colon cancer

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.