Friday, January 23, 2009

My impressions of the medical condition of Mr. Steven Jobs

Introduction and Disclaimer: Before I start a few introductory comments,
  1. I have not been, nor am I actively involve in the treatment of Mr. Jobs
  2. All my comments about his condition are based on publicly released information. my personal observations and experience
My medical qualifications are as follows: I am trained as a surgeon, have passed the 'boards' in surgery (an examination given to surgeons at the beginning of their practice and repeated every 10 years thereafter) I also have special qualifications in nutritional support having passed the certification examination in nutritional support given by the National Board of Nutritional Support Certification. I have been involved in the past, and continue to be, involved in the care of patients with pancreatic carcinoma with particular attention to the nutritional complications of their disease.

Pancreatic carcinoma
In reality the pancreas is two glands merged into one. The first and larger portion of the gland is involved in the production of digestive enzymes. These enzymes are secreted directly into the digestive tract in response food. The second part of the pancreas consists of neuroendocrine cells (also called islet cells) which produce various hormones. These hormone are secreted directly into the blood stream and include such commonly known ones as insulin, other hormones include glugacon (a type of 'anti-insulin' responsible for raising blood sugar) and gastrin, a hormone which causes the stomach to produce acid.

Cancer can arise in either the two cell types, the more common form of pancreatic carcinoma arises in the cells which produce digestive enzymes (to be specific, in the cells which line the ducts of the pancerase). This the the type of cancer which is usually though of when pancreatic carcinoma is mentioned and, unfortunatly, has a very high death rate. This is due in part to the fact that the tumor may not produce any symptoms until it has become to large to remove and, if it does recur or spread, does not respond well to either chemotherapy or radiation treatment. The second, and less common, cancer arises in the endocrine cells. The cure rate for these tumor is much higher since the tumors are slower growing and are much less likely to spread. Also these tumors tend to produce symptoms related to the hormones they produce and are therefore found at a very early stage making removal easy. Depending on the tumor type the cure rate for such tumors can be as high as 80% to 90% and even if not cured are consistent with a life span of years after discovery before the tumor recurs and causes problems.

In 1984 it was revealed that Mr. Jobs had developed a neuroendocrine pancreatic carcinoma although the exact type of tumor has never been publicly released. At that time he underwent surgical removal of the head of the pancreas (the area where the tumor was) in an operation called the Whipple procedure. In this operation the head of the pancreas, the main bile duct and the duodenum (the part of the intestine the stomach empties into) are removed and the stomach is reattached to the small intestine. The bile duct and remainder of the pancreas are also reattached to the small bowel to allow for drainage of bile and digestive enzymes.

Although considered major surgery there is nothing done in the Whipple procedure which precludes the patient from living a relatively normal life until, and if, the tumor recurs. Nutritional complications can occur after the Whipple procedure unless the patient is careful to follow an appropriate dietary program. The majority of these complication are related to the 'rearrangement' of the digestive tract.
The most common of these is 'dumping syndrome'. This is related to the rapid passage of food from the stomach into the jejunum, especially foods high in simple sugars such as juices. After eating such foods a person can develop severe abdominal pain, drop in blood pressure and sweating. The symptoms can be so severe that the patient will refrain from eating to prevent further attacks. Fortunately this is usually relatively easily treated by alteration of the patient's eating habits and only rarely become a chronic problem. A more worrisome condition arises when the remaining pancreas is unable to produce sufficient digestive enzymes to allow for normal food digestion. The most common food which is not digested under these circumstances is fat and the symptoms produces are related to the presence of undigested fat in the intestines (diarrhea, crampy pain and inability to absorb fat related vitamins such as A and D). This is treated by dietary alterations (limiting the amount of fat in the diet) as well as the taking of digestive enzyme, not hormone, capsules with every meal. The final type of malnutrition related to a whipple procedure is the possible development of diabetes. The type of diabetes developed is the 'juvenile' type related to a lack of insulin as opposed to the adult type where the body has enough insulin but no longer responds properly to the hormone. For this to occur the a normal adult needs to lose about 75% or more of his pancreas, much more that is removed during a normal Whipple.
One other type of chronic complication which can develop is related to scarring in the pancreas. If sufficient scar tissue develops to prevent the release of digestive enzymes into the intestines chronic pancreatitis occurs. This is an incredibly painful disease and can require surgery to releave the scarring, hoping that further scars do not develop, and may lead to a life time of chronic pain killer useage. The pain of this condition can lead to loss of appetitie and weight loss.

With all the above as background here is what I believe is going on with Mr. Jobs.
Reviewing pictures of him over the past few years it is obvious that he has undergone a significant weight loss since the surgery. This weight loss has accelerated in the past year and as of last year's Developers' Conference, where the iPhone 3G was announced, it was apparent that he has developed cachexia, a severe, pathological, weight loss. It was not just that he is extremely thin but that he showed evidence of loss of muscle mass. Observation of his face shows that the temporal muscles (the sheets of muscle on either side of the face) have severely wasted and that there is also significant loss of muscles in his hands. Hair loss is also a part of this condition but with Mr. Jobs' short hair and male pattern baldness it is difficult to assess. At that time Apple released a statement that Mr. Jobs' weight loss was due to an 'infection', while this is possible it is almost certainly only a single part of his overall condition.
Weight loss like this due to severe malnutrition either from the patient failing to take in and absorb sufficient nutrients or from the body failing to properly utilize them.

Now on to the statements Mr. Jobs has released. His first statment addressing his condition was that his weight loss was due to "A condition causing him to lose protein which would be treated by hormones". Mr. Jobs in a very intelligent person who is unlikely confuse digestive enzymes with hormones and make such as misstatement. Therefore I take him at his word that he needed 'hormone therapy". This implies one of two things, either he has developed severe, out of control diabetes which will need insulin therapy or he has cancer cachexia (a condition where the patient can absorb nutrients normally but the body can't use them) . The hormone treatment for cancer cachexia is the use of anabolic steroids to rebuild muscle mass and that may be what he was referring to. Anabolic steroids have such a bad reputation that it would not be surprizing to me that would not wish to mention the type of hormones he would be using.

Two further treatment options have been mentioned by other, credible, physicians interviewed about Mr. Jobs. First a further pancreatectomy has been mention, the reasons for that would be the development of chronic pancreatitis, as mentioned above, or recurrence of the tumor in the remaining pancreas. If he undergoes a further pancreatectomy it almost certain that he will develop diabetes and malabsorption due the the complete loss of insulin and digestive enzyme production. These will further complicate his current malnutrition.
The second treatment mentioned is a liver transplant. Liver transplantation is done for several reasons. In the United States one of the most common is the development of cirrhosis or liver cancer from chronic hepatitis which has never been mentions about Mr. Jobs. Liver damage from chronic obesity or overfeeding can also lead to liver transplant but this is also extremely unlikely in his case. If a transplant is being considered the most likely reason is recurrent of his tumor and its spread to the liver. Although not commonly done for metastatic neuroendocrine tumors it is not unheard of if there is no evidence of tumor spread to anywhere but the liver.

All of the above statements and observations lead me to believe that, unfortunately, Mr. Jobs has a recurrence of his original tumor and that this may be spreading. What does this mean for his long term prognosis? Under usual circumstances a person with a neuroendocrine tumor of the pancreas has a 50/50 chance of surviving 5 years. These percentages have actually improved since the usual cause of death used to be related to the symptoms caused by the hormones produced by the tumors (insulin producing tumors causing hypoglycemia, gastrin tumors causing severe bleeding ulcers, etc.). Since these can now be better controlled the life expectance of these patients have improved even if the tumor cannot be cured. Once cancer cachexia has occured, however, the prognosis is grim. If this condition cannot be reversed the mortality can be increased by as much as 30%. In Mr. Jobs case, by his own admission, this has progressed to the point where he feels that he can no longer continue to run Apple Inc. If the condition can be reversed by hormone treatment, and/or further surgery it is likely that Mr. Jobs will need several months to a year to fully recover. During this time it is likely that his mental faculties will continue to be unimpaired and it is not impossible that he would be able to provide input into Apple Computers even if he cannot run the company on a day to day basis.

1 comment:

Kevin said...

Excellent blog post! Very informative. I enjoyed reading it