T**********e
发帖数: 29576 | 1 下面这篇文章对Jobs的胰腺内分泌癌治疗总结的不错，看来死的有点冤。
1. 10-2003 确诊，07-2004终于手术切除，期间Jobs一直在试自己选的diet疗法。扫描发现癌变在扩大才动了手术，这段时间癌转移的多少不可知，但肯定越拖转移的越多。
2.手术后没化疗和放疗。Jobs 2005年演讲说这表明病情乐观，不知是哪个庸医给他灌输的。2004年手术是大面积切除，部分胰腺和胃和小肠，胆和胆管都切除，目的是要消除扩散，但不系统化疗和放疗怎么能最大程度减少扩散威胁？哪个外科大夫这么信自己的手艺？
3.2009年换肝，这在扩散性癌治疗是有争议的，因为换肝后压制免疫反应有可能促进别处癌的生长。也有可能当时肝已经不行了没办法。
这种癌正常治疗大多数可活10年以上，Jobs真该到东岸Hopkins或Harvard找个靠谱的大夫。
Jobs’s Unorthodox Treatment
Some of Apple trailblazer Steve Jobs’s cancer treatment choices, from
alternative therapies to a liver transplant, may not have extended his life
—and may have even shortened it, reports Sharon Begley.
by Sharon Begley | October 5, 2011 10:01 PM EDT
Steve Jobs was right to be optimistic when, in 2004, he announced that he
had cancer in his pancreas. Although cancer of the pancreas has a terrible
prognosis—half of all patients with locally advanced pancreatic cancer die
within 10 months of the diagnosis; half of those in whom it has metastasized
die within six months—cancer in the pancreas is not necessarily a death
sentence.
The difference is that pancreatic cancers arise from the pancreatic cells
themselves; this is the kind that killed actor Patrick Swayze in 2009. But
cancers in the pancreas, called neuroendocrine tumors, arise from islands of
hormone-producing cells that happen to be in that organ. Jobs learned in
2003 that he had an extremely rare form of this cancer, an islet-cell
neuroendocrine tumor. As the name implies, it arises from islet cells, the
specialized factories within the pancreas that produce and secrete insulin,
which cells need in order to take in glucose from the food we eat. Unlike
pancreatic cancer, with neuroendocrine cancer “if you catch it early, there
is a real potential for cure,” says cancer surgeon Joseph Kim of City of
Hope, a comprehensive cancer center in Duarte, Calif.
But although neither Apple nor those close to Jobs were willing to discuss
the treatments he elected or the course of his disease, interviews with
experts on neuroendocrine tumors suggest that some of the choices he made
did not extend his life and may have shortened it.
The cancer was detected during an abdominal scan in October 2003, as Fortune
magazine reported in a 2008 cover story. It was 7:30 in the morning, Jobs
said in his 2005 commencement address at Stanford University. He reportedly
had the scan—which is seldom done, much less advised, as a routine part of
a physical—because he had a history of gastrointestinal problems, but he
also may have been experiencing symptoms, most likely gastrointestinal ones.
Those tend to arise from the hormone that the particular neuroendocrine
tumor produces, explains medical oncologist Matthew Kulke of Dana-Farber
Cancer Institute in Boston. In Jobs’s case, that was insulin. (Other
neuroendocrine tumors produce gastrin, glucagon, and other digestive
hormones.) The main effect of high insulin levels is a profound drop in
blood sugar, says surgeon John Chabot of Columbia University Medical center,
which can lead to shakiness, cold sweats, nausea, vomiting, blackouts, and
neurological changes such as impaired judgment, moodiness, irritability,
apathy, and confusion.
There is virtually no debate about the best treatment. “It has long been
held that surgery can lead to very long-term survival,” says Kim. In a 2010
analysis of cancer registries, he and colleagues found that patients with
neuroendocrine cancer who were eligible for surgery (the cancer has not
spread beyond the pancreas) “can have outstanding outcomes,” living for
many more years. In part, that is because neuroendocrine cancers tend to be
quite slow growing, or indolent. Even those that have been present for years
, and in some cases decades, often stay safely confined to the pancreas.
This kind of cancer can be so indolent that patients often die with it than
from it. Although an estimated 2,000 to 3,000 people in the U.S. are
diagnosed every year with neuroendocrine tumors of the pancreas, autopsies
find the disease in hundreds more—people who were apparently not harmed by
this very slow-growing cancer.
Despite the expert consensus on the value of surgery, Jobs did not elect it
right away. He reportedly spent nine months on “alternative therapies,”
including what Fortune called “a special diet.” But when a scan showed
that the original tumor had grown, he finally had it removed on July 31,
2004, at Stanford University Medical Clinic. In emails to Apple employees
immediately after, Jobs said his form of cancer “can be cured by surgical
removal if diagnosed in time (mine was),” and told his colleagues, “I will
be recuperating during the month of August, and expect to return to work in
September.” Despite the delay in having the surgery, Jobs’s upbeat report
was not unrealistic: most patients diagnosed with neuroendocrine tumors in
the pancreas live at least another 10 years.
Not that the surgery was a walk in the park. In many cases, says Kim, “you
can just remove the tumor with a little of the surrounding [pancreatic]
tissue.” But Jobs’s was not such a simple case. He underwent an operation
called a modified Whipple procedure, or a pancreatoduodenectomy, Fortune
reported. The surgery removes the right side of the pancreas, the
gallbladder, and parts of the stomach, bile duct, and small intestine. The
fact that so much more than the pancreas itself had to be removed suggests
that Jobs’s cancer had spread beyond the pancreas. The cancer might have
already spread by the time it was discovered in 2003, though Jobs’s
sanguine description of his prognosis suggests that if that were the case,
the metastasis might have been so small— “micrometastases”—as to be
undetectable. Alternatively, the cancer could have spread during the nine
months that Jobs was experimenting with nonstandard therapies.
Within five years, it was clear that Jobs was not cured. He underwent a
liver transplant at Methodist University Hospital in Memphis in 2009. That
strongly suggests the cancer had spread beyond the digestive system that was
the focus of the surgery and into the organ that is one of the most common
sites of metastasis. Liver transplants are a well-established treatment for
tumors that originate in that organ, such as hepatocellular cancer, says
City of Hope’s Kim. But removing the liver because it has become riddled
with tumors that originated elsewhere is rare. For one thing, liver
metastases probably mean the cancer is elsewhere, too, such as in the bones
or brain. Swapping out a cancer-ridden liver for a new one may therefore buy
some time, but not much.
Swapping out a cancer-ridden liver for a new one may buy some time, but
not much. It can even be counterproductive.
It can even be counterproductive. Transplant patients need massive doses of
immune-suppressing drugs to keep their bodies from rejecting the foreign
organ. Although experts differ on how big a role the immune system plays in
keeping cancer, especially micrometastases, in check, there is a consensus
that it provides some benefit. “Immune-suppressing drugs after a liver
transplant for hepatocellular cancer are therefore a major concern,” says
Kim. “They may increase the risk of recurrence.” A more standard treatment
is to remove only those parts of the liver that contain malignant cells. “
If there are a limited number of such spots, we recommend surgeons go in and
take them out,” says Kulke. Since the liver regenerates, “that can be
curative—or at least it can let patients do a lot better.” Presumably,
Jobs was being carefully monitored by his physicians, so it is odd that the
liver would suddenly be so riddled with metastases—especially given that
neuroendocrine tumors are usually indolent—that more limited, targeted
surgery was rejected in favor of a full, and risky, transplant.
Fewer than two dozen cases of liver transplant after metastatic
neuroendocrine cancer have been reported in the medical literature. The
first such studies were done in France, with surgeons reporting the first
results in 1997. Based on 31 cases, including three patients who had a
Whipple procedure similar to Jobs’s, they calculated that 59 percent of
patients survived at least one year, 47 percent were alive at three years,
and 36 percent survived five years or more. The rates were better for the
kind of neuroendocrine cancer Jobs had: 69 percent of patients with
metastatic carcinoid tumors were alive at five years. But less extreme
surgery arguably offers more hope. In a 2003 study, surgeons at the Mayo
Clinic found that when only those parts of the liver that are riddled with
neuroendocrine metastases (which Jobs apparently had) are removed, half of
patients live 45 months or more. This surgery, they concluded, “adds many
months of symptom-free survival to the lives of most patients.” In contrast
, with a liver transplant “the overall costs and complications ... override
its benefits, especially when compared with partial [removal of the liver].
” Indeed, liver transplants for metastatic cancer “have been largely
abandoned,” says Columbia’s Chabot, because the immune-suppressing, anti-
rejection drugs “lead to such a high recurrence rate. If there are spots of
metastasis in the liver, it’s better just to remove them. Often, that can
let you stay ahead of the disease for another eight to 10 years.” (The
liver is one of the few human organs that regenerates, so having pieces
removed usually does not impair function.)
Jobs was relieved that, as he put it in that 2004 email, he did “not
require any chemotherapy or radiation treatments.” He took that as a sign
that the surgery “got it all,” as every cancer patient desperately wishes
to hear. In fact, any surgeons who say they “got it all” should be slapped
rogue malignant cells floating in the bloodstream or lymph fluid and just
waiting to invade some vital organ. If Jobs did not receive chemotherapy, he
might have reduced his chances of survival. One of the few bright spots
when it comes to neuroendocrine cancer was the Food and Drug Administration
’s decision, in May 2011, to approve two new drugs against the disease. One
, called Sutent, from Pfizer, was previously approved for the treatment of
kidney cancer; it is an angiogenesis inhibitor, targeting the blood vessels
that tumors require for their survival. Specifically, it targets a molecule
called VEGF that sends signals that promote the growth of blood vessels. “
Neuroendocrine tumors are highly vascularized”—full of blood vessels on
which they depend for nutrients, says Kulke. “So angiogenesis inhibitors
might be a very good start.” The other newly approved drug, Afinitor from
Novartis, is what’s called an mTOR inhibitor. It blocks signals involved in
both cell proliferation and angiogenesis. According to research in the New
England Journal of Medicine, both drugs roughly double progression-free
survival from 5.5 months to 11.
Why do neuroendocrine tumors kill? Not because they destroy the insulin-
producing cells. As Kulke points out, “you can take insulin injections. But
if the cancer metastasizes, you can get wasting and weakness.” Indeed,
some 90 percent of cancer fatalities are the result of the metastasis rather
than the primary tumor.
http://www.thedailybeast.com/articles/2011/10/05/steve-jobs-die |
