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Steve Jobs’ medical reality distortion field

As I pointed out in my previous post about Steve Jobs, I’m a bit of an Apple fan boy. A housemate of mine got the very first Mac way back in 1984, and ever since I bought my first computer that was mine and mine alone back in 1991 (a Mac LC), I’ve used nothing but Macintosh computers, except when compelled to use Windows machines by work—and even then under protest. Indeed, as I searched for jobs at various times in my life, I asked myself whether I could accept a job at an institution that didn’t permit me to have a Mac in my office, such as the V.A. Fortunately, I never had to make that choice. All of this explains why I paid a lot of attention to Steve Jobs and also why his death saddened me and, relevant to this blog, the clinical history of the cancer that killed him fascinates me.

It’s often been said that there was a sort of “reality distortion field” around Steve Jobs. It was a part joking, part derogatory, part admiring term applied to Jobs’ talent for persuasion in which, through a combination of personal charisma, bravado, hyperbole, marketing, and persistence, Jobs was able to persuade almost anyone, even developers and engineers, of almost anything. In particular, it referred to his ability to convince so many people that each new Apple product was the greatest thing ever, even when that product had obvious flaws. Unfortunately, as more news comes out about how Steve Jobs initially dealt with his diagnosis of a neuroendocrine tumor of the pancreas (specifically, an insulinoma) back in 2003 and 2004, it’s become apparent that Jobs had his own medical reality distortion field, at least in the beginning right after his diagnosis of a rare form of pancreatic cancer, that allowed him to come to think that he might be able to reverse his cancer with diet plus various “alternative” modalities.

In the immediate aftermath of Steve Jobs’ death, I summarized the facts about Jobs’ case that were known at the time. In particular, I took issue with the claims of a skeptic that “alternative medicine killed Steve Jobs.” At the time, I pointed out that, although it was very clear that Steve Jobs did himself no favors by delaying his initial surgery for nine months after his initial diagnosis, we do not have sufficient information to know what his clinical situation was and therefore how much, if at all, he decreased his odds of survival by not undergoing surgery expeditiously. To recap: Did Steve Jobs harm himself by trying diet and alternative medicine first? Quite possibly. Did alternative medicine kill him? As I’ve argued before, that’s impossible to say, and any skeptic who dogmatically makes such an argument has taken what we known beyond what can be supported. Regular readers know that when I see a story that looks as though “alternative medicine” directly contributed to the death of someone, I usually pull no punches, but in this case I had a hard time being so definitive because the unknowns are too many, with all due respect to Ramzi Amri, a Research Associate at Harvard Medical School who in my opinion also went too far. I did, however, point out that I’m always open to changing my opinion if new evidence comes in. Jobs was always incredibly secretive about his medical condition, so much so that it didn’t even come out in the press until after it had happened that he had undergone a liver transplant in 2008 for metastatic insulinoma in his liver, just as his cancer diagnosis in 2003 remained secret for 9 months, not being revealed until he sent an e-mail to Apple employees announcing that he had undergone surgery.

It turns out that, with the imminent release of a major biography of Steve Jobs, more information is finally trickling out about his medical history. For instance, Jobs’ biographer Walter Isaacson is going to appear on 60 Minutes this Sunday, and apparently he is going to say this:

Everyone else wanted Steve Jobs to move quickly against his tumor. His friends wanted him to get an operation. His wife wanted him to get an operation. But the Apple CEO, so used to swimming against the tide of popular opinion, insisted on trying alternative therapies for nine crucial months. Before he died, Jobs resolved to let the world know he deeply regretted the critical decision, biographer Walter Isaacson has told 60 Minutes.

“We talked about this a lot,” Isaacson told 60 Minutes of Jobs’s decision to treat a neuroendocrine tumor in his pancreas with an alternative diet rather than medically recommended surgery. “He wanted to talk about it, how he regretted it….I think he felt he should have been operated on sooner… He said, ‘I didn’t want my body to be opened…I didn’t want to be violated in that way.’”

Isaacson is also quoted as saying about Jobs:

He’s regretful about it… Soon everybody is telling him, ‘Don’t try and treat it with these roots and vegetables and these kinds of things…’ By the time they operate on him they notice it has spread to the tissues around the pancreas.

You know, I think I’ll have to buy this book when it comes out next week, if only to read the chapters on Jobs’ illness. Assuming that the account above is true, what does it tell us? First, it doesn’t significantly change my original assessment that, at the time of surgery in 2004, Jobs probably didn’t have metastatic disease. The reason I say that is because if Jobs had any evidence of metastatic disease, it is highly doubtful that a surgical oncologist would have undertaken as huge an operation as the Whipple procedure, an operation that is usually only performed with curative intent. It’s very rare that this operation is done for solely palliative purposes, because the potential for complications is fairly high, and even when there are no complications it permanently alters the GI physiology of the person undergoing it. With that in mind, the report above implies to me is that Jobs’ tumor had grown larger and started to invade through the capsule of the pancreas into the surrounding fatty connective tissue. Further, it’s also not clear whether this tumor was seen on imaging before his operation or whether it was the finding of microscopic tumor deposits outside of the pancreas in the surgical specimen removed. Given how indolent insulinomas usually are, especially if they’re functional, as Jobs’ tumor appears to have been from all news reports (when it recurred Jobs attributed his medical leave to a “hormone imbalance”), it’s not clear that his surgeon wouldn’t have found tumor spread found outside of the pancreas if he had undergone surgery right away. As Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society has pointed out, people “live with these tumors far longer than nine months before they’re even diagnosed.” I suggest going back and read my post on the early detection of cancer, particularly the part about lead time bias, for an explanation of why the nine month delay might not have mattered much. As I have said before, biology is king and queen, and for certain tumors in certain patients biology trumps whatever we can throw at them.

Another interesting tidbit of information coming out just now is just what Jobs did during those nine months during which he delayed having surgery. This ABC News report hints at it:

Jobs, fascinated by Eastern mysticism in his youth, believed in alternative herbal treatments, and sources have told ABC News in the past that they thought he minimized the seriousness of his condition. One source close to Jobs said he kept his medical problems private, even from members of Apple’s board of directors — who finally had to persuade him his health was of critical importance to Apple’s success and the value of its stock to shareholders.

And this AP report states:

Instead, he tried a vegan diet, acupuncture, herbal remedies and other treatments he found online, and even consulted a psychic. He also was influenced by a doctor who ran a clinic that advised juice fasts, bowel cleansings and other unproven approaches, the book says, before finally having surgery in July 2004.

This is fairly vague, although one wonders if this acupuncturist is identified in the book, you know, the one who allegedly told Dr. Nicholas Gonzalez that she was trying to get Jobs to see him. Maybe Gonzalez wasn’t lying after all, because the description in the passage above does sound a lot like the Gonzalez protocol, which involves juice fasts, a whole lot of supplements, various other radical diet manipulations, plus daily (or more) coffee enemas. Could it be that Gonzalez did for a while influence Jobs?

Perhaps the book will tell.

Then there’s this video from the ABC News report:

There he is, at right about the 2:00 mark: Dr. Dean Ornish. In fact, from the news report, it appears that Dr. Ornish was not only Jobs’ friend but his doctor as well. Dr. Ornish is a problematic woo-prone physician in that, while hanging out with the likes of Andrew Weil, Rustum Roy, and Deepak Chopra, he tries to do actual science but unfortunately just doesn’t do a particularly good job of it. That in and of itself wouldn’t be so horrible, except that he draws very strong inferences from what his data show that go far beyond what is supportable by the science. Despite all these problems, there is still hope that Ornish is reachable by science-based medicine; he just has to give up his tendency to keep linking his diet with “complementary and alternative medicine” (CAM) and “integrative medicine” and embrace more rigorous, hypothesis-grounded science.

So, until I can get my hands on the book (and actually have time to read it, or at least the chapters on Jobs’ illness), what can I reasonably conclude based on what is known now? First, my original assessment has changed only slightly. Based on this new information, it appears likely to me that Jobs probably did decrease his chances of survival through his nine month sojourn into woo. On the other hand, it still remains very unclear by just how much he decreased his chances of survival. My best guesstimate is that, thanks to the indolent nature of functional insulinomas and lead time bias, it was probably only by a relatively small percentage. I also feel compelled to point out that accepting that Jobs’ choice to try “alternative medicine” first probably decreased somewhat his chances of surviving his cancer is a very different thing than concluding that “alternative medicine killed Steve Jobs,” which is in essence what Ramzi Amri and Brian Dunning both did. The first statement is a nuanced assessment of probabilities based on science and taking into account uncertainty; the latter statement is black-and-white thinking, in essence the mirror image of Nicholas Gonzalez’s claim that if only Jobs had come to see him he could have been saved.

Finally, what does this incident say about alternative medicine for cancer? Certainly, it shows that even someone as brilliant as Steve Jobs can be prone to denial, and, yes, even magical thinking, as this ABC News report points out:

How could Jobs have made such a decision?

“I think that he kind of felt that if you ignore something, if you don’t want something to exist, you can have magical thinking…we talked about this a lot,” Isaacson told CBS News.

No doubt that’s another key component of the appeal of alternative medicine: Magical thinking. Just eat this root, do these colon cleanses, let this healer manipulate your energy fields, and everything will be fine. No nasty invasive surgery that will permanently alter your body and how it functions. No poisonous chemotherapy. Unfortunately, reality doesn’t work this way, no matter how powerful the reality distortion field. Ultimately, reality intrudes, as it did for Jobs. When it did, when a followup scan apparently revealed that his insulinoma had grown, Jobs realized he had made a horrible mistake and tried to correct his course by undergoing surgery right away. It’s not clear whether his time in his self-created medical reality distortion field ultimately led to his demise or whether his fate was sealed when he was first diagnosed. Again, there’s just too much uncertainty ever to know for sure, and even if Jobs did decrease his odds of survival significantly it’s impossible to say whether the delay meant the difference between life and death in his specific case. What is clear is that no reality distortion field can long hold cancer at bay. Reality always eventually wins over magical thinking, no matter how much it might appear that magical thinking is winning at any given time.

Posted in: Cancer, Nutrition, Science and the Media

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24 thoughts on “Steve Jobs’ medical reality distortion field

  1. I’m not as optimistic about Ornish as you are. For all political and public relations purposes, he is firmly ensconced in the quack camp. He is one of its superstars (look here: http://www.bravewell.org/transforming_healthcare/supporting_physician_leadership/pioneers_integrative_medicine/ ) and undoubtedly revels in that. He won’t change.

    Whether or not Jobs died too soon because of postponing rational treatment, it is clear that if Ornish was the slightest bit involved in that decision—in other words, if he did not try to convince Jobs in no uncertain terms to get over his idiotic “don’t want to be violated” point of view—then Ornish was an active quack.

  2. sandman says:

    Hopefully Steve Jobs has done the world a final service in providing a reminder of something we should all know – that even the brightest among us can be seduced by the allure of charlatans and their magical nostrums. But I suspect the spin from the dark side will be along the lines of, “look how alternative therapy prolonged his life – pancreatic cancer usually kills within 2 years” and they’ll conveniently ignore the fact that he had islet cell tumor rather then the typical pancreatic adenocarcinoma. And they’ll hold it up as a victory for their cause and we’ll shake our heads and dial up the SGU podcast on our iPods.

  3. Quill says:

    …even someone as brilliant as Steve Jobs can be prone to denial, and, yes, even magical thinking….

    As they say where I’m from, brain surgeons make lousy plumbers. “Brilliant” is, literally, a sparkling word that I think a lot of people take to mean “knowledgable in everything” instead of “brightly shining in one or a few areas of life.” Sometimes it is true that a person who achieves incredible things in one are does go on to others. Polymaths are a fact. However, it seems much more often the case that brilliance-genius in one area leads to incredibly silly stuff in others. For example, Linus Pauling.

    In Jobs’ case, I think its instructive that genius is, indeed, not insurance or guarantee against anything, be it denial, magical thinking or simply making mistakes with profound if not grave consequences.

    I bring all this up because I think there is a parallel area where CAM excels in that it convinces people that if Natural Wonderful Substance (or Treatment) X cures or treats one condition then it must be good for many (if not all) others. “This pill is brilliant for arthritis so naturally it must be good for cancer, IBS, lice, high blood pressure, etc.” It’s this same fallacious idea that excellence in one area translates into excellence in others, when in fact it likely means dangerous ignorance operating with a kind of unquestionable certainty.

  4. ConspicuousCarl says:

    Quill on 21 Oct 2011 at 3:29 pm
    I bring all this up because I think there is a parallel area where CAM excels in that it convinces people that if Natural Wonderful Substance (or Treatment) X cures or treats one condition then it must be good for many (if not all) others.

    And that brings us to the old placebo issue. If getting a spa treatment makes someone’s back feel better, why not let them pretend it is because of some magic “chi” crap? Because believing that there is some real mechanism at work will make them more likely to spread that bad logic over to a more serious issue.

  5. DBonez5150 says:

    Sincere layman’s question: Why Jobs’ liver transplant? Wouldn’t a donor liver do slightly more good in someone without such a poor long-term prognosis? In fact, how did he get one? Isn’t it difficult to get to the top of a transplant list at his disease stage?

  6. tmac57 says:

    DBonez5150-That’s a good question,and I have heard some speculation about his money,fame and influence playing a part,but I haven’t seen any evidence about it.The same kind of question came up when Mickey Mantle,and Larry Hagman got their transplants.

  7. BillyJoe says:

    DBonez5150′

    “Why Jobs’ liver transplant? Wouldn’t a donor liver do slightly more good in someone without such a poor long-term prognosis? In fact, how did he get one? Isn’t it difficult to get to the top of a transplant list at his disease stage?”

    Here is David Gorski’s response to his question from the comments section of his previous post

    http://www.sciencebasedmedicine.org/index.php/the-death-of-steve-jobs/

    “Cancer is one of the indications that puts a patient near the top of the transplant list.
    On the other hand, Jobs established residence in Tennessee in order to be in a state where the waiting list for a donor wasn’t as long as it was in his region of California and lived there for a few months before he got his liver. That’s not something that someone of limited means could do.”

  8. lilady says:

    Dbonez5150: I commented about the availability of livers in certain areas of the country, versus other areas of the country at the Respectful Insolence blog.

    Most people who need liver transplants for whatever reason are too debilitated to work and are on Social Security and Medicaid. There are certain procedures and treatments that are “required” for every state to offer through their Medicaid programs and others that are “optional”…organ transplants are considered “optional”.

    Jan Brewer, Governor of Arizona heartlessly cut out the that state’s “optional” Medicaid organ transplant program in order to decrease the State’s share of the Medicaid costs for “optional” organ transplants and some people died due to this decision. That draconian cut was widely criticized and some (limited) organ transplants have be re-instated…yet all the cuts to organ transplants jointly funded by Arizona and Federal Medicaid dollars will not be restored fully until 2013.

    It is my understanding that for those individuals in need of organ transplants and who still have private medical insurance of their own or through a spouse/domestic partner, the transplant center still demands a large chuck of money—up front—before you meet their financial criteria for eligibility. Who would have $ 50-100K readily “available” to put down, without remortgaging their home or depending on the generosity of family/friends to facilitate your ease your entry into a transplant center’s organ recipient program?

    As Dr. Gorski stated, wealthy people can relocate to a state with a shortened list of eligible recipients and have a far greater chance of receiving a donor organ and the “upfront” money is not problematic.

    If you assume that these comments mean I am for major health care reform and a national health care plan…you would be correct.

  9. Thanks for another excellent piece David Gorski.

    I greatly admired Jobs. I think he was one of the few prominent executives that gave good design a real chance in the marketplace. I suspect he had the heart of a designer.

    Did alternative medicine cause Steve Jobs to delay treatment? It sounds to me from DG’s piece that fear of the diagnoses and the surgical treatment caused Jobs to make decisions that he may not have made in another state of mind. Magical thinking is not uncommon when we experience a life altering shock. Even when we understand what is going on intellectually, the emotions can impair our perspective, ability to sleep, concentrate and predict the consequences of our actions.

    I am driving and I suddenly come upon a tree over the road. If I panic and hit the gas instead of the brakes, did the gas pedal cause my death?

    On the other hand, the gas pedal probably wasn’t attempting to persuade me that there was excellent anecdotal evidence behind acceleration as a means to prevent collision. So lay some of the blame on Job’s alt med practitioners.

    But I still think a better understanding of how to help patients through the shock of serious diagnoses would be helpful. Perhaps there are more reliable ways to soften the impact of the magical thinking response…

  10. LMA says:

    In my opinion, y’all are being far, far too kind to the late Steve Jobs. His decision to try to cure his cancer with fruits and vegetables almost certainly killed someone. That someone being whomever was actually next on the list for that liver he was able to purchase with his vast wealth and influence! It’s horrible enough that we live in a society where the best health options are only available to those who have the good fortune to work for companies with really decent medical plans, but putting that aside, if the fact of his access got him that liver, Jobs owed it to everyone else who needed a liver and didn’t get it, not to waste it!

    Yes, I love my MacBook, but that doesn’t have anything to do with the fact that Steve Jobs should be used as the *perfect* poster boy for the ignorance, dangers and immorality of CAM treatments. He does not deserve our sympathy or apologies with regard to his choice to commit slow suicide — and to have doomed someone else to death when he “moved” to Tennessee.

  11. Medical Oncologist says:

    Great post, Dr. Gorski. Sums it all up pretty nicely.

    I think Ramzi Amri went a bit too far as well, and I replied in an answer comment to him on Quora.

    Based on the growth characteristics of islet cell insulinomas, my strong suspicion is that he has micrometastases in his liver at the time of diagnosis. For all we know he may have had some liver abnormalities that were given the benefit of the doubt by his treating physicians.

    This has lead time bias written all over it. It is likely that the tumor was present for a long time, was likely in the liver to some degree, and any local intervention was not going to cure it. In the interest of SBM, there never has been a randomized clinical trial of surgical removal versus watchful waiting in slow growing islet cell tumors, and there likely never will be, so we have no true data concerning the efficacy of this intervention. Mr. Jobs outlived the median survival of his disease by a few years in any event.

    You know as a surgical oncologist, as I know as a medical oncologist, that when a guy like Steve Jobs walks into our office we want to do everything to cure him. This may include putting him through a Whipple procedure and a liver transplant even when we do know that the odds of cure are fairly low. I am sure there was a bit of this flavor in the initial interactions with Mr. Jobs and his treating physicians. Surgeons, as you and I both know, tend to be on the aggressive side.

    All of this is speculation on all of our parts, in any event. We can only try to read the tea leaves of from what is publicly released.

    I too am an absolute Apple fanboy from my medical student days in the mid 80s (I used the initial DNA sequencing management software for the Mac (which talked the sequence back to you!) when we used large thin gels to sequence DNA) to my fellowship days at the Farber to my days now as a senior attending owning just about everything Apple makes, and my kid programming apps for the iPhone. Steve Jobs vision and creativity were amazing.

    I hate to see the guy dragged through the mud after his death. Did he have magical thinking on this? I have seen many powerful and creative people have the same reaction (if he even did). Did he treat his tumor with what we colloquially call “herbs and spices?” Who knows?

    The bottom line, as you allude to, is that the biology of his tumor, and the lack of effective systemic therapy, were the causes of this outcome. I believe that nothing he did would have influenced the ultimate biology of this disease.

  12. David Gorski says:

    This has lead time bias written all over it. It is likely that the tumor was present for a long time, was likely in the liver to some degree, and any local intervention was not going to cure it. In the interest of SBM, there never has been a randomized clinical trial of surgical removal versus watchful waiting in slow growing islet cell tumors, and there likely never will be, so we have no true data concerning the efficacy of this intervention. Mr. Jobs outlived the median survival of his disease by a few years in any event.

    True, but the same could be said of a lot of solid tumors; i.e., that we don’t have a randomized clinical trial of watchful waiting versus surgery. We can conclude based on a lot of other lines of evidence that surgery is effective. Also, given that Jobs’ tumor was, as far as the news reports seem to indicate, functional, removing it at the very least would alleviate symptoms of hyperinsulinemia. In any case, these tumors are so uncommon that clinical research on them with sample sizes of sufficient power to make definitive conclusions is very difficult, if not impossible.

    As for the lead time bias thing, that doesn’t really change my discussion even if it’s true, mainly because micrometastases would by definition be undetectable on preoperative imaging and therefore not change management. We naturally assume when there is a recurrence that there were probably micrometastases at the time of surgery. Indeed, as you know the very reason for adjuvant chemotherapy is to “mop up” these micrometastases that contribute to recurrence. Unfortunately, there is no known effective adjuvant therapy for insulinoma; surgery is it, as far as initial attempts at curative treatment go.

  13. LMA “It’s horrible enough that we live in a society where the best health options are only available to those who have the good fortune to work for companies with really decent medical plans, but putting that aside, if the fact of his access got him that liver, Jobs owed it to everyone else who needed a liver and didn’t get it, not to waste it!”

    Jobs made his decision to delay treatment for 9 months in 2003. After that, as far as I can see, he followed the directions of his doctor. His transplant was in 2008, 4-5 years later. Could he have known in 2003 that a possible liver transplant was in his future? How far back are we going to go in judging behavior previous to the transplant. If a person with hepatitis was an alcoholic, but has been successfully recovered for 4 years do we admonish them for seeking a liver transplant?

  14. David Gorski says:

    In my opinion, y’all are being far, far too kind to the late Steve Jobs. His decision to try to cure his cancer with fruits and vegetables almost certainly killed someone. That someone being whomever was actually next on the list for that liver he was able to purchase with his vast wealth and influence! It’s horrible enough that we live in a society where the best health options are only available to those who have the good fortune to work for companies with really decent medical plans, but putting that aside, if the fact of his access got him that liver, Jobs owed it to everyone else who needed a liver and didn’t get it, not to waste it!

    First off, Jobs delayed his surgery for nine months, but then, after he realized his woo wasn’t working, as far as we can tell he followed his doctors’ recommendations closely, undergoing surgery and then later a liver transplant. Also note that that liver transplant was nearly five years later. By the time Jobs underwent his liver transplant, there is no evidence that he was even indulging in woo anymore. Your comment about his having “wasted” the liver is, quite frankly, not supportable.

    Also, your anger is seriously misplaced. You clearly do not understand how the transplant system in this country operates. Although Jobs could afford to move to another state with a shorter waiting list to get on the list there, his wealth did not allow him to “jump the queue.” UNOS is very rigorous about such things, as a fellow blogger described at the time:

    Number one, it isn’t illegal or even difficult to get on several wait lists for transplant organs. Liver transplants are allocated according to a scoring system whereby the sickest patients have priority. The MELD (Model for Endstage Liver Disease) is a pretty straight forward and mathematical system. Higher scores get you a higher priority. Special points are awarded for the presence of malignancy (usually hepatocellular cancers, but obviously can include other histologic types). You can’t game the system. UNOS, one of the most ethical medical organizations in the world, isn’t the sort of organization that can be bribed with an offer of a thousand free MacBooks.

    Livers are further doled out based on blood types. If you have a rare blood type (for your state) then even if you are very sick, your chances of getting a liver are low. So putting yourself on a transplant list in a state where your blood type is less uncommon is not only not unethical, but it’s a rational move. A surgical colleague of mine’s father had a liver transplant twenty years ago in Alabam even though he was living in northeast Ohio. He had a weird blood type and his wait time if he stayed in Ohio might have been over a year longer. And the guy wasn’t some rich computer mogul. He just did what he thought he needed to do.

    What almost certainly put Jobs near the top of the list was malignancy. You can argue whether that’s the most appropriate standard, but it is the standard and there is no evidence that it was breached in Jobs’ case. In terms of “gaming the system,” it’s hard even for transplant surgeons to do that. They jeopardize their transplant programs if UNOS ever catches them trying to do that, and no transplant center wants to risk its very existence.

    As for Jobs’ having “killed” whoever was next on the liver transplant list in UNOS region in which he was listed for transplant, that is an assumption on your part that, as lawyers say, relies on facts not in evidence. The only way you can say such a thing based on anything other than sheer speculation would be if you knew (1) who the next highest priority patient on the transplant list was at the time a liver became available for Jobs; (2) whether that patient was a match for that liver; and (3) whether that person died before a new liver became available after Jobs’ transplant. You don’t know any of those facts. You assume.

    And you know what they say about when you assume. The old saying fits very well here.

  15. ConspicuousCarl says:

    LMA on 22 Oct 2011 at 6:07 pm

    That someone being whomever was actually next on the list for that liver he was able to purchase with his vast wealth and influence!

    I explained this in more detail last time, but the short answer is that randomly being born in Tennessee is not an especially ethical reason why that other person should have been at the top of the list to begin with.

    Steve Jobs did what EVERYONE should be able to do, i.e. he got a new liver based on need without his location being a barrier. He did not do something which nobody should be able to do.

  16. Medical Oncologist says:

    “True, but the same could be said of a lot of solid tumors; i.e., that we don’t have a randomized clinical trial of watchful waiting versus surgery. We can conclude based on a lot of other lines of evidence that surgery is effective. Also, given that Jobs’ tumor was, as far as the news reports seem to indicate, functional, removing it at the very least would alleviate symptoms of hyperinsulinemia. In any case, these tumors are so uncommon that clinical research on them with sample sizes of sufficient power to make definitive conclusions is very difficult, if not impossible.
    As for the lead time bias thing, that doesn’t really change my discussion even if it’s true, mainly because micrometastases would by definition be undetectable on preoperative imaging and therefore not change management. We naturally assume when there is a recurrence that there were probably micrometastases at the time of surgery. Indeed, as you know the very reason for adjuvant chemotherapy is to “mop up” these micrometastases that contribute to recurrence. Unfortunately, there is no known effective adjuvant therapy for insulinoma; surgery is it, as far as initial attempts at curative treatment go.”

    That’s the whole point here. There is no effective systemic therapy for insulinoma, be it adjuvant or metastatic. The symptoms of hypoglycemia could be treated with diet, which he tried. Was there magical thinking as well? Who knows, but dietary alteration can control insulinoma symptoms.

    I think we will never know the answer, and I am one who would probably not counsel dietary therapy for a patient in this setting. However, if a well informed patient said to me that (1) there is a 65-70% chance of the tumor already being metastatic, and (2) a Whipple is pretty severe surgery, therefore (3) I’d like to try to control my disease symptoms with diet for some time until we saw which way the disease declared itself one way or the other, I think I could respect his argument.

  17. Medical Oncologist says:

    Just saw the interview on 60 minutes. Again, without seeing the films and speaking to his MDs it’s hard to know what happened. Did the 9 month delay mean anything in terms of respectability and prognosis? Unclear still to me. But it is clear, at least from the impression of Issacson, that there was some magical thinking going on here. It was not a simple decision of trying to treat an insulinoma with diet. It was a fear of surgery.

    Still not sure it made a difference in the end, but in terms of a decision, it was not made using SBM, that I am now sure of.

  18. Josie says:

    LMA’s comment reminded me of other times I’ve seen such arguments made.

    Is there a logical fallacy for the assertion that a set of individuals who did not get the desired *thing* were somehow more deserving or morally superior to the individual who did get the desired *thing*?

    I just have to wonder, assuming there was in fact someone else of equivalent medical/moral eligibility that was in line for a transplant with uncle Steve, if they behaved any more up to LMA’s standard than did Steve himself?

    I feel comfortable starting out with the idea that probably a lot of people on that transplant list have done things not entirely science based just after receiving the diagnosis. Cancer and other life threatening conditions are terrifying. Denial and playing down the actual severity of the situation seem like reasonable coping mechanisms –in the short term.

  19. ConspicuousCarl says:

    Josie on 24 Oct 2011 at 2:20 pm

    LMA’s comment reminded me of other times I’ve seen such arguments made.

    Is there a logical fallacy for the assertion that a set of individuals who did not get the desired *thing* were somehow more deserving or morally superior to the individual who did get the desired *thing*?

    “Unstated major premise”

    The premise, regarding the reason why the not-Steve-Jobs recipient actually deserves to be at a particular spot on the transplant list, was not asserted explicitly, hence my proposition that LMA is implying that someone deserves to get a new liver first because they were born in Tennessee. If the real premise is something else, LMA is welcome to state it.

    The SGU fallacy page discusses premise issues separately from formal “fallacies”, since a bad or unstated premise is not technically a logic issue (though I think a logic issue probably leads to false, unstated, or unproven things being used as premises).
    http://www.theskepticsguide.org/resources/logicalfallacies.aspx

  20. Josie says:

    awesome, thanks!

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