Did "Alternative Medicine" Kill Steve Jobs?
A flurry of articles has shown up following the death of Apple founder, Steve Jobs, asserting that “alternative medicine” killed him.
His choice to delay surgery to treat his pancreatic cancer for 9 months, during which time he pursued alternative diets, herbs, and acupuncture, is claimed to be responsible for his death. The allegation is that immediate surgery would have cured him or at least greatly extended his life and that his reliance on nonconventional therapies led to his death. Is this an accurate assessment?
First, it appears that no one commenting on his care had any hard data on his condition, including the specific type and stage of his cancer. What we do know is that he had a pancreatic neuroendocrine tumor (NET) discovered incidentally in 2003. He began some unknown combination of a vegan/macrobiotic diet, juices, herbs, and acupuncture. Nine months later, he had surgery, at which point the cancer had spread to his liver.
The only physician with any actual knowledge of his case who has spoken publicly is Dean Ornish, MD, who encouraged Jobs to have the initial surgery but also stated in the October 31 edition of the New York Times that Jobs “spent a few months consulting with a number of physicians and scientists worldwide as well as his team of superb physicians. . . .No one can say whether or not having surgery earlier would have made any difference because of the possibility of micrometastases [spread of tumors that are too small to detect].”
Second, it’s important to understand the type of cancer he had, and it would help to know its grade/stage when he was first diagnosed. Let me point out that an NET is a very rare form of cancer, comprising only 1 to 2 percent of all pancreatic tumors. This is significant considering that the much more common form (adenocarcinoma, which makes up more than 90 percent of pancreatic cancer cases) has a five-year survival rate of 5 percent, with only a 6-month life expectancy (with treatment) once it begins to spread. In contrast, a recent report examining a large number of patients with incidentally discovered pancreatic NETs found improved survival rates after surgical intervention: as high as a 90-percent survival rate after 5 years for those with benign disease and 50 percent for those with malignancies. Interestingly, the authors of this study point out that the “management of incidentally identified lesions poses a quandary to health care professionals,” suggesting that optimal therapy is not always clear. This is particularly true for rare cancers, for which treatments are often based upon expert opinion rather than on hard data.
I think the extra attention given to the Jobs case highlights the complexity of decision-making among both providers and individuals with cancer, rather than possible harm caused by alternative therapies. Keep in mind that his decision to delay surgery was made in 2003, and significant (though still limited) progress has been made in understanding these types of tumors since then. For example, the study I mentioned above found that even small, asymptomatic, and nonfunctioning NETs are potentially lethal, with long-term outcomes similar to those patients who had larger tumors that were surgically removed. Even today, we still have a hard time differentiating which tumors are likely to be lethal and which are not, thus optimal therapy may be early removal of all pancreatic NETs whenever surgically possible. But is this information that either Steve Jobs or his doctors had in 2003?
In 2004, a paper published in the World Journal of Surgery concluded that surgery is recommended for solitary benign tumors presenting as incidental, nonfunctional pancreatic NETs that are symptomatic, and also for asymptomatic patients with tumors larger than 1 cm in diameter. Thus it is possible that Jobs’s tumor was less than 1 cm in size and was asymptomatic (it was discovered incidentally). This would not necessarily have conflicted with recommendations at the time.
It is now known that size is not a reliable indicator of malignancy in these tumors, but that was not clear then. Furthermore, a study published in 2000 followed 11 patients with surgically removed pancreatic NETs. Two of the participants died postoperatively; such results might frighten patients who feared surgery (as Jobs reportedly did). It wasn’t until 2011 that a study based on US National Cancer Institute data was published, which found that surgical removal has survival benefit for all subtypes of pancreatic NETs. The study included patient data from the period 1980 to 2004 and noted that only 21 percent of these patients’ treatment included surgical removal, which also indicates that Jobs’s choice to not undergo surgery was fairly common during this time period.
While of course we don’t have any specific information about the grading or staging of Steve Jobs’s tumor in 2003, I think we can appreciate that treatment decisions are not easy and involve a complex analysis of risk verses benefit for each treatment offered, whether “alternative” or conventional. For some cancer types, the documented benefit of conventional therapy may be minimal and is often overshadowed by a regrettable decline in quality of life. We also don’t know the reasons for Jobs’s use of “alternative therapies.” For example, he may have been using acupuncture for its documented efficacy for pain relief (abdominal pain is a possible symptom of pancreatic NETs) rather than to treat the cancer directly. Too often, supportive nonconventional therapies are not utilized for optimal patient care. We don’t know whom the alternative doctor was that Jobs allegedly consulted with or if that doctor had any experience treating cancer patients. We also don’t know whether or not that person was an advocate for surgery.
I think lost in this retrospective analysis of his choice is respect for his autonomy and for each patient’s autonomy in deciding his or her own treatment course. By all accounts, Jobs was a brilliant man, and although his treatment choice may possibly have shortened his life, it’s too easy to apply our own priorities and values to someone else’s life. It’s also not immediately obvious that the information he had at the time outlined a clear superiority for surgery, although today many of us might make a different decision if facing a similar situation. Ultimately these are all personal decisions, which ideally are informed and guided by health care practitioners with full knowledge of all available therapies.
Perhaps a better question to ask is whether the delay of his surgery contributed to his death. I think today we have more evidence to suggest that immediate surgery is probably indicated, but it still may not improve survival given the likelihood that tumors too small to detect may have already spread to other organs. The Steve Jobs story really underscores a lack of understanding of the optimal treatment course for a rare cancer rather than an indictment of alternative medicine. Our patients do better when we offer them good medicine and are poorly served when health-care professionals create artificial divisions between therapies.
Evidence-Based Recommendations for Cancer Patients
All practitioners have had—and will continue to have—the experience of patients, family, and/or friends diagnosed with cancer asking for guidance. Some simply want reassurance that the conventional medicine approach is the best, while others hope for a “natural” miracle that does not involve surgery, radiation, or chemotherapy. There is rarely a simple or entirely satisfactory answer. Following is the advice I provide when asked.
1) Stop the cause(s). Regardless of treatment options, the conditions that allowed the cancer to develop must be addressed. Cancer is not a sudden event; rather, it is the end stage of a process that is likely ongoing.
2) If the cancer is surgically removable without significant disability, get it out as soon as possible. Take modified citrus pectin to help clean up any cancer cells released and be sure to optimize immune function.
3) If chemotherapy or radiation is the only conventional therapy available, undergo that
treatment only if it has been documented to actually increase quality of life. If that treatment does increase quality of life significantly, then use nutrition and botanicals—at the guidance of an integrative medicine practitioner experienced in cancer care—to increase its efficacy and decrease side effects. If the treatment does not improve quality of life, then why go through the pain, suffering, and likely destruction of family finances
for just a few months of poor life quality?
4) Take curcumin: It appears to inhibit all stages of cancer development and progression.
5) No natural medicine intervention has been conclusively demonstrated to be effective. That does not mean they are not effective, only that the results are inconsistent and dependent on factors we do not yet understand.
Joseph Pizzorno, ND, is editor in chief of Integrative Medicine: A Clinician’s Journal and received the Natural Products Association Clinician Award for 2012. He is president emeritus at Bastyr University; president of SaluGeneticists Inc.; and a writer, speaker, and researcher in the area of science-based natural medicine.