CEO of JPMorgan has Throat Cancer

Image from Wikipedia by Steve Jurvetson

The CEO and President of JPMorgan, Jamie Dimon, announced that he has throat cancer and is currently undergoing treatment at Memorial Sloan Kettering Cancer Center in Manhattan for the next eight weeks. According to a letter he sent to shareholders on July 1, 2014:

"I wanted to let you know that I have just been diagnosed with throat cancer. The good news is that the prognosis from my doctors is excellent, the cancer was caught quickly, and my condition is curable. Following thorough tests that included a CAT scan, PET scan and a biopsy, the cancer is confined to the original site and the adjacent lymph nodes on the right side of my neck. Importantly, there is no evidence of cancer elsewhere in my body." [link]

Based on this information, he has a Stage 3 or 4 (out of possible 4) throat cancer. Stage 1 is the early and best stage to have. It is less clear exactly where the throat cancer is whether it be tonsil, tongue, oropharynx, or some other location. Based on probabilities, he most likely has squamous cell carcinoma which is the most common type of cancer of the head and neck including the throat.

Although he states the prognosis is good, it is not as good compared to patients where no neck mass is present (Stage 1 or 2) where chemotherapy may not even be necessary.

He also mentions the word "curable" which I am leary of when he has just started treatment. Even if no cancer is detectable at the end of treatment, throat cancer, especially stage 3 or 4, has the potential to come back.

Recall the case of actor Larry Hagman of Dallas fame... He had throat cancer and was declared "cured" 8/29/12. Than on 11/24/13, he died of cancer recurrence and complications.

The risk of cancer recurrence is highest within the first 2-3 years after treatment completion, and markedly decreases after 5 years.

Typically if cancer has not come back after 5 years, the word "cure" may than be used, but even than, such patients are seen yearly for the rest of their life for cancer monitoring.

Because the risk of cancer recurrence is so high in the first few years after treatment completion, patients are seen frequently for the first 2-3 years after treatment.

Every 2 months for the first year. Every 3-4 months in the 2nd year. Every 4 months in the 3rd year. Every 6 months in the 4th year. Yearly starting at 5 years after treatment.

This type of follow-up applies to all head and neck cancer.

Source:
JPMorgan CEO Jamie Dimon has cancer. USA Today 7/2/14

JPMorgan CEO Jamie Dimon's letter to shareholders. USA Today 7/1/14

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Argentine President Had Surgery for Wrongly Diagnosed Thyroid Cancer

On Jan 4, 2012, Argentine President Cristina Kirchner underwent a total thyroid gland removal for papillary thyroid cancer.

On Jan 7, 2012, it was announced that she never had thyroid cancer in the first place! See news report.

Why did this happen? And it does happen unfortunately to not only President of a nation, but to ordinary citizens.

Without benefit of having access to her medical records, I suspect her medical course went something like this which is what happens in the vast majority of patients with a thyroid mass...

She probably had a full medical evaluation including an ultrasound of her thyroid gland which revealed a nodule or mass.

She underwent an ultrasound guided needle biopsy in order to obtain some cells for pathology review. I suspect that the pathologist reported suspicion for papillary thyroid carcinoma. She may even have undergone a thyroid scan which revealed a cold nodule (increasing the likelihood but does not confirm cancer).

Based on a diagnosis obtained on a needle biopsy, standard of care treatment is complete thyroid removal followed by radioactive iodine treatment.

I suspect the surgeon who did the surgery did discuss with the patient the option of removing only half the thyroid gland (side with the mass) and waiting on final pathology to confirm presence of cancer before removing the rest of the thyroid gland. However, this would mean TWO separate operations on different days as it does require time for final pathology results to become available.

Given I'm sure President Kirchner is a VERY busy person, she probably elected to have the whole thyroid gland removed rather than undergoing the possibility of two operations. The risk being she may ultimately have a total thyroidectomy done when no cancer was actually present at all!

SO... was there a mistake made (if any)?

Was it the pathologist who reported cancer in the needle biopsy?

Was it the surgeon who did not confirm cancer by removing only half the thyroid first?

Let's look into the mind of the pathologist...

From the pathologist perspective, it is better to be safe and over-call things... because it is FAR worse to miss a cancer diagnosis. Imagine if the pathologist stated NO thyroid cancer was seen on the needle biopsy... only to be wrong and the Argentine president dying of thyroid cancer at some point in the future due to this misdiagnosis. The medical-legal liability and fear of being sued forces not only pathologists but also radiologists to report slight abnormal findings just to be on the safe side. Such reports will often state:

 "Cells [or CT scan] have some features suggestive of cancer. Clinical correlation recommended."

This vague statement can be interpreted in two ways... The pathologist is NOT saying there is cancer present. He is stating it might be present, but he's not sure. Which means the burden of liability now passes to the surgeon...

From the surgeon's perspective, he now has to deal with whether to operate or not based on an equivocal diagnosis on needle biopsy. What if he does NOT operate and cancer WAS present? There was than a delay in cancer treatment and theoretical decrease in survival.

OR... take the safe route and operate, but acknowledge that there is the possibility that no cancer was present and that surgery was actually not truly needed in the end. Complicating this course of action is that surgery has risks (and what a bummer if "unnecessary" surgery was performed and complications happened).

The compromise solution would have been to remove just the side where the thyroid nodule was present, but than a 2nd operation would have been needed if cancer WAS found.

So, was there "malpractice" committed by any physician in the care of President Kirchner?

Probably not because the decision making by various physicians in her care probably tended towards being safe rather than sorry (for not only the patient, but also the physicians).

There are many variations on this theme... Other courses of action that could have occurred or been taken include:

1) Monitoring with repeat ultrasounds and needle biopsies
2) Getting multiple 2nd opinions
3) Repeating radiological scans
etc
etc

Danger is what if some say do it and some say don't do it. Some scans or needle biopsies suggestive for cancer and others that aren't?

As the old saying goes, too many cooks ruin the soup. OR, you see five doctors, you may get 5 different opinions.

At some point, YOU as the patient needs to decide what to do and live with the consequences of your decision.

Why does this even occur???

Because NO test is 100% accurate.

Read more about the surgery here or watch the video!

Source:
Argentine President Cristina Kirchner wrongly diagnosed with cancer. The Telegraph Jan 7, 2012.

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Argentine President Undergoes Thyroid Surgery

BBC News reported today that popular Argentine President Cristina Fernandez de Kirchner underwent total thyroidectomy for papillary thyroid carcinoma, a highly curable form of thyroid cancer.

Thankfully, there were no complications and she is expected to be discharged from the hospital in the next 2 days.

Thyroidectomy is when the entire thyroid gland is removed which is necessary whenever thyroid cancer is present.

What are some of the complications that could have occurred?

• Vocal cord paralysis, either one or both vocal cords
• Hoarseness
• Calcium level problems which can lead to heart arrhythmias
• Bleeding which can compress the airway necessitating a tracheostomy

Read more about thyroid surgery here. Watch video of a thyroid being removed.

Source:
Argentine President Fernandez undergoes cancer surgery. BBC News Jan 4, 2012.

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