Sunday, June 21, 2009

Steve Jobs get a new liver


Steven Jobs apparently underwent an orthotopic liver transplant two months ago in Tennessee. In 2004, Mr Jobs was diagnosed with a pancreatic islet cell tumor (specialized neuroendocrine cells in the pancreas responsible for hormonal production) and subsequently had the defintive pancreatic resection. Over the past year or so rumors have abounded about his health given his rather skeletal, almost insectile, appearance. Turns out, his islet cell tumor recurred with liver metastases. Orac does a great job reviewing the literature and the treatment options for metastatic pancreatic neuroendocrine tumors so I'll just link to it here.

It seems that some in the media and the blogosphere have tried to tiptoe around the suggestion that something unsavory occured in this case. Two facts are often cited: 1) Steven Jobs received the transplant in a state where he doesn't reside. 2) The indications for a liver transplant for metastatic neuroendocrine cancers are a little controversial. The unstated implication then is that he used his power and influence as a famous bazillionaire to get priority on a new liver.

I don't buy it.

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.

As to whether it is appropriate to transplant a liver for a metastatic neuroendocrine tumor, I would have to defer to the oncologists and transplant surgeons involved in Mr. Jobs' case. You won't ever find a randomized controlled trial proving "comparative effectiveness" of such a strategy. But liver transplant in such a clinical scenario isn't unprecedented. Islet cell tumors are a strange breed. Their behavior can be very aggressive or indolent. If this was an insulinoma then I would assume that his symptoms were potentially incapacitating. The procedure may improve his survival and will certainly attenuate his symptoms. Assuredly, he would not have been considered for a transplant unless imaging confirmed that the tumor was restricted to his liver. It's a tough call, either way. But it certainly isn't any of our business; Monday morning quarterbacking just makes us look petty and small.

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