What the Diagnosis Means

By Peter Stoler

Ever since they learned that the polyp removed from President Reagan's colon during a 3-hr, operation was a startling 2 in. across, most doctors following his case had been predicting the outcome of the pathologists' tests. So they were prepared last week for Dr. Steven Rosenberg's dramatic announcement that "the President has cancer." But ordinary citizens may have been confused when, with the dread words still hanging in the air, Rosenberg went on to say that the malignancy had been removed and that no further treatment seemed necessary. Indeed, under the circumstances, it might have been more appropriate to say that Reagan "had" cancer.

Pathologists examining the polyp had discovered that it was cancerous and that the malignancy had grown through the connective tissue under the colon's inner lining into the layer of muscle that helps the colon contract. Yet their tests suggested that none of the malignant cells had spread beyond the intestine. Thus it was likely, though not certain, that in removing the 2-ft. section of Reagan's colon that contained the polyp, the surgical team had freed the President of cancer.

Most doctors classify colorectal cancers according to a scale developed by an English pathologist named Cuthbert Dukes in the 1930s. The Dukes scale uses the letter A to describe a malignant tumor that is confined to the colon's inner lining, B to characterize one that has spread beyond the inner lining but has not reached the lymph nodes, and C for one that has pierced the outer wall or begun to spread to the lymph nodes. Doctors also use these classifications to estimate patients' chances of survival. Patients with Dukes A tumors have a 90% chance of surviving five years following surgery; with Dukes B, which the President had, the chances drop to between 60% and 80%; for those with tumors in the most advanced part of the C range, the percentage drops to 40. Doctors placed the President's cancer in the middle of the Dukes B range, and Reagan's medical team declared that the President had a better-than-50% chance of living his normal life-span.

There were other reasons for an optimistic prognosis. Rosenberg reported that the malignant cells found in the presidential polyp were moderately well differentiated, suggesting that they are of a fairly slow-growing variety. It was also encouraging, he said, that physicians had found no evidence that the President's cancer had spread beyond the section of the bowel removed during surgery. It was particularly significant that no malignant cells were found in the 15 lymph nodes in the excised section of the colon. These bean-shape structures act to screen the lymph, a watery fluid drained from between the body's cells, for bacteria and abnormal cellular matter. The absence of cancer cells in the nodes suggests that any cells that may have been shed from Reagan's tumor had not reached the bloodstream or the lymphatic system, although Rosenberg conceded that doctors could not be certain of that. By either route, cancer cells can be transported to other parts of the body, where some of them may lodge, multiply and form new tumors.

Reagan's doctors acknowledged that some cancer cells may have spread from the President's colon and could seed new tumors. Unfortunately, there is little that can be done to prevent them from seeding. Radiotherapy, or X-ray treatment, which sometimes works well to prevent recurrences of breast or lung cancers, has not generally proved effective against recurring cancers of the colon. And chemotherapy, or drug treatment, which works well against leukemia and cancers of the lymphatic system, will not help. "Currently available information is that chemotherapy does not improve survival" for colorectal cancer patients, Rosenberg said.

This means that all the President's doctors can do is watch their patient carefully and hope to catch any recurrence in its earliest stages. Doctors have recommended that six months after the President's discharge from the hospital he should undergo another colonoscopy, a visual examination of the colon (see diagram). They will check his blood regularly for carcinoembryonic antigen, a chemical marker that may indicate the presence of cancer cells, and examine his lungs, liver and other organs by means of X rays and CAT scans.

Several gastroenterologists have publicly declared that Reagan should have undergone a complete colonoscopy when a polyp was discovered in his lower bowel in 1984. They feel certain that the cancerous polyp, then at a less advanced stage, would have been detected at that time. "I don't understand why they didn't do a colonoscopy right then and there," says Dr. Donald Ritt, the San Diego gastro-enterologist who performed colon surgery on the President's brother Neil, 76.

Last week Ritt revealed the uncanny similarity between the two Reagan cases. He had examined Neil in January, discovered two intestinal polyps and removed them. At the same time, he performed a colonoscopy, spotted a suspicious area and took a biopsy, which turned out negative. But in June, after Neil complained of abdominal pain, Ritt performed another colonoscopy; this time tissue taken from the same spot contained malignant cells. On July 3, only ten days before the President's operation, Neil had major surgery to remove the growth. Ritt reports that it was in the same area of the colon as the President's, that it was classified as Dukes B, and that a 2-ft. section of Neil's colon had been removed. Even though some doctors believe that a tendency to develop intestinal polyps may run in a family, Ritt is incredulous. Says he: "I've never seen a family where the incident happened at the same time in the same place."

Dr. Dale Oller, the Navy surgeon who headed the team that operated on the President, admitted that he now wished a colonoscopy had been performed in 1984, after the first intestinal growth was discovered. But he defended the decision not to carry out the procedure at that time. What was discovered, he said, was a pseudopolyp that was clearly not malignant nor likely to become so. He insisted that no other signs suggested the presence of cancer.

Dr. Walter Karney, a Navy captain and the internist who coordinated the President's annual physical examination in 1985, said last week that Dr. Edward Cattau, a member of the examining team, had in an April letter "strongly urged" a colonoscopy after the second intestinal growth was discovered. But White House sources deny that the letter, written a month after the examination, conveyed any sense of urgency.

The President's illness and the ensuing debate have already had a beneficial effect. Officials of the American Cancer Society had been making little headway in educating the public about colorectal cancer, which was generally discussed in whispers, if at all. Now as a result of the President's illness, they report, public attitudes about colorectal cancer are suddenly undergoing a radical change, much as they did about breast cancer after Betty Ford's and Happy Rockefeller's well-publicized surgery. Since the news about the President's cancer, A.C.S. offices report that their telephones are "ringing off the hook."

This upsurge in concern comes none too soon. Colorectal cancer will strike an estimated 138,000 Americans this year, will kill an additional 60,000, and ranks second only to lung cancer as a cause of cancer deaths in the U.S.[*] a toll that can be reduced substantially by early detection. Doctors recommend that everyone over 40 have a digital rectal exam and that people over 50 in addition undergo a simple test to screen for the presence of blood in the stool every year. Also after age 50 they should undergo at least two successive annual examinations by a proctosigmoidoscope, a device that enables doctors to examine visually the lower third of the colon, where most tumors occur. If both of these tests prove negative, the next exam may be delayed three to five years. These precautions alone, if widely followed, would sharply reduce the number of deaths from colon cancer. --By Peter Stoler