The Odds

Mary’s cancer, like all cancers, comes with a complete dossier of odds and probabilities. I’d like to share my thoughts on the odds as they apply to Mary.

If you have read any of the medical links I provide on our website (www.lamey-hughes.com), you already know there are two kinds of studies. One group is the patients who are unresectable (not operable). The other group is the resectable group. Fortunately, Mary falls into the resectable group which increases her probabilities to beat this cancer.

First, there is the issue of surviving the surgery. I’ve tried to find statistics to help us understand Mary’s risk. The surgeon said that typical mortality rate from the surgery is 10% but because Mary is young, active, healthy and thin he would rate her probability at 5%. How does this compare? Well, the only data I’ve found is for those on Medicare (over 65) having plain old gall bladder surgery. They have a 0.7 to 2.0% mortality rate. Assuming a young, active, healthy and thin patient, the number is probably 0.35 to 1%. So this surgery is 10 to 30 times more risky than a plain vanilla gall bladder resection.

In the USA, there are about 700,000 gall bladder surgeries each year for all reasons: stones, infection, cancer, etc. So they have pretty good statistics. For they type of surgery Mary is having (hepatic trisegmentectomy), the numbers are a lot smaller. In fact, a survey paper published last year (citation below) stated an average of 160 cholangiocarcinoma resections were reported annually in the literature globally (not just USA) over the past decade. The good news is that sample is too small to be statistically meaningful. The bad news is that the sample is too small to know the likely outcome for any individual patient.

Second, the regeneration of the liver will occur over the 8 weeks or so after the surgery. Mary is shooting for July 1. However, during that regeneration time, Mary is super susceptible to bugs, flu and colds. And, if she does come down with anything, her not yet full size liver may be overwhelmed with the infection. The result would be liver failure. As I noted before, Mary is not a candidate for liver transplant because of the nature of her tumor.

Third, Mary will be undergoing chemotherapy (perhaps radiation too) in the late summer or fall. This chemo supposedly is not as aggressive—no hair falling out or massive weight loss. But it is chemo just the same and it also represents risk.

Fourth, the cancer may have spread beyond the bits and pieces being removed by surgery and the chemo may not be fully effective. In that case, the cancer will run its course in less than two years.

There was a paper published September 2008 via the American College of Surgeons and authored by Murad Aljiffry, MD et al. The authors are from the Queen Elizabeth II Health Science Centre, Dalhousie University, Halifax, Nova Scotia, Canada. The title of the paper is “Evidence-Based Approach to Cholangiocarcinoma: A Systematic Review of the Current Literature”

They have compiled survival numbers for all types of Cholangiocarcinoma surgical techniques for a number of years. I have done some massaging of the data and what is says is that out of 357 resected cases reported in the literature in the period 2002-2007, 133 individuals were healthy after five years (37%). Please note, in order to report a 5 year success, the surgeries were performed between 1997 and 2002 which is not exactly current data.

What do all those numbers say? There is a 1 in 3 chance that Mary will be with us in 5 years. Of course, any one of the risk factors I mentioned above could be the reason Mary doesn’t make it—and, realistically, that could happen as early as next week. Are we dwelling on that? Nope. Do we realize the precarious position Mary is in? Absolutely. What are we doing about it? We already have done it. Mary is being treated at a world class cancer hospital, Stanford, by one of the two surgeons in the bay area qualified to perform this surgery. It doesn’t get much better than that and Mary should beat all the odds.

Why can we feel so confident in the face of the data? All of this data is an average on a small sample size. Most patients are over 70, have other complications caused by old age and in many cases already have one foot in the grave. Mary is young, active, healthy and thin. Even the surgeon improved her odds because she is otherwise a very healthy individual.

The bottom line is simple. Mary is convinced she can beat this monster and we can return to our normal life. I believe her and it will be so!