Regular readers may recall that seven months ago, I wrote an article entitled “Justice Ginsburg is Probably Quite Ill.” To recap briefly, Justice Ginsburg had two malignant tumors removed from her lungs and her physicians stated she was cancer free. Unfortunately, she has now been diagnosed with a recurrence of pancreatic cancer, an entity she was treated for in 2010.
According a statement from the Supreme Court:
“Justice Ruth Bader Ginsburg today completed a three-week course of stereotactic ablative radiation therapy at Memorial Sloan Kettering Cancer Center in New York City. The focused radiation treatment began on August 5 and was administered on an outpatient basis to treat a tumor on her pancreas. The abnormality was first detected after a routine blood test in early July, and a biopsy performed on July 31 at Sloan Kettering confirmed a localized malignant tumor.
As part of her treatment, a bile duct stent was placed. The Justice tolerated treatment well. She cancelled her annual summer visit to Santa Fe, but has otherwise maintained an active schedule. The tumor was treated definitively and there is no evidence of disease elsewhere in the body. Justice Ginsburg will continue to have periodic blood tests and scans. No further treatment is needed at this time.”
As there is no blood test specific for pancreatic cancer, the overwhelming likelihood is that the routine blood tests found abnormalities in the function of her liver. The liver destroys toxins in the blood and sends these toxins to the digestive tract via a tube called the common bile duct, where they are then excreted in the feces. This duct passes through the pancreas so that a tumor in this organ blocks some of the drainage resulting in abnormal blood tests for liver function. This scenario is likely given that a stent was placed in her bile duct.
Traditionally, pancreatic cancer that shows no evidence of distant metastases is treated surgically to attempt a cure and oncologists (cancer specialists) usually consider a patient cured if no cancer recurs in five years. Justice Ginsburg had a pancreatic tumor surgically removed 2010 and was cancer free for nine years.
Thus Justice Ginsburg has had a second recurrence of pancreatic cancer. Her physicians did not opt for a surgical cure this time but that does not necessarily mean that her cancer had spread. It may be that her physicians did not want to subject her to another brutal surgical procedure. Instead she received “stereotactic ablative radiation therapy.” This advanced technique uses three dimensional imaging to deliver highly focused radiation beams to the tumor.
But what is disconcerting about this statement is what is not said. When Justice Ginsburg had her lung tumors removed seven months ago, there was no statement as to the pathology of these tumors. Now that another tumor was discovered in Justice Ginsburg’s pancreas, the pathologists should be able to compare it to the tumors removed from her lungs. If it is the same type, this means Justice Ginsburg had metastatic pancreatic cancer seven months ago, worsening her prognosis. The two-year survival is 20% and the five-year survival is 3-7%. On the other hand, pancreatic cancer does not typically metastasize to the lung without spreading to the local lymph nodes and liver first. So the lungs tumors could have been primary tumors or metastases from another organ besides the pancreas.
But if the primary pancreatic cancer has been destroyed by radiation and tumors in her lungs have not recurred, she may be cured. This is all we can hope for.
But a salute to Justice Ginsburg is in order. As she recently stated: “There was a senator, I think it was after my pancreatic cancer [the bout in 2010], who announced, with great glee, that I was going to be dead within six months. That senator, whose name I have forgotten [it was Senator Jim Bunning of Kentucky], is now himself dead, and I am very much alive.”
This is one tough patient.
I would like to thank my friend and colleague Dr. Mehdi Saeedi for his invaluable comments in helping me write this article.