Exact details of the alternative natural and traditional therapies tried by Steve Jobs before he underwent surgery in 2004 and eventually died of pancreatic cancer earlier this month have not been disclosed. (A representative from Apple declined to comment on any aspect of the Apple co-founder's illness.) He reportedly restricted his diet to just fruits or just fruits and vegetables, tried out something called hydrotherapy and consulted psychics. In any case, a mounting body of scientific and anecdotal reports provides compelling evidence about the potential impact, both positive and negative, of so-called complementary practices on the health and longevity of cancer patients following their diagnosis. And, although Jobs's unconventional early-treatment choices may not have done much to stave off the spread of deadly cancer cells in his case, they provide an opportunity to discuss what makes cancer grow and how to stop it.
Jobs had a rare form of pancreatic cancer known as pancreatic neuroendocrine tumor (pNET). Accounting for about 1 percent of all pancreatic cancers, pNET is a cancer of the endocrine cells, known clinically as the islets of Langerhans, which exist in small clusters throughout the pancreas. These cells produce hormones such as insulin, which lowers blood sugar, and glucagon, which increases it.
Unlike the vast majority of pancreatic cancers (known as pancreatic adenocarcinomas) of the ductal part of the pancreas, pNET is not always deadly. These cancer cells tend to be slow growing, and so the cancer does not spread to other sites in the body as quickly. That means surgical removal of the tumor can sometimes be curative. For patients whose disease is detected while it's still confined to the pancreas, the five-year survival rate is 87 percent—in other words, the majority of patients live for quite a while.
For patients in whom this cancer has spread outside the pancreas, the median survival is 27 months. "That said, there are groups of patients with metastatic disease who can live much longer," says James Yao, associate professor and deputy chairman in gastrointestinal medical oncology at the University of Texas M. D. Anderson Cancer Center, "some even up to 5 to 10 years."
It's impossible to know whether surgery would have been curative if Jobs had undergone the procedure at the time of his diagnosis. But what about the role of acupuncture and other naturopathic approaches he tried? Could they have extended his life and improved his health or had the opposite effect?
Acupuncture has gained traction in Western medicine as a helpful complementary component to cancer care. Some clinical studies have confirmed the efficacy of this traditional Chinese medicine approach, in which needles are shallowly inserted at different points on the body, in diminishing the nausea, pain and fatigue that often follow chemotherapy, radiation and surgery, the mainstays of modern cancer treatment.
But although it may have contributed to overall well-being, acupuncture is unlikely to have had an impact on the tumor itself. "It is not enough to change the course of the disease," says Lowell Kobrin, a medical doctor who now focuses on acupuncture and herbal medicine at Northbend Medical Center in Coos Bay, Ore. "It could not affect the cancer itself."
As Tim Birdsall, vice president of integrative medicine at the Cancer Treatment Centers of America, explains it, cancer is a disease in which the cells become less and less responsive to their external environment. Multiple mutations in DNA—specifically, abnormalities in the p21 and p53 genes, among other changes—stop the process of apoptosis, or programmed cell death, that normal cells undergo. In addition to becoming immortal, cancer cells invade the surrounding tissue, rendering it nonfunctional.
But, Birdsall says, natural therapies such as those reportedly taken by Jobs center on altering the bodily environment, not the tumor itself. "Once a cancer is established, in the vast majority of cases, simply changing the environment will not be sufficient to eradicate that established tumor," he says. "Cancer requires surgery, radiation or chemotherapy to [be eradicated]."
Could Jobs have put himself in greater danger by delaying surgery in favor of alternative medicine? Because pNET grows so slowly, it's unlikely that much damage was done either, says Yao, who often monitors pNET patients before recommending therapeutic intervention. "Nine months is not a long time in this disease," he adds. "One can reasonably argue that you can observe things very carefully."
Still, at least one treatment embraced by some in the alternative care community, namely juice fasts, can be counterproductive for cancer patients, says Donald Abrams of the Osher Center for Integrative Medicine at the University of California, San Francisco (U.C.S.F.). Drinking squeezed juice delivers an intense burst of sugar to cells that would otherwise be moderated by the fiber within a fruit. "Cancer cells love sugar," he says. And from the perspective of a cancer cell, fresh-squeezed juice is no different from sugary cola. Either drink delivers a sugar shot that increases insulin and insulinlike growth factor, "both of [which] promote inflammation and both lead to cancer cell division," says Abrams, who is also professor of clinical medicine at U.C.S.F., and chief of hematotology/oncology at San Francisco General Hospital. He now provides consultations for cancer patients undergoing traditional treatment who want to incorporate complementary (or alternative) approaches into their care.
Evidence isn’t available showing whether the juice fasting Jobs reportedly tried accelerated the spread of cancer cells in his pancreas, and possibly other organs, but Abrams notes that he rarely recommends juicing to the cancer patients he counsels. In addition to producing potentially dangerous levels of insulin, the process can also harm the body overall. "The basis for these extreme dietary manipulations is to starve the tumor of the nutrients it needs," says Abrams, "but healthy cells of the body also get depleted of nutrients."
Rather, Abrams typically recommends an organic diet that is mainly plant-based but includes deep coldwater fish (for their omega-3 content); mushroom blends for immune enhancement; vitamin D and other supplements, depending on the patient; and vitamin C for wound recovery, along with physical activity and acupuncture, to address treatment side effects. He also emphasizes the importance of decreasing stress because it produces cortisol, a steroid hormone that suppresses the immune system.
Many news outlets have reported that Jobs had insulinoma, meaning it was the insulin-producing endocrine cells that had turned cancerous. If this is true, eliminating sugar, as a macrobiotic diet would have done, "could be very dangerous," Yao says, because his body may already have been depleted of insulin from the cancer rendering nonfunctional the cells that would have been producing this vital hormone.
Yet as it turns out, the idea of starving cancer cells turns out to be a key mechanism behind some of the latest medical treatments for pNET. The growth of pNET malignant cells is closely tied to a cellular pathway known as mTOR (mammalian target of rapamycin). As Yao explains, one of the functions of the mTOR pathway is to sense if a cell is not receiving its necessary nutrients. When that happens, mTOR can trigger the production of proteins, including several that promote cell proliferation and the growth of blood vessels. In normal cells, the mTOR pathway can be turned on and off, but in some cancers mTOR becomes impossible to switch off, and the cells are left to grow without any regulation. A class of drugs known as mTOR inhibitors blocks that pathway. One way they are thought to work is to "trick the cancer cell into thinking it's starving," says Yao. As a result, the cell begins a process known as autophagy, in which it begins digesting parts of itself to try to survive—but it doesn't.
Dietary change alone is insufficient to trigger autophagy because the human body can simply shift to converting muscle and amino acids into energy. Taking that concept into biomedical research has yielded a breakthrough: This past May the mTOR inhibitor everolimus was approved by the U.S. Food and Drug Administration for the treatment of advanced pNET, the first drug in this class approved for this disease.
With few facts available, we can only speculate about whether the approach that Jobs took early on had any impact on his survival. Medical and TCM professionals tend to agree that it's unlikely that they did any real harm, and in another context—as part of a preventative or recovery regimen, or alongside medical care—some of these measures can improve one's overall health.
Kobrin says that the scientific evidence confirming that benefit may be elusive for philosophical reasons at the core of conventional and alternative medicine, which both offer an "understanding of the human through [a different] paradigm." For now, the evidence remains anecdotal and alternative practitioners tend to point to thousands of years of Eastern medical history, and to individual patients. Or as Abrams puts it: "The proof is that so many of my colleagues continue to refer their patients to me."