Famous Patients, Famous Operations, 2002 - Part 4: The Case of the Actor with Weight Loss and Cough

Albert B. Lowenfels, MD

Disclosures

August 22, 2002

Introduction

A 57-year-old male actor was admitted to a hospital with the chief complaints of weight loss, cough, and difficulty swallowing. The present illness began about 6 months before admission with gradually progressive difficulty swallowing foods. During the 6 months prior to hospitalization, the patient lost approximately 30 pounds. Another annoying symptom was a frequent cough, coming on in paroxysms, and often lasting for 30 minutes.

The review of symptoms was negative except for persistent mild hoarseness as an adult. The only reported injury or illness in his past medical history was a laceration to his lip during his 1920s. There had been no previous hospitalizations. The patient had smoked cigarettes for many years, and the cumulative exposure to tobacco was estimated to be 60 pack-years. The patient was known to also consume alcohol. His family history was noncontributory; his father was a surgeon, his mother was an artist. Shortly after admission, the patient underwent a 9 1/2-hour surgical procedure.

Who is this mystery patient?

The patient is the Academy Award-winning actor, Humphrey Bogart. The symptoms he described are characteristic of esophageal cancer, and in early 1956 he underwent resection of an esophageal tumor and adjacent lymph nodes. He also received postoperative chemotherapy. An illustrative example representing the type of tumor removed during Bogart's surgery is shown in Figure 1. Bogart recovered and regained some weight, but after 6 months he suffered a recurrence, for which he was treated with a course of radiotherapy. He remained at home during the next few months, where he died with recurrent disease on January 14, 1957.

Esophageal tumor, similar to the one removed from Bogart in 1956.



Humphrey Bogart (1899-1957) was born in New York city to an upper class family. His father was a successful New York surgeon, perhaps explaining why Bogart initially planned to study medicine. However, because of poor grades and disciplinary problems, Bogart dropped out of school to join the Navy during World War I. It was during his naval enlistment that he injured his lip, which upon healing formed a permanent scar.

During his acting career, Bogart appeared in over 75 films, beginning at age 31 and continuing until the last year of his life. In many of his films he portrayed a "tough guy" character who smoked and drank (Figure 2). In one of his most famous films, Casablanca, Bogart portrays Rick Blaine, a nightclub owner who smokes about 10 cigarettes during the first 45 minutes of the movie! When Bogart died, the funeral eulogy was delivered by his best friend, John Huston, who said: "He got all he asked for out of life and more. We have no reason to feel sorrow for him -- only for ourselves for having lost him. He is quite irreplaceable." In 1999, the American Film Institute selected Bogart as the best actor of the 20th century.

Bogie, the tough guy in the 1930s.



Why did Bogart develop esophageal cancer?

Esophageal cancer is uncommon; only about 5 in 1000 persons will eventually die from this tumor. Bogart's social habits mimicked hose of the characters he portrayed: he smoked heavily and he consumed alcohol. We now know that both of these lifestyle factors can lead to esophageal cancer. We also know that these 2 agents, although they are independent risk factors, when combined produce a very high risk profile. Heavy smokers who also drink large amounts of alcohol have about a 40- to 50-fold increased risk of developing this lethal cancer compared with persons who do not smoke or drink.

How is esophageal cancer diagnosed now vs in the 1950s?

At the time Bogart contracted esophageal cancer, the diagnosis would have been established by a barium swallow, as shown in Figure 3, followed by endoscopy and biopsy. These modalities are effective for establishing a diagnosis, but not for accurate staging of the disease. Modern diagnostic procedures include the 2 techniques available in the 1950s, contrast radiography and endoscopy with biopsy, along with newer procedures such as a computed tomography (CT) scan or magnetic resonance imaging (MRI), endoscopic ultrasonography, and, more recently, the positron emission tomography (PET) scan. PET scanning may be more accurate than the CT scan, MRI, or endoscopic ultrasonography for detecting distant metastatic disease. Bronchoscopy is sometimes required if extension of the tumor into the tracheo-bronchial tree is suspected.

Barium swallow showing tumor in the esophagus.



Have there been changes in overall survival?

In the United States, the overall mortality rate for esophageal cancer, as recorded by the Surveillance, Epidemiology and End Results (SEER) unit of the National Institutes of Health, has risen steadily from 1969 to the present (Figure 4).[1] However, much of this increase is probably due to an unexplainable rise in the frequency of adenocarcinoma of the lower esophagus. Survival rates for white patients for all types of esophageal cancer have risen from 4% in the early 1960s to a current survival rate of 13%. Survival rates for African-American patients have increased from 1% to 9% during the same time period.

Increase in mortality rate for esophageal cancer in males in the United States (1970-2000).



Since cure for this tumor is unusual, what are the current methods for palliation?

Humphrey Bogart, whose operation must be considered palliative, was treated with all the therapeutic measures available in the 1950s: surgery, chemotherapy, and radiotherapy. We now have additional measures that can provide some relief from the distressing symptom of dysphagia. Laser therapy performed during endoscopy can obliterate tumor tissue, with success rates of around 75%. Photodynamic therapy uses photosensitizing agents that become activated after insertion of an endoscopically placed light catheter. Improvement occurs in over half of patients, but the treatment is relatively expensive. Endoscopic stenting is a widely used palliative measure, especially now that self-expanding metal stents are available. They have almost completely replaced rigid plastic stents because they function effectively and are easier to insert.

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