The Case of the Ruthless Ruler With a Deadly Disease

Albert B. Lowenfels, MD; Patrick Maisonneuve, Eng

Disclosures

May 19, 2008

How Would Ferrante Be Treated Today?

As a monarch, Ferrante would have received the best treatment. He was at average risk of developing cancer, and today he would have several acceptable screening methods for colorectal cancer available to him, including colonoscopy beginning at age 50 and every 10 years thereafter. Colonoscopy would have revealed the lesion at a resectable, presumably curable stage.

Colonoscopy began to replace the far less effective sigmoidoscopy in 1969, when new optically sophisticated endoscopes became available that made visualization of the entire colon feasible. Several reviews support the concept that screening for colorectal cancer is beneficial, with an estimated cost of $10,000 to $25,000 per year of life saved. Although it is still uncertain whether colonoscopy is the best preventive strategy, the risk for colorectal cancer is less than 1% five years after a negative colonoscopy, and the procedure has become accepted as an effective screening tool.[16,17,18,19] President Reagan had undergone diagnostic but not screening colonoscopy in 1985 prior to his surgery for right-sided colon cancer. In contrast, President George W. Bush has already undergone several colonoscopies for the removal of benign polyps.

During 2002, endoscopists performed more than 14 million colonoscopies in the United States, allowing for a fast, accurate, reliable diagnosis of bowel cancer, which may be one of the factors responsible for the steady decrease in the incidence of colorectal cancer (Figure 2).[11]

Graph shows decline in colorectal cancer mortality in the United States, which is partly related to screening. From the National Cancer Institute SEER Web site. Available at: http://seer.cancer.gov/faststats/sites.php?site=Colon

Undoubtedly Ferrante would have had full insurance coverage and sought care at a recognized institution skilled in the diagnosis and management of colorectal cancer. This would have improved his chances of survival because, as pointed out in several studies, differences in survival in colorectal cancer are related to income and/or socioeconomic status.[20,21] Today it is likely that Ferrante would have had a laparoscopic surgical bowel excision, given that recent studies appear to show outcomes similar to those of conventional open colectomy.[22,23,24,25] The decision for adjuvant therapy would depend on the stage of disease and the molecular characteristics of the excised tumor. Presuming that the tumor was detected before spreading, his expected 5-year survival would be about 60% to 70%.

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