Former President Jimmy Carter Being Treated for Melanoma

Pam Harrison

August 20, 2015

UPDATED August 21, 2015 // The liver mass that former President Jimmy Carter recently had resected has been identified as melanoma, and it has already spread to four regions in his brain, according to news presented at a briefing today in Atlanta.

"The doctors were pretty sure it was cancer before they operated," the former president, who will be 91 in October, told journalists.

The mass, which was only about 2.5 cm³ in size but which necessitated resection of about one-tenth of Carter's liver, was removed on August 3 by Emory University Hospital surgeon Juan Sarmiento, MD.

"They did a biopsy and found it was indeed cancer and they had a very high suspicion — then as now — that the melanoma started somewhere else and spread to the liver," Carter said.

A follow-up MRI revealed four additional spots of melanoma in Carter's brain, each only about 2 mm in size, for which he will receive four cycles of radiation given every 3 weeks, the first of which is scheduled for today.

Yesterday, Carter received the first cycle of intravenous immunotherapy with pembrolizumab (Keytruda, Merck & Co.), which, in September 2014, became the first programmed cell death inhibitor for melanoma to be approved in the United States.

Physicians will continue to monitor Carter with MRI and PET scans to try to pinpoint where the melanoma originated and where else it might have migrated to.

In addition to Dr Sarmiento, Carter is receiving care from David Lawson, MD, who specializes in the treatment of melanoma at the Winship Cancer Institute at Emory University, and Walter Curran Jr., MD, who is chair of the Department of Radiation Oncology and executive director of the Winship Cancer Institute.

These physicians have been working closely with consultants from other cancer centers, including the University of Texas M.D. Anderson Cancer Center in Houston and the Memorial Sloan Kettering Cancer Center in New York City.

Specialists from these and related centers are proffering their expertise and helping corroborate any treatment decisions taken by the Emory University cancer team to ensure Carter receives optimal care.

Carter Center Responsibilities

Meanwhile, Carter admits that the diagnosis is finally going to put a crimp in his responsibilities at the Carter Center, which he founded together with his wife, former First Lady Rosalynn Carter, in 1982.

"We talked about this when I was 80, and we talked about it again when I was 85, and we talked about it again when I turned 90," Carter said. "So this is a propitious time to carry out our long-delayed plan to cut back on our obligations at the Carter Center, although I will continue to sign letters requesting contributions and makie key calls about prospects for funding."

Indeed, Carters' grandson, Jason Carter, had already been approved to take over as chair of the board of trustees, a position he will assume in November.

"The Carter Center is well prepared to continue without any handicap if Rose and I back away from a lot of the activities we have been doing," Carter reassured members of the press.

In fact, the nonprofit center has some $600 million in endowment funds and plans to continue with its mission to help the poorest and most disadvantaged families and individuals around the world.

Carter is no stranger to cancer. In fact, he is lucky to have been spared the fate of four members of his family; his father, his only brother, and both of his sisters died of pancreatic cancer.

Carter was the thirty-ninth president of the United States, and is now the second-oldest living president.

He reported a number of years ago that he used to receive regular CT and MRI scans in an attempt to nip any nascent pancreatic tumors in the bud.

He has since abandoned regular surveillance but still undergoes a thorough physical exam at Emory University at appropriate interludes.

"When I learned that the melanoma had shown up already in four places in my brain, I just thought I had a few weeks left," Carter acknowledged.

"But I was surprisingly at ease — I've had a wonderful life, thousands of friends, and an exciting and gratifying existence," he said. "And while I won't deviate from my commitment to do whatever my physicians recommend in terms of proceeding with treatment, my message is one of hope and acceptance — hope for the best and acceptance of whatever is coming."

Good Disease Control

Asked to comment on the former president's prognosis, Keith Black, MD, chairman and professor, Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, told Medscape Medical News that the prognosis for melanoma, particularly melanoma that has spread to the brain, is driven both by how well one can control the disease within the brain and by the extent of the disease outside of the brain and how well that is controlled.

"The president is being treated with the very promising medication, pembrolizumab, which is able to activate the immune system and help it eradicate the cancer," Dr Black said.

"Melanoma is one of the tumors where this drug has shown some of the greatest promise," he said, "so if the president is able to respond to that therapy, then his prognosis could be much better."

Dr Black noted that it is difficult to predict which patients are going to respond to drugs such as pembrolizumab, but those who do respond can achieve very durable responses that often last for quite a long time.

"In terms of the spread of the disease to the brain, the approach I understand his team is planning to use is focal radiotherapy (stereotactic radiotherapy), and that actually does a very good job of controlling the disease that has metastasized to the brain," Dr Black added.

If one or more of the brain metastases fail to respond to focal radiotherapy, then the option would be to go in with surgery for the lesions that do not respond or to use whole-brain irradiation, he explained.

Asked whether he would take a similar course of action if Carter were his own patient, Dr Black felt that he probably would.

"I think it's really the best course of action for him, given what we know within the public domain," Dr Black said.

"These treatments are probably some of the most exciting new advances that we have in cancer therapy, and I think our ability to control the disease that has spread to the brain with radiosurgery is very important, after which we monitor the patient very carefully with MRI scans and do any additional treatment that's necessary."

Treating Elderly Patients With Cancer

When the news broke last week that President Carter had cancer, several media reports carried comments from physicians about treating cancer in elderly patients, making the point that age is not necessarily the most important factor.

"Older patients should not be written off cancer treatments just because of their age," said Lodovico Balducci, MD, from the Moffitt Cancer Center in Tampa, Florida, in an NBC news report.

"We can't automatically think that a 90-year-old person cannot tolerate treatment, because sometimes they can," said Gijsberta van Londen, MD, oncologist and geriatrician at the University of Pittsburgh Cancer Institute, in a report published in the Tribune Review.

"Doctors no longer look at years in the calendar, they look at the person sitting in front of them.... Nowadays, there are some treatments with side effects that aren't as severe," said Len Lichtenfeld, MD, deputy chief medical officer at the American Cancer Society, in the same report.

However, another oncologist noted that "this is a 90-year-old gentleman with apparent widespread disease. The goals of treatment would be his comfort," Robert Mayer, MD, from the Dana Farber Cancer Institute in Boston, told NBC.

Elderly patients with cancer are a standard part of the oncologist's workload, as previously reported by Medscape Medical News. Because cancer is a disease of aging, with the majority of diagnoses and deaths occurring in patients older that 65 years, every oncology practice will have a fair proportion of elderly patients, maybe as much as 55% to 60%. "So every oncologist is a geriatric oncologist, whether they realize it or not," said Stuart Lichtman, MD, attending physician at the 65+ clinical geriatrics program at the Memorial Sloan Kettering Cancer Center and professor of medicine at the Weill Cornell Medical College in New York City. "It's just the nature of the disease."

Dr Black has disclosed no relevant financial relationships.

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