MacHaggard

Something is wrong with Steve Jobs, the head of Apple Computers. He is looking increasingly haggard. He recused himself from his usual keynote address at the MacWorld Expo. Rumours are fierce, and there's a lot at stake: this isn't any ordinary CEO, but the man who gave us the Apple Mac, iPhone, iPod, and iTunes.

Generally, an individual's illness and diagnosis is private business. But not always. The illness of a senior politician, for instance, can affect the lives of thousands, even millions. The health of drivers in the public transport sector - buses, trains, or aircraft - is of public concern.

Likewise, there is sometimes public concern about the health of senior executives. Some CEOs, like Jobs, are really critical to the future success of their company; they personify their company. So anything which reduces their ability to function at their very best, is, quite reasonably seen as relevant to employees and investors.

Disclosure
In the US and many other countries, companies have to disclose to the public any information significantly relevant to investors deciding whether to buy or sell shares. There are no detailed rules or guidelines, but the fatal illness of a CEO, for instance, should be disclosed. Someone who did this was Andy Grove, CEO of Intel: he revealed his diagnosis of prostate cancer (a slow-developing and usually long-term cancer), in a magazine interview within the year.

The Jobs rumours and concerns about the man and his company were so serious and widespread that on January 5, he posted a letter on his company's website, insisting that he is generally well, and that he has a "hormonal imbalance" causing nutritional malfunction and significant weight loss. His board of directors called for everyone to support him during his "recuperation".

In the letter, Jobs added that the "remedy for this nutritional problem is relatively simple and straightforward", and that he had begun treatment. He expects recovery to take some months, he said. He closed off with the words: "So now I've said more than I wanted to say, and all that I am going to say, about this".

MacCancer
Not that this was likely to end rumours and concerns. In 2004, Jobs underwent surgery for pancreatic cancer. Generally, this cancer is terminal. Jobs said, however, that his was an Islet Cell Neuroendocrine tumour, which is significantly less aggressive; that it was successfully treated; and that, by implication, it no longer a concern.

Reportedly, for nine months Jobs declined orthodox medical treatment in favour of a diet-based 'cure', which increased the risk to his life. Later, he agreed to surgery and had a Whipple pancreaticoduodenectomy, apparently without chemotherapy or radiotherapy.

If these further measures were not recommended, his doctors were presumably content that the tumour had been fully removed. And this is, indeed, a variety of tumour where surgery can be curative.

There are ominous reports, however, that his decision to accept surgery was because a possible spread of the tumour to his liver had been identified. Amd then, during 2008, there were rumours of further surgery.

Doctors and others who have not been treating him can only speculate on what may be happening. Of course a return of the cancer and a spread of it, would lead to weight loss and other symptoms. But after major abdominal surgery of the type used to treat pancreatic cancer, digestion would often be notably affected, causing weight loss. The cancer, and various of the treatments for it, can cause malabsorption, in which the digestion and absorption of nutrients would be changed, and these problems can start some years after the original surgery.

A the weekend, Reuters health quoted Roderich Schwarz, a cancer surgeon at the University of Texas Southwestern Medical Center in Dallas as saying that pancreatic cancer tumours "are easily removed surgically but recur in roughly half of patients." They also quoted Dr Clay Semenkovich, an endocrinologist at Washington University in St. Louis, who said that, "(Jobs) may have a new mass that's substantially altering his physiology and causing him to lose weight."

The article went on to say that surgery on patients with recurrent islet-cell tumors can be "extremely difficult, if not risky. Semenkovich said Jobs may need new surgery, and that six months is a reasonable time for preparation, surgery and recovery, given his weight loss. "Surgery in somebody who has lost a lot of weight is a risk," and recovery could take longer, he said.

MacPancreas
A normal pancreas is very important for healthy digestion, and has many important functions including the production of digestive enzymes that help the body digest proteins, carbohydrates and fats.

So when a pancreas is damaged by the growth of a tumour, and then by the removal of the tumour, which generally includes removing some of the pancreas itself, and often the bile duct and part of the nearby small intestine, it is hardly surprising that the ability to absorb nutrients from the diet, will be impaired.

Surgery could disrupt the supply of insulin, glucagon, somatostatin, and gastrin. Also, not uncommonly, adhesions may form after such surgery, which can obstruct part of the flow of the intestines, leading to other potential causes of malabsorption. Removal of a significant portion of the pancreas can also lead to diabetes.

Some types of pancreatic tumour can produce hormones which themselves cause a wasting syndrome. But when Jobs said he expected to recover weight by the North American Spring, this suggested we were hearing the truth: weight regain would be highly unlikely if there had been an extension of the tumour.

Jobs is said to be a vegan/fruitarian, which, depending on the diet he chooses, might complicate the picture, but is unlikely to be a significant part of this problem. He might need an adjustment of his diet, along with nutritional supplements and he could also be given supplements of normal pancreatic enzymes, to replace those that he may be lacking.

MacPuzzlement
My main puzzlement was that the doctors were said to have been puzzled, because problems with malabsorption are so common after this surgery. Anyhow, Apple stock went up by 4% after the announcement, presumably because a less serious health problem caused significant relief. But as I drafted this story, I felt uneasily that we did not have the full picture.

Yesterday, January 15th, Jobs unexpectedly announced he would stand down until summer as chief executive of Apple, because the health issues were "more complex than I originally thought". Apple shares, temporarily suspended, plunged when trading resumed. If the problem was as simple as he recently told us, treatment should be mainly by medication and diet, and he'd hardly need to stand down.

The way this whole matter has been handled is a textbook example of how not to do it. Providing no credible and satisfactory comment when it is obviously needed, creates and fuels rumours.

(Sources include : the Apple company website, Wikipedia, CNN.com, Times Online, Reuters Health, and various computer commentary websites.)

(Professor M.A. Simpson, aka CyberShrink, January 2009)