Surgery, drugs, radiation, comfort care. What's next for Jimmy Carter depends on how widely his cancer has spread and where, and how aggressively the 90-year-old former president wants to fight it.
Carter said Wednesday that surgery on Aug. 3 to remove a mass in his liver revealed cancer that had spread to other parts of his body. He did not say whether the cancer started in his liver, or even if the origin is known. His father, brother and two sisters died of pancreatic cancer, and his mother had it, too.
"There is clearly a family history of cancer, but we don't know if that plays a role in his current situation," said Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society.
The first step is finding where the cancer started and spread. Are there a lot of little tumors in many places, or a couple large ones in places that are easily accessible?
"The process usually starts with imaging - CT scans or PET scans or ultrasound - to try to get a sense of how extensive the cancer is, what organs are involved," said Dr. Efrat Dotan, a gastrointestinal cancer specialist at Fox Chase Cancer Center in Philadelphia. If a biopsy has been done, "pathologists often are able to say what the source is," just by studying the types of cells involved, she said.
WHY DOES THAT MATTER?
It will tell doctors whether the cancer might be curable; cancer that has spread very widely usually is not. It also suggests whether the disease is treatable, with a reasonable chance of putting it into remission or meaningfully prolonging Carter's life.
WHAT IF DOCTORS CAN'T FIND THE ORIGIN?
Sometimes the primary site remains a mystery. Even when it is known, some doctors do genetic analyses to see if there are mutations driving the tumor that can be targeted by some of the newer cancer medicines. A landmark federal study was just launched to test this approach - treating patients on the basis of their tumor gene mutations rather than the site of origin, such as breast or lung.
WHAT TREATMENTS MIGHT CARTER HAVE?
If the cancer is in places where it can easily be removed, Carter may be a candidate for more surgery - he already tolerated one operation well.
Focused radiation is sometimes used to treat tumors in areas that can't be easily operated on, such as the brain. Radiation also can help ease symptoms from tumors in places like the spinal cord or bone, and improve a patient's quality of life.
Drugs can be considered, from traditional chemotherapy to newer medicines that target specific genes. Doctors also might advise Carter to join a clinical trial, which gives all cancer participants the current standard of care plus a chance to try something new.
WHAT ABOUT HIS AGE?
"Any treatment in a 90-year-old would be carefully considered, both for its potential to help and the impact on quality of life and general health," and his doctors likely will explain his options in those terms, Lichtenfeld said. "They're going to pay attention to his age but he's obviously someone who's been very active," not a frail older person, he said.
Some chemotherapies can be especially tough, causing low blood cell counts that older people have a harder time handling.
"Any treatment in older adults is more likely to cause more side effects," Dotan said.
WHAT IF TREATMENT IS NOT LIKELY TO PROLONG LIFE?
The key to informed decision-making is to understand the patient's goals, said Dr. Lodovico Balducci, a specialist on treating cancer in the elderly at the Moffitt Cancer Center in Tampa.
Many people want to try everything possible to gain even a small amount of extra time.
On the other hand, "if someone says, `I have lived a wonderful life; I want to die without pain,' then the best thing may be to do nothing" to fight the disease and instead focus on quality of life and comfort care, he said.
WHAT DO CARTER'S ACQUAINTANCES SAY?
Carter gave his usual Sunday school lesson on Aug. 2, the day before his liver biopsy, and is still scheduled to teach eight more classes through October, said Jeremy Shoulta, the pastor at Carter's Maranatha Baptist Church in his hometown of Plains.
"He has energy at 90 years old that I wish I had now at 31," Shoulta said. "He's going to move through the next few weeks with strength and give every effort to continue to live out the calling he has received in his life."
Habitat for Humanity CEO Jonathan Reckford said Carter told him after announcing his cancer that he and his wife Rosalynn still hope to help build 100 houses in Nepal this November.
"If anyone can beat this, he'll do it," Reckford said. "I've never met someone with more determination and resilience."