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October 27, 2011

Steve Jobs, the iPatient

Daily Briefing

    Dan Diamond, Managing Editor  

    Steve Jobs was a famously private patient—and as detailed before, the Apple CEO's insistence on medical confidentiality made it difficult to cover his high-profile illness. 

    But a new posthumous biography lays bare Jobs' course of care, the cutting-edge treatment that nearly staved off his cancer and, ultimately, his public regrets about pursuing alternative therapies.

    First medical leave
    After returning to Apple in 1997, Jobs had developed kidney stones while attempting to turn around his company's flagging fortunes. Jobs' condition indirectly led to discovery of his cancer six years later: his urologist urged Jobs undergo a routine CT scan in October 2003, which showed a shadow on his pancreas. A biopsy soon revealed that Jobs had developed a pancreatic neuroendocrine tumor, a rare but slow-growing condition that is often treated successfully with surgery.

    However, "to the horror of his friends"—which included Art Levinson, the chair of Genentech, and Andy Grove, the former Intel CEO who was a prostate cancer survivor—Jobs elected to delay surgery in favor of alternative medicines. "I really didn't want them to open up my body," Jobs would tell his biographer years later, with some regret.

    Jobs' friends and family also suggest his obstinancy reflected what made Jobs' so successful in business: a desire to "think different," block out negative news, and will himself to success. 

    For nine months, Jobs committed to his vegan diet, adding acupuncture, juice fasts, and even seeking psychic counsel. However, a July 2004 CT scan revealed that his tumor had grown and likely spread. Jobs finally took medical leave and underwent surgery at Stanford University Medical Center, as physicians performed a modified "Whipple procedure" that removed part of his pancreas.

    Delaying surgery may have created complications for Jobs. Surgeons discovered three liver metastases during the procedure; an earlier intervention might have caught Jobs' cancer before it spread.

    Second medical leave
    After his tumor was removed, Jobs became one of the first twenty people in the world to have his cancer tumor genetically sequenced, which at the time cost more than $100,000. The sequencing and analysis, performed by teams at Stanford, Johns Hopkins, and the Broad Institute of MIT and Harvard, ultimately would allow Jobs to receive molecular targeted therapy—essentially, enabling physicians to craft specific drug regimens that directly targeted defective cells—that proved more effective than traditional chemotherapy in fighting off his cancer's effects.

    However, Jobs' cancer was rapidly spreading by early 2008—and while Jobs refused to publicly acknowledge his illness, the visible effect on his health was causing complications for Apple and eventually sparked a public debate about CEO confidentiality.

    Apple's stock price fell across 2008, in part, as photos surfaced of an increasingly gaunt Jobs; the per-share price was $188 at the start of June but down to $97 by October. The company's own statements, referring to Jobs' illness as a "common medical bug," did little to quell concern and prompted some journalists to argue that Jobs' failure to disclose his health condition reflected inappropriate governance of a public company.

    Desperately in need of a liver transplant, Jobs finally took medical leave in January 2009 and was placed on California's transplant wait list. However, "it became clear [Jobs] would never get one there in time" given the limited number of matching donors and United Network for Organ Sharing's model of prioritizing hepatitis and cirrhosis patients over cancer patients. 

    Instead, Jobs' wife discovered that it was permissable to be on a transplant list in two states simultaneously, if the recipient could meet certain conditions, such as being able to get to the chosen hospital within eight hours. Jobs was one of the few who qualified—owning a private plane allowed him to travel on a moment's notice—and he ultimately underwent a transplant in March 2009 at Methodist University Hospital in Memphis.

    While the procedure was a success, physicians found some worrying signs; Jobs had tumors throughout his liver and there were spots on his peritoneum, signaling that his cancer had likely mutated and rapidly spread.

    Final medical leave
    In January 2011, Jobs' condition had worsened and he was forced to "bow to the inevitable" and take his final medical leave from Apple. While the targeted therapies had proved promising—one physician even told Jobs that there were signs his cancer, and others like it, would eventually be treated as a manageable chronic disease—they had ceased to be effective.

    "I'm either going to be one of the first to be able to outrun a cancer like this, or I'm going to be one of the last to die from it," Jobs told his biographer in early 2011. "Either among the first to make it to share, or the last to get dumped" (Isaacson, "Steve Jobs," 2011).

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