pancreatic cancer is the most virulent of the major cancers; it is also the least funded of the major cancers. every year approximately 32,000 people in the us will be diagnosed with pancreatic cancer, and approximately 32,000 will die from it. pancreatic cancer is the second most common cause of death in the developed world, the fourth leading cause of death related to cancer in the us, the third most common cause of cancer death in men and the fourth in women.

however, it is extremely difficult to treat and has an extremely low cure rate. it has been approximated that about 30% of the changes which initiate cancer of the pancreas are caused by smoking; and that about 8% are secondary to hereditary genetic predisposition. there appears to be a mild correlation between the onset of diabetes and pancreatic cancer, but it is not entirely clear if this is fully a cause or perhaps an effect of the cancer. there is currently no effective way to detect pancreatic cancer early (80% of pancreatic cancers are already metastatic by the time they are detected), making it extremely difficult to detect during the period in which treatment would be most effective.

the following is the staging protocol used to classify the progression of pancreatic cancer:

the surgical procedure our father had is known as the whipple procedure and currently remains the only possible cure for pancreatic cancer. the five-year survival rate for patients who underwent a whipple procedure for cancer of the pancreas at hopkins is now approaching 25% (40% for some patient subgroups), compared with a five-year survival rate of less than 3% overall for patients who do not receive treatment. this procedure generally involves the removal of the gallbladder, common bile duct, part of the duodenum, and the head of the pancreas.

chemotherapy uses drugs to kill cancer cells with side effects including fatigue, mouth sores, nausea, and vomiting that usually go away during recovery periods between treatments. the following are descriptions of the three different drugs my father has been taking:

• 5-fu (fluorouracil) acts in several ways, but principally as a thymidylate synthase inhibitor, interrupting the action of an enzyme which is a critical factor in the synthesis of pyrimidine-which is important in dna replication. in short, 5-fluorouracil prevents cells from making dna and rna by interfering with the synthesis of nucleic acids, thus disrupting the growth of cancer cells.

  the underlying principle in many standard chemotherapy agents has to do with interfering with the normal progression of the cell cycle. as cancer consists of uncontrolled cell growth, one if its weaknesses is inherent genetic instability. if an agent hurts the ability of the cell to progress through its normal cycle eventually to replicate itself, although this will tend to hurt all the cells in the body, its effect will be selectively severe on unstable and rapidly growing cells-the cancer itself.

• gemcitabine is a more recently approved chemotherapy drug which tends to offer a slightly increased median survival duration (and increased one year survival rates) as compared to 5-fu, and also appears confer substantially improved quality-of-life measures over treatment with 5-fu and over no treatment.

  gemcitabine belongs to a general group of chemotherapy drugs known as antimetabolites. gemcitabine prevents cells from making dna and rna by interfering with the synthesis of nucleic acids. this stops the growth of cancer cells, causing the cells to die.

• cisplatin is a platinum compound chemotherapy drug that acts like an alkylating agent. cisplatin interferes with the growth of cancer cells, which are eventually destroyed. cisplatin is believed to kill cancer cells by binding to dna and interfering with its repair mechanism, eventually leading to cell death. since the growth of normal body cells may also be affected by cisplatin, other effects will also occur.

• radiation therapy uses high-energy rays directed at a tumor. this therapy damages the cancer cells and stops them from growing and dividing. it may be used before or after surgery to shrink the tumor alone or with chemotherapy. the side effects of this treatment can include fatigue, reddened skin, tenderness, itchiness, nausea, vomiting, diarrhea, and digestion problems. these effects usually subside when treatment ceases.

most of the following information has been compiled by dannielle from the johns hopkins pancreatic cancer webpage and pancreatica.org. please visit these web pages for information not covered in this overview.

for those more scientifically inclined, you can read this paper.

a book which has helped all of us in our family cope with dea's cancer is tuesdays with morrie. we highly recommend it to anyone.

well, i am sure that you like me and my family, have had it with statistics. we have beaten one prognosis already and are going to continue leaving them in the dust. here is an inspirational story about a brilliant scientist and his battle against statistics.

dr. gould died in may of 2002 at the age of 60. dr. gould lived for 20 very productive years after his diagnosis, thus exceeding his 8 month median survival by a factor of thirty! although he did die of cancer, it apparently wasn't mesothelioma, but a second and unrelated cancer.

my life has recently intersected, in a most personal way, two of mark twain's famous quips. one i shall defer to the end of this essay. the other (sometimes attributed to disraeli), identifies three species of mendacity, each worse than the one before - lies, damned lies, and statistics.

consider the standard example of stretching the truth with numbers - a case quite relevant to my story. statistics recognizes different measures of an "average," or central tendency. the mean is our usual concept of an overall average - add up the items and divide them by the number of sharers (100 candy bars collected for five kids next halloween will yield 20 for each in a just world). the median, a different measure of central tendency, is the half-way point. if i line up five kids by height, the median child is shorter than two and taller than the other two (who might have trouble getting their mean share of the candy). a politician in power might say with pride, "the mean income of our citizens is $15,000 per year." the leader of the opposition might retort, "but half our citizens make less than $10,000 per year." both are right, but neither cites a statistic with impassive objectivity. the first invokes a mean, the second a median. (means are higher than medians in such cases because one millionaire may outweigh hundreds of poor people in setting a mean; but he can balance only one mendicant in calculating a median).

the larger issue that creates a common distrust or contempt for statistics is more troubling. many people make an unfortunate and invalid separation between heart and mind, or feeling and intellect. in some contemporary traditions, abetted by attitudes stereotypically centered on southern california, feelings are exalted as more "real" and the only proper basis for action - if it feels good, do it - while intellect gets short shrift as a hang-up of outmoded elitism. statistics, in this absurd dichotomy, often become the symbol of the enemy. as hilaire belloc wrote, "statistics are the triumph of the quantitative method, and the quantitative method is the victory of sterility and death."

this is a personal story of statistics, properly interpreted, as profoundly nurturant and life-giving. it declares holy war on the downgrading of intellect by telling a small story about the utility of dry, academic knowledge about science. heart and head are focal points of one body, one personality.

in july 1982, i learned that i was suffering from abdominal mesothelioma, a rare and serious cancer usually associated with exposure to asbestos. when i revived after surgery, i asked my first question of my doctor and chemotherapist: "what is the best technical literature about mesothelioma?" she replied, with a touch of diplomacy (the only departure she has ever made from direct frankness), that the medical literature contained nothing really worth reading.

of course, trying to keep an intellectual away from literature works about as well as recommending chastity to homo sapiens, the sexiest primate of all. as soon as i could walk, i made a beeline for harvard's countway medical library and punched mesothelioma into the computer's bibliographic search program. an hour later, surrounded by the latest literature on abdominal mesothelioma, i realized with a gulp why my doctor had offered that humane advice. the literature couldn't have been more brutally clear: mesothelioma is incurable, with a median mortality of only eight months after discovery. i sat stunned for about fifteen minutes, then smiled and said to myself: so that's why they didn't give me anything to read. then my mind started to work again, thank goodness.

if a little learning could ever be a dangerous thing, i had encountered a classic example. attitude clearly matters in fighting cancer. we don't know why (from my old-style materialistic perspective, i suspect that mental states feed back upon the immune system). but match people with the same cancer for age, class, health, socioeconomic status, and, in general, those with positive attitudes, with a strong will and purpose for living, with commitment to struggle, with an active response to aiding their own treatment and not just a passive acceptance of anything doctors say, tend to live longer. a few months later i asked sir peter medawar, my personal scientific guru and a nobelist in immunology, what the best prescription for success against cancer might be. "a sanguine personality," he replied. fortunately (since one can't reconstruct oneself at short notice and for a definite purpose), i am, if anything, even-tempered and confident in just this manner.

hence the dilemma for humane doctors: since attitude matters so critically, should such a sombre conclusion be advertised, especially since few people have sufficient understanding of statistics to evaluate what the statements really mean? from years of experience with the small-scale evolution of bahamian land snails treated quantitatively, i have developed this technical knowledge - and i am convinced that it played a major role in saving my life. knowledge is indeed power, in bacon's proverb.

the problem may be briefly stated: what does "median mortality of eight months" signify in our vernacular? i suspect that most people, without training in statistics, would read such a statement as "i will probably be dead in eight months" - the very conclusion that must be avoided, since it isn't so, and since attitude matters so much.

i was not, of course, overjoyed, but i didn't read the statement in this vernacular way either. my technical training enjoined a different perspective on "eight months median mortality." the point is a subtle one, but profound - for it embodies the distinctive way of thinking in my own field of evolutionary biology and natural history.

we still carry the historical baggage of a platonic heritage that seeks sharp essences and definite boundaries. (thus we hope to find an unambiguous "beginning of life" or "definition of death," although nature often comes to us as irreducible continua.) this platonic heritage, with its emphasis in clear distinctions and separated immutable entities, leads us to view statistical measures of central tendency wrongly, indeed opposite to the appropriate interpretation in our actual world of variation, shadings, and continua. in short, we view means and medians as the hard "realities," and the variation that permits their calculation as a set of transient and imperfect measurements of this hidden essence. if the median is the reality and variation around the median just a device for its calculation, the "i will probably be dead in eight months" may pass as a reasonable interpretation.

but all evolutionary biologists know that variation itself is nature's only irreducible essence. variation is the hard reality, not a set of imperfect measures for a central tendency. means and medians are the abstractions. therefore, i looked at the mesothelioma statistics quite differently - and not only because i am an optimist who tends to see the doughnut instead of the hole, but primarily because i know that variation itself is the reality. i had to place myself amidst the variation.

when i learned about the eight-month median, my first intellectual reaction was: fine, half the people will live longer; now what are my chances of being in that half. i read for a furious and nervous hour and concluded, with relief: damned good. i possessed every one of the characteristics conferring a probability of longer life: i was young; my disease had been recognized in a relatively early stage; i would receive the nation's best medical treatment; i had the world to live for; i knew how to read the data properly and not despair.

another technical point then added even more solace. i immediately recognized that the distribution of variation about the eight-month median would almost surely be what statisticians call "right skewed." (in a symmetrical distribution, the profile of variation to the left of the central tendency is a mirror image of variation to the right. in skewed distributions, variation to one side of the central tendency is more stretched out - left skewed if extended to the left, right skewed if stretched out to the right.) the distribution of variation had to be right skewed, i reasoned. after all, the left of the distribution contains an irrevocable lower boundary of zero (since mesothelioma can only be identified at death or before). thus, there isn't much room for the distribution's lower (or left) half - it must be scrunched up between zero and eight months. but the upper (or right) half can extend out for years and years, even if nobody ultimately survives. the distribution must be right skewed, and i needed to know how long the extended tail ran - for i had already concluded that my favorable profile made me a good candidate for that part of the curve.

the distribution was indeed, strongly right skewed, with a long tail (however small) that extended for several years above the eight month median. i saw no reason why i shouldn't be in that small tail, and i breathed a very long sigh of relief. my technical knowledge had helped. i had read the graph correctly. i had asked the right question and found the answers. i had obtained, in all probability, the most precious of all possible gifts in the circumstances - substantial time. i didn't have to stop and immediately follow isaiah's injunction to hezekiah - set thine house in order for thou shalt die, and not live. i would have time to think, to plan, and to fight.

one final point about statistical distributions. they apply only to a prescribed set of circumstances - in this case to survival with mesothelioma under conventional modes of treatment. if circumstances change, the distribution may alter. i was placed on an experimental protocol of treatment and, if fortune holds, will be in the first cohort of a new distribution with high median and a right tail extending to death by natural causes at advanced old age.

it has become, in my view, a bit too trendy to regard the acceptance of death as something tantamount to intrinsic dignity. of course i agree with the preacher of ecclesiastes that there is a time to love and a time to die - and when my skein runs out i hope to face the end calmly and in my own way. for most situations, however, i prefer the more martial view that death is the ultimate enemy - and i find nothing reproachable in those who rage mightily against the dying of the light.

the swords of battle are numerous, and none more effective than humor. my death was announced at a meeting of my colleagues in scotland, and i almost experienced the delicious pleasure of reading my obituary penned by one of my best friends (the so-and-so got suspicious and checked; he too is a statistician, and didn't expect to find me so far out on the right tail). still, the incident provided my first good laugh after the diagnosis. just think, i almost got to repeat mark twain's most famous line of all: the reports of my death are greatly exaggerated.

a special thanks to dannielle for compiling all of this information for us!