The Balcony is Closed – Roger Ebert’s Story

Roger Ebert, the popular film critic and television co-host who along with his fellow reviewer and sometime sparring partner Gene Siskel could lift or sink the fortunes of a movie with their trademark thumbs up or thumbs down, died on Thursday in Chicago. He was 70.

His death was announced by The Chicago Sun-Times, where he had worked for many years.

Mr. Ebert’s struggle with cancer, starting in 2002, gave him an altogether different public image — as someone who refused to surrender to illness. Though he had operations for cancer of the thyroid, salivary glands and chin, lost his ability to eat, drink and speak (a prosthesis partly obscured the loss of much of his chin, and he was fed through a tube) and became a gaunter version of his once-portly self, he continued to write reviews and commentary and published a cookbook he had started, on meals that could be made with a rice cooker.

“When I am writing, my problems become invisible, and I am the same person I always was,” he told Esquire magazine in 2010. “All is well. I am as I should be.”

Roger Ebert’s Fight With Cancer

In early 2002, Ebert was diagnosed with papillary thyroid cancer. In February, surgeons at Northwestern Memorial Hospital successfully removed the cancer with clean margins. He later underwent surgery in 2003 for cancer in his salivary gland, and in December of that year, underwent a four-week follow-up course of radiation to his salivary glands, which altered his voice slightly. Ebert continued to be a dedicated critic of film, not missing a single opening while undergoing treatment.

Ebert underwent further surgery on June 16, 2006, two days before his 64th birthday, to remove additional cancerous tissue near his right jaw, which included removing a section of jaw bone. On July 1, Ebert was hospitalized in serious condition after his carotid artery burst near the surgery site and he “came within a breath of death”. He later learned that the burst was likely a side effect of his treatment, which involved neutron beam radiation. He was subsequently kept bedridden to prevent further damage to the scarred vessels in his neck while he slowly recovered from multiple surgeries and the rigorous treatment. At one point, his status was so precarious that Ebert had a tracheotomy performed on his neck to reduce the effort of breathing while he recovered. Although it was not revealed at the time, Ebert also lost the ability both to speak and to eat or drink (so that he would have to use a feeding tube).

Next, Roger Ebert underwent surgery on January 24, 2008, this time in Houston, to address the complications from his previous surgeries. A statement from Ebert and his wife indicated that “the surgery went well, and the Eberts look forward to giving you more good news…” but on April 1, his 41st anniversary as a film critic at the Sun-Times, Ebert announced that there had been further complications and his speech had not been restored. He wrote, “I am still cancer-free, and not ready to think about more surgery at this time. I should be content with the abundance I have.” His columns resumed shortly after the April 23 opening of his annual film festival at the University of Illinois. During his various surgeries, doctors carved bone, tissue and skin from his back, arm, and legs, and transplanted them in an attempt to reconstruct his jaw and throat, though these transplants would each be unsuccessful, and eventually removed. As a result of these procedures, his right shoulder was visibly smaller than his left, and his legs had been scarred and weakened.

“More Harm Than Good”

As of February 2010, Ebert had a full-time, live-in nurse to attend to him when he needed assistance. Although doctors asked him to allow them to make one more attempt to restore his voice, Ebert refused, indicating that he was done with surgery, and would likely decline significant intervention even if his cancer returned, since he felt that the last procedure he underwent did more harm than good. Regarding his death one day, he wrote:

I know it is coming, and I do not fear it, because I believe there is nothing on the other side of death to fear. I hope to be spared as much pain as possible on the approach path. I was perfectly content before I was born, and I think of death as the same state. What I am grateful for is the gift of intelligence, and for life, love, wonder, and laughter. You can’t say it wasn’t interesting. My lifetime’s memories are what I have brought home from the trip. I will require them for eternity no more than that little souvenir of the Eiffel Tower I brought home from Paris.

Ebert employed a Scottish company called CereProc, which custom-tailors text-to-speech software for voiceless customers who record their voices at length before losing them, and mined tapes and DVD commentaries featuring Ebert to create a voice that sounded more like his own voice. He used the voice they devised for him in his March 2, 2010, appearance on The Oprah Winfrey Show,in which he discussed his methods of coping with the loss of his voice and his other post-surgical difficulties. Ebert later proposed a test to determine the realism of a synthesized voice. By January 2011, Ebert had been given a prosthesis for his chin created by University of Illinois craniofacial doctors and other specialists. The prosthesis, which took two years to fabricate, was worn by Ebert on Ebert Presents: At the Movies, in a medium shot of him that was used for the “Roger’s Office” segment.

In December 2012, Ebert was hospitalized with a fractured hip, which his wife Chaz jokingly blamed on “tricky disco dance moves”.

On April 2, 2013, Roger Ebert announced that he would be taking a “leave of presence” from his duties because the hip fracture he suffered a few months earlier was determined to be cancer and he would be receiving radiation treatment. He died two days later. The closing sentence on his final blog post, two days before his death, said, “So on this day of reflection I say again, thank you for going on this journey with me. I’ll see you at the movies.”

What is Papillary Thyroid Cancer?

Papillary carcinoma typically arises as an irregular, solid or cystic mass that comes from otherwise normal thyroid tissue. This cancer has a high cure rate with 10-year survival rates for all patients with papillary thyroid cancer estimated at 80% to 90%. Cervical metastasis (spread to lymph nodes in the neck) are present in 50% of small papillary carcinomas and in more than 75% of the larger papillary thyroid carcinomas.

The presence of lymph node metastasis in these cervical areas causes a higher recurrence rate but not a higher mortality rate. Distant metastasis is uncommon, but lung and bone are the most common sites if the papillary carcinoma does spread. Tumors that invade or extend beyond the thyroid capsule have a much worse prognosis because of a high local recurrence rate.

Characteristics of Papillary Thyroid Cancer

  • Peak onset ages are 30 to 50 years old.
  • Papillary thyroid cancer is more common in females than in males by a 3:1 ratio.
  • The prognosis directly related to tumor size. (Less than 1.5 cm [1/2 inch] is a good prognosis.)
  • This cancer accounts for 85% of thyroid cancers due to radiation exposure.
  • In more than 50% of cases, it spreads to lymph nodes of the neck.
  • Distant spread (to lungs or bones) is uncommon.
  • The overall cure rate is very high (near 100% for small lesions in young patients).

Considerable controversy exists when discussing the management of well-differentiated thyroid carcinomas (papillary and even follicular). Some experts contend than if these tumors are small and not invading other tissues (the usual case) then simply removing the lobe of the thyroid that harbors the tumor (and the small central portion called the isthmus) will provide as good a chance of cure as removing the entire thyroid.

These proponents of conservative surgical therapy relate the low rate of clinical tumor recurrence (5% to 20%) despite the fact that small amounts of tumor cells can be found in up to 88% of the opposite lobe thyroid tissues. They also cite some studies showing an increased risk of and recurrent laryngeal nerve injury in patients undergoing total thyroidectomy (since it is an operation on both sides of the neck).

Proponents of total thyroidectomy (more aggressive surgery) cite several large studies that show that in experienced hands, the incidence of recurrent nerve injury and permanent hypoparathyroidism are quite low (about 2%). More importantly, these studies show that patients with total thyroidectomy followed by radioiodine therapy and thyroid suppression, have a significantly lower recurrence rate and lower mortality when tumors are greater than 1.5 cm. Remember that it is also desirable to reduce the amount of normal gland tissue that will take up radioiodine.

Based on the these studies and the above natural history and epidemiology of papillary carcinoma, the following is a typical plan for treating papillary thyroid cancer: Papillary carcinomas that are well circumscribed, isolated, and less than 1 cm in a young patient (20 to 40) without a history of radiation exposure may be treated with hemithyroidectomy and isthmusthectomy.

What are some other papillary thyroid cancer treatments? All other patients should probably be treated with total thyroidectomy and removal of any enlarged lymph nodes in the central or lateral neck areas. The surgical options are covered in greater detail (with drawings) on our article on surgical options for thyroid cancer. Often, other characteristics of the tumor that can be seen under the microscope will have an influence on whether the surgeon should take all the thyroid out (things such as vascular invasion, nerve invasion, and capsule invasion).

The Use of Radioactive Iodine and Papillary Thyroid Cancer

Thyroid cells are unique in that they have the cellular mechanism to absorb iodine. The iodine is used by thyroid cells to make thyroid hormone. No other cell in the body can absorb or concentrate iodine. Physicians can take advantage of this fact and give radioactive iodine to patients as a treatment option for papillary thyroid cancer.

There are several types of radioactive iodine, with one type being toxic to cells. Papillary thyroid cancer cells absorb iodine; therefore, they can be destroyed by giving the toxic isotope (I-131). Again, not everyone with papillary thyroid cancer needs this treatment, but those with larger tumors, tumors that have spread to lymph nodes or other areas, tumors that are aggressive microscopically, and older patients, may benefit from this treatment.

This is an extremely effective type of “chemotherapy” will little or no potential downsides (eg, no hair loss, nausea, or weight loss).

Uptake is enhanced by high thyroid-stimulating hormone (TSH) levels; thus, patients should be off thyroid replacement and on a low iodine diet for at least 1 to 2 weeks before being treated with radiactive iodine. It is usually given 6 weeks after surgery (although it depends on the patient), and it can be repeated every 6 months if necessary (within certain dose limits).

Thyroid Hormone Replacement and Papillary Thyroid Cancer

Regardless of whether a patient has just one thyroid lobe and the isthmus removed, or the entire thyroid gland removed, most experts agree they should be placed on thyroid hormone replacement for the rest of their lives. This replaces the hormone in those who have no thyroid left, and to suppress further growth of the gland in those with some tissue left in the neck.

There is good evidence that papillary carcinoma responds to TSH secreted by the pituitary, therefore, exogenous thyroid hormone is given, which results in decreased TSH levels and a lower impetus for any remaining cancer cells to grow. Recurrence and mortality rates have been shown to be lower in patients receiving suppression.

An Alternative Treatment – CAAT

Angelo P. John, cancer theorist for over 40 years, devised a unique form of nutritional therapy designed to starve and kill off malignant cells while still feeding the patient. The process is called CAAT or controlled amino acid treatment. A special blend of amino acids is prepared and taken by the patient in conjunction with a strict diet rich in nutrients & certain supplements. These nutrients and supplements are designed to heal the body (such as vitamins A, C & D) but are devoid of supplements that would encourage the growth and spread of cancer (such as B6). The process has been used since 1994 to treat a wide variety of cancer patients.

We’ll see you at the movies, Roger Ebert. Rest in peace.

Sources: USA Today, Cancer.gov, Yahoo Health

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