Experts Debate Whether Doctors Responded Too Slowly : Reagan Case: An Anatomy of a Cancer

Did President Reagan develop cancer because 14 months ago, when the first small benign tumor was removed from his large intestine, his doctors failed to pursue aggressively the possibility that another polyp might be growing in his body?

The medical care of the President of the United States is widely assumed to be the finest in the world, with nothing left to chance. Yet the treatment of Reagan since March, 1984, when the first tiny polyp was found, has become the subject of an increasingly edgy debate--with some cancer specialists suggesting that the White House and Reagan’s doctors responded too slowly to what now could become a life-threatening problem.

Nationally and internationally known cancer experts have voiced differing opinions, while Navy and civilian doctors involved in the case have defended their conduct. Adding to the controversy has been an undercurrent of suggestions that White House decisions on the timing of some medical procedures may have been influenced by political considerations, especially during last year’s presidential campaign.

It may be too early to say whether Reagan’s doctors responded too slowly. However, based on what is now known, the decisions made on the President’s treatment appear to reflect not so much negligence or incompetence as the judgment calls and compromises of a profession that is not yet precise in every situation--especially with diseases as elusive as cancer.

Medically, the current debate hinges primarily on decisions made when the first benign polyp was discovered in Reagan’s colon 14 months ago. At issue is whether Reagan’s doctors should have strongly encouraged him to undergo a procedure called colonoscopy, which allows the entire length of the six-foot-long colon to be explored for other polyps.

Some cancer specialists now argue that such an examination should have been performed on Reagan, because those who develop one polyp have an increased tendency to develop others and because they sometimes are malignant.

Here, step by step, is a reconstruction of the President’s bout with colon cancer and the points of debate:

May 18, 1984--Reagan undergoes his first complete physical examination in 2 1/2 years, and doctors discover a small “inflammatory pseudo-polyp” in his large intestine. The polyp, determined to be benign, is only partly removed.

It is detected by an instrument called a sigmoidoscope, which reaches only about 10 inches into the colon. When asked whether a colonoscopy would be done, White House spokesman Larry Speakes says doctors will decide later “if they need to do anything.”

A series of tests, known as “hemoccults,” which are intended to detect the presence of blood in the stool--a sign that cancer may be present in the intestines--shows no evidence of blood.

July 24, 1984--Dr. Daniel Ruge, Reagan’s personal physician, says that doctors have decided not to conduct a further examination of the colon and that the President probably will not have another physical for “two or three years.” Ruge says the growth removed in May was “something you don’t have to worry about.”

That assessment would later become the center of controversy when the President is found to have developed colon cancer.

March 8, 1985--A physical exam detects a second polyp in Reagan’s colon, and doctors say it should be removed. The White House decides to put off the procedure until mid- or late June, after Reagan’s European summit tour in May and after a period of work and speeches on his tax revision proposal.

The results of hemoccult tests taken at this time and the doctors’ response to them would eventually become part of the controversy. Some specialists would suggest later that, even though the results were not conclusive, they should have been followed up more aggressively because they contained some indications of blood in the stool.

June 14, 1985--The 17-day hostage crisis further delays removal of the new polyp.

July 12, 1985--Reagan receives a colonoscopy, and the new polyp is discovered to be a large villous adenoma nearly six feet into the colon, near the point where it joins the small intestine.

July 13, 1985--Surgeons at Bethesda Naval Medical Center remove the polyp, together with a two-foot-long section of Reagan’s colon, and report no visual signs of cancer, though they caution that it cannot be ruled out until pathologists complete a detailed study.

Doctors say X-rays and CAT scans give no indication that cancer has spread to the liver or other nearby organs.

July 15, 1985--Dr. Steven Rosenberg, a National Cancer Institute specialist and member of the surgical team, says the pathology report shows that the polyp was malignant and had spread into several layers of the wall of the colon segment that was removed, but that no cancer cells were detected at either end of the segment.

He reports no evidence that cancer spread to the lymph nodes, blood vessels or nerves.

The cancer is classified as a Duke’s type B, a type in which cancerous cells are just short of invading the lymph nodes. Node involvement would have greatly increased the possibility that cancer cells had spread to other organs. Rosenberg says the likelihood of Reagan surviving for five years or more is “certainly greater than 50%.”

News that the polyp was malignant renews speculation that the cancer might have been prevented if Reagan’s doctors had done the colonoscopy in May, 1984.

Dr. Edward Cattau, the Bethesda hospital gastroenterologist who found and treated both polyps, says that the first one was not the type that would indicate a subsequent cancerous growth elsewhere in the body.

Other Procedure Cited

Doctors not connected with the case, on the other hand, suggest that at least the proper procedure would have been to give Reagan a barium enema to see if other polyps were present. Even if the barium enema proved negative, the standard of care would have been to do a colonoscopy within six months.

Cattau says that a lot of thought had been given to colonoscopy but that Reagan’s doctors had decided against it on grounds that the cellular characteristics of the original polyp did not indicate cancer.

Rosenberg, the National Cancer Institute specialist, said last week that he endorses the treatment plan followed by Cattau in May, 1984. That plan, based on Reagan’s age of 74 and no known risk of colon cancer, consisted of annual examinations of the stool for blood and sigmoidoscopy examination every three to five years.

Only if one of those examinations proved positive, Cattau said, would there be an indication that a colonoscopy was needed. And when the March, 1985, hemoccult suggested the possibility of blood in Reagan’s stool, his doctors did indeed recommend a colonoscopy.

That was the test delayed for more than four months because of Reagan’s schedule.

‘Impossible’ to Determine

Rosenberg, addressing the question at the heart of the controversy, said it would be “impossible” to determine now whether the adenoma was benign or malignant 14 months ago, if indeed it had developed then.

Angered by what they called “second-guessing” by outside doctors, White House spokesmen and First Lady Nancy Reagan have defended the decision made in May, 1984, not to do a colonoscopy. They have said that they are “content” with that decision.

Speakes said Thursday that “it is correct to say that there was no recommendation that we have any further testing done in 1984.”

Questions about the urgency with which the medical team recommended a colonoscopy in March of this year also have arisen. White House officials have indicated that the Bethesda Naval Medical Center doctors who detected the presence of the second polyp made no recommendation of urgency.

But in an interview Wednesday with the New York Times, Capt. Walter W. Karney, an internist who coordinated the President’s physical examinations in 1984 and 1985, said Cattau had “strongly urged” in March that the colonoscopy be done “as soon as possible.”

Public Explanation Urged

Karney indicated that the naval medical center has been criticized unfairly because a colonoscopy was not done 14 months ago. He said the White House doctors, who have final authority on what is done, should “set the record straight” by explaining publicly why they agreed that a colonoscopy was not needed then.

Another issue that has raised questions concerns the hemoccult tests that were given to Reagan to detect the presence of blood in his stool. In May, 1984, the tests were negative. But in March of this year, the first two tests were positive and the second two were negative. According to most authorities, a positive hemoccult test should be followed with a barium enema or colonoscopy or both.

Some experts say that a positive test of any kind should raise suspicion and trigger further investigation. One basis for this opinion is that polyps sometimes bleed for a while and then stop. It is possible, they say, that the tests were negative for that reason.