Two cancers, but only one is (mostly) accurate

“The Bucket List,” directed by Rob Reiner, Warner Bros. Pictures, limited release Dec. 25th.

The Premise: Edward Cole (Jack Nicholson) is a billionaire in his 70s who develops choriocarcinoma, a rare and highly malignant cancer belonging to a larger category, germ cell tumors, arising from reproductive tissues. It has spread throughout his body. He undergoes brain surgery, and two masses are removed. His oncologists monitor blood tumor markers (proteins produced by the cancer) called AFP and HCG and treat him with chemotherapy, including the drug bleomycin. He is told he has six months to one year to live.

Cole shares a hospital room with Carter Chambers (Morgan Freeman), an auto mechanic also in his 70s who has metastatic lung cancer. Chambers is told that he, too, has one year at most to live. The pair embark on a trip around the world to play out their fantasies before dying. Cole’s cancer goes into remission, and Chambers is largely fine until he returns home, when he has a seizure. The tumor has spread to his brain, and he dies during surgery to remove it. Cole dies some months later.

The medical questions: Are choriocarcinomas and other germ cell tumors routinely monitored by tumor markers and treated with brain surgery and chemotherapy? Is this type of tumor generally fatal in less than one year? How long can a patient with metastatic lung cancer expect to live? Is surgery to remove a brain metastasis likely to be fatal?

The reality: “If [Cole] really existed, he would be the oldest patient in the country with this type of cancer,” says Dr. Lawrence H. Einhorn, oncologist and distinguished professor of medicine at Indiana University School of Medicine. Einhorn’s pioneering treatment of testicular cancer in the 1970s increased survival rates from 10% to more than 95%, and he led the medical team that treated and cured cyclist Lance Armstrong. “Most patients with germ cell cancers are in their 20s, 30s or 40s,” Einhorn says.

He says that the film may have patterned Cole’s case after Armstrong’s. Armstrong was in his 20s when diagnosed and suffered from a less aggressive germ cell tumor (an embryonal cell carcinoma or yolk sac tumor) that had spread to his brain and was treated with surgery and chemotherapy.

Einhorn says Cole’s treatment is medically correct but points to other inaccuracies in the movie. Whereas Armstrong’s type of tumor is associated with elevations of HCG and AFP, Cole’s would cause elevations only of HCG. Also, bleomycin can cause lung damage and is thus not typically used to treat elderly people (or professional athletes such as Armstrong).

Instead, Einhorn has found that another drug, ifosfamide, combined with other treatments for germ cell tumors (cisplatinum and etoposide), has comparable results to bleomycin.

Einhorn also thinks the oncologist should not tell Cole he has less than one year to live, since this kind of cancer, even with brain metastases, has a 40% to 50% cure rate. “There are more side effects from treating the elderly, but no evidence that they have a lower cure rate,” he says.

The film’s portrayal of Chambers’ cancer, compared with Cole’s, is largely accurate, says Dr. Roy S. Herbst, chief of thoracic medical oncology at the University of Texas M.D. Anderson Cancer Center. Herbst says he believes telling such a patient that he has less than one year to live is appropriate. Such a patient may sometimes have eight to 12 months without disease or symptoms before calamity strikes, he adds. The tumor’s eventual reappearance as a brain mass causing a seizure is also realistic.

Less accurate is Chambers’ death during surgery to remove the mass. Dr. Simon S. Lo, director of neuro-radiation oncology at Ohio State University Medical Center, says that such a death is quite rare. “Patients are far more likely to die of later complications such as aspiration pneumonia or another infection,” he says.

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Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. In The Unreal World, he explains the medical facts behind the media fiction. He can be reached at marc@doctorsiegel.com.