Alec Guinness, Reluctant Intergalactic Icon
Merula, Guinness’ wife of 62 years, also suffered from deteriorating health during that time and spent much of July in the hospital. On Aug. 3, 2000, her doctor informed Matthew, their only child, that she had liver cancer. After Matthew described his father’s symptoms, the doctor looked at Guinness’ medical record and then drove out to Guinness’ home to examine him. Improbably, he diagnosed Guinness with liver cancer as well.
Risk Factors and Treatment
Liver cancer is the third most common cause of death from cancer in the world, responsible for nearly 700,000 deaths globally each year. Because hepatitis B, an important risk factor for liver cancer, is far more prevalent in less-developed countries, the cancer is much more common in these areas than in the United Kingdom or the United States, where an estimated 28,700 Americans will be diagnosed with liver cancer in 2012. (See “Likely Culprits of a Disease on the Rise.”
) It is about twice as common in men as in women, and it is primarily a disease of older age: The average age at diagnosis is 63, and it is rarely diagnosed in people under 40.
The exact type of liver cancer Guinness had is unknown, but it is likely that he had hepatocellular carcinoma, a form of liver cancer that accounts for close to 90 percent of all primary liver cancers. According to Steven Alberts, a medical oncologist at the Mayo Clinic in Rochester, Minn., very few cases of hepatocellular carcinoma occur without known risk factors. The majority are related to chronic infection with the hepatitis B or hepatitis C viruses, which are transmitted through contaminated blood, sexual activity, or from mother to child. After a person is infected, these viruses can lay dormant for decades, causing chronic inflammation that may lead to cirrhosis and cancer. Cirrhosis caused by heavy, chronic alcohol use is another major risk factor. Over the past few decades, other causes—like the hereditary disorder hemochromatosis, a condition in which excess iron builds up in the liver—have also been found to be behind a small but significant number of these cancers.
Because so many of the risk factors for hepatocellular carcinoma are associated with socially frowned-upon behaviors, patients are often unfairly blamed for their illness, says Ghassan Abou-Alfa, a medical oncologist at Memorial Sloan-Kettering Cancer Center in New York City. “It’s important to remove the ‘sin’ stigma from liver cancer patients,” he says. “Many people think of it as associated with IV drug abuse, unprotected sexual contact and alcoholism—and that’s often a tragic misconception.”
Screening of the nation’s blood supply became routine only in 1992, and because cancer usually follows infection decades later, many of the liver cancers that doctors are diagnosing today were likely caused by contaminated blood transfusions or medical equipment. In other cases, the hepatitis viruses have been passed on from mother to child. Neither Alec nor Merula Guinness was known to be a heavy drinker, but it’s possible that one was infected with hepatitis B or C through a transfusion or medical equipment and inadvertently exposed the other, leading to their similar diagnoses of liver cancer.
Although screening and vaccination for hepatitis B—a vaccine was developed in 1982 and the American Academy of Pediatrics has recommended since 1992 that all children be immunized—have dramatically reduced the number of hepatitis B–associated cancers in the United States, no vaccination exists for hepatitis C. “A vaccination for hepatitis C is the single most important thing we can do to reduce the rate of hepatocellular carcinoma in this country and probably the world,” says Mayer.
Improvements in the treatment of liver cancer have not been as dramatic as the steps taken toward the disease’s prevention in the last couple of decades, according to Mayer. Alberts points out that in the decade since Guinness’ diagnosis, small but significant treatment advances have been made; however, the standard treatment for advanced liver cancer in 2000 would have been much the same as it is today.
According to the National Cancer Institute (NCI), for purposes of treatment, patients with liver cancer are grouped into one of three categories: those with localized tumors that can be removed with surgery, those with localized tumors that cannot be treated with surgery, and those with advanced disease. In the first group, surgery usually leaves no signs of the disease. For patients who aren’t candidates for surgery but who have cancer confined to a single lobe of the liver, options may include a liver transplant or local treatments, such as radiofrequency ablation or transarterial chemoembolization (TACE). With radiofrequency ablation, a needle is inserted into the tumor to emit high-energy radiowaves that heat and destroy the tumor tissue. With TACE, chemotherapy drugs, such as doxorubicin or cisplatin, are injected directly into the hepatic artery along with a gel foam that blocks the blood supply so the drugs can be trapped in the liver. “TACE has been around for a while,” says Mayer, “but randomized trials about 10 years ago really showed an improved outcome of TACE versus giving the same chemo drugs intravenously.”
For advanced liver cancers—ones that have spread throughout the liver or metastasized—chemoembolization may still be an option. Another newer option is Nexavar (sorafenib), a type of molecularly targeted therapy called a multikinase inhibitor, which the U.S. Food and Drug Administration approved in 2007 for the treatment of hepatocellular carcinoma that cannot be removed with surgery. Nexavar targets enzymes that control tumor cell proliferation and angiogenesis, the growth of new blood vessels. “Nexavar is the only drug that has been shown to benefit patients with advanced liver cancer,” says Abou-Alfa. Even so, the drug increases survival by just a couple of months—to about 11 months from eight months, on average, for patients with advanced disease. “We’re still talking about a few more months, not years,” says Abou-Alfa. However, many more molecularly targeted drugs are in the pipeline, and doctors hope that hitting on a combination of drugs will lead to more dramatic increases in life expectancy, he says.
For patients with small, surgically removable tumors or early stage cancers, the five-year survival rate is 27 percent, according to the NCI. Those patients are a minority, however, because more than 80 percent of hepatocellular carcinomas tend to be diagnosed late, partly because many of the disease’s symptoms are vague and easily attributable to a less serious health problem, notes Abou-Alfa.
By far the biggest problem with trying to improve survival, says Mayer, is that by the time a large percentage of patients are diagnosed, they are already in liver failure or close to it. With many other cancers, deaths are due to metastasis, he explains, but most liver cancer deaths tend to be caused by liver failure. Adds Alberts, “You only need a fraction [of the liver] to function normally, so by the time symptoms develop, most of the liver is irreparably damaged.” Guinness’ symptoms—swollen legs, decreased appetite and fatigue—are, along with abdominal pain, nausea and jaundice, common symptoms of liver failure.
An Actor’s Legacy
Guinness died two days after his diagnosis, on Aug. 5, 2000, at King Edward VII Hospital, near his home in Steep Marsh, England. His wife died 72 days later. Colleagues from the acting world paid tribute to him in the international media, attesting to his role as a father figure not only to Anakin and Luke Skywalker, but to multiple generations of actors.
In keeping with his character, Guinness had never been comfortable being a famous intergalactic icon. His Star Wars contract—in addition to giving him 2.25 percent of the director’s cut—had stipulated that he would do only minimal publicity appearances. And he ignored Star Wars fan mail. As he recounted in A Positively Final Appearance, “I have no intention of revisiting any galaxy. I shrivel inside each time it’s mentioned.”
Even so, Star Wars’ success provided Guinness with financial security, and the fact that he continued to work was a testament to his love of acting. Author Piers Paul Read recounts a telling anecdote in Alec Guinness: The authorized biography: After completing his final scene as George Smiley in what would become a critically acclaimed performance for the original 1979 BBC miniseries Tinker, Tailor, Soldier, Spy, Guinness, with typical humility, wrote, “Think I’ve enjoyed it more than any job I’ve done, though probably feeble in the part.”
Jocelyn Selim is a veterinary student and freelance science and health writer in Gonzales, La.