WHEN STAR WARS OPENED in 1977, Sir Alec Guinness’ role as Obi-Wan Kenobi made him an instant cult hero. In a very real sense, Guinness was perfect for the role of the master Jedi knight who would uphold the metaphysical sense of good and spirituality embodied by “the force.”
Guinness had not only been knighted in real life, but he had established himself as one of the greatest British actors of his generation. He had also developed a famously retiring, sage-like persona and a reputation as a devoted follower of Catholicism. In letters to his friends, Guinness described the Star Wars script as “fairy-tale rubbish,” but the movie’s sense of moral good—and the studio’s doubling of his initial salary offer—appealed to him, and he signed on.
Guinness’ participation lent the film much-needed credibility—the bizarre sets of George Lucas’ space opera had more than a few people doubting the film would be a success, and most of the actors, including Harrison Ford and Carrie Fisher, were relative newcomers. Guinness, on the other hand, had started his career onstage doing Shakespeare with the likes of Laurence Olivier and John Gielgud, and he had successfully navigated the transition to television and film, starring in classics like the Bridge on the River Kwai, Lawrence of Arabia and Doctor Zhivago.
By the time Guinness died of liver cancer at age 86 in 2000, his career had spanned six decades and included parts in about 70 theater productions, more than 50 films and over a dozen television shows. He had received two Oscars, been knighted by Queen Elizabeth II of England, and been made a Companion of Honour as well.
Today, a dozen years after his death, the liver cancer that ended his career still remains a frustrating disease. “I think it’s fair to say that … we haven’t seen dramatic increases in life expectancy,” says Robert J. Mayer, a gastrointestinal oncologist at the Dana-Farber Cancer Institute in Boston. But that doesn’t mean advances haven’t been made: The last two decades have seen the emergence of treatments designed to cut off the blood vessels that feed liver tumors. Those treatments have been only modestly successful, but they do suggest a new approach to therapy. “While they’re not home runs, they are certainly base hits,” says Mayer.
Humble Beginnings to Legendary Career
When asked what it was that drew him to acting, Guinness was fond of telling interviewers, “One became an actor to escape from oneself.” That Guinness might have a deep-seated need to escape was understandable. The circumstances of Guinness’ birth in 1914 were scandalous: His mother, Agnes Cuff—perhaps in an attempt to give her illegitimate son some semblance of social acceptability—listed his name on his birth certificate as Alec Guinness de Cuffe. His real father, he later believed, was a Scottish banker named Andrew Geddes, whom Guinness saw only occasionally. Geddes, posing as an uncle, paid for the boy’s boarding school fees but had little else to do with his life.
“I … was born to confusion,” Guinness recounted in a journal in 1985, “owning three different names until the age of fourteen and living in about thirty different hotels, lodgings and flats, each of which was hailed as ‘home’ until such time as my mother and I flitted, leaving behind, like a paper-chase, a wake of unpaid bills.”
At age 5, young Alec had his last name changed to Stiven, when his mother married a violent army lieutenant, who at various times held him by his ankles over a river threatening to drown him, or held a gun to his head. The marriage lasted less than a decade, and Alec’s escape to a young gentleman’s boarding school was a mixed blessing. It afforded young Alec some protection from his promiscuous, often tipsy, and notoriously thieving mother. But an awareness of gentlemanly conduct instilled by his schoolmasters also led him to a sense of embarrassment and shame about his mother that he would carry with him the rest of his life.
Guinness caught the acting bug early, putting on productions for his schoolmates in a makeshift cardboard theater and spending his small amount of pocket money on theater tickets whenever possible. After he graduated from secondary school, he worked briefly at an advertising agency and then enrolled in a drama school after winning a scholarship—the only way he could afford to pursue training. By his early 20s, Guinness had already begun to establish a name for himself onstage, most notably in a version of Shakespeare’s Hamlet. Minus a stint in World War II as a British navy lieutenant, he would work steadily as an actor until his 70s.
Guinness’ ability to blend into any role was the stuff of legend. In the 1949 classic Kind Hearts and Coronets, he took on eight different roles. His career saw him playing an improbable range of characters, from the acquiescing Herbert Pocket of Great Expectations to Adolf Hitler in Hitler: The last ten days. In a 1953 study of Guinness’ work, theater critic Kenneth Tynan mused that “were he to commit a murder … the number of false arrests following the circulation of his description would break all records.”
Tynan also gave Guinness credit for an almost preternatural acting ability. “At the core of Guinness’s impersonations there is a kind of impersonal peace,” he wrote. “He is a master, but he is the master of anonymity. His obsequious magic gets its results not by noise or declamation, but—almost—by spells.”
In his final decades, Guinness found success as an author as well, publishing three best-selling autobiographical journals. In the last, A Positively Final Appearance, Guinness reflected, “My life has been enjoyable and basically content; the rewards I have received, both professionally and privately, have been undeserved and surprising. If, God forbid, I am struck gravely ill in my last days, I pray I won’t have the effrontery to complain.” In another chapter, in an entry in June 1998, he writes, in a moment of uncharacteristic moroseness, “I sat up abruptly in bed on this gloomy morning saying to myself, you have only another 700 days to live. … A quick rough reckoning gave me until November 2000.”
Guinness’ premonition would prove eerily close to reality. In February 2000, he was diagnosed with early stage prostate cancer, which he referred to in a letter to a friend as “the old gent’s disease.” Tests showed that the cancer was confined to his prostate, and Guinness began anti-androgen hormone treatment. In his letter, he wrote that his doctors “tell me I’m far more likely to die from being knocked down by a train in Liverpool than from the disease. So I am avoiding Liverpool.”
But despite the good prognosis for Guinness’ prostate cancer, by that spring, his legs had become swollen. He was thought to have phlebitis—inflammation of the veins—and was given pills to reduce the swelling. He also lost his appetite, refusing to eat anything but fruit and spending more and more time in bed.
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.
Likely Culprits of a Disease on the Rise
Several factors have contributed to an increase in liver cancer.
The percentage of Americans developing liver cancer has been rising for several decades. The National Cancer Institute estimates that new diagnoses in the mid-2000s were triple those of the mid-1970s. In the period from 2001 to 2006, the most recent period for which statistics are available, the number of new liver cancer diagnoses rose by an average of 3.5 percent a year.
Yet, since 1992, the nation’s blood supply has been screened for both hepatitis B and C—two of the major risk factors for liver cancer. And a vaccine against hepatitis B has been recommended for all children and at-risk adults since 1992, as well. So why are liver cancer rates still rising?
“In the United States, most of this increase can be traced to hepatitis C infections,” says Ghassan Abou-Alfa, a medical oncologist at Memorial Sloan-Kettering Cancer Center in New York City. Although the number of new hepatitis C infections has dropped over the last two decades, approximately 3.2 million Americans are already infected with chronic hepatitis C, according to the Centers for Disease Control and Prevention. “It can take 30 years before chronic infection leads to cirrhosis and hepatocellular carcinoma,” the most common form of liver cancer, says Abou-Alfa. “So many of the cancer cases we’re seeing today are those people who were infected as early as the 1970s.”
Another contributor to U.S. liver cancer incidence, says Abou-Alfa, is nonalcoholic fatty liver disease, a growing problem that is associated with diabetes and morbid obesity—two conditions that are also on the rise.
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” above.) 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.
Who Should Get Tested for Hepatitis B and C?
The Centers for Disease Control and Prevention offers guidelines for testing.
According to the Centers for Disease Control and Prevention, you should talk to your doctor about being tested for hepatitis B or C if any of the following apply:
For hepatitis B:
- Individuals born in geographic regions with intermediate or high rates of hepatitis B
- U.S.-born individuals who were not vaccinated as infants and whose parents were born in geographic regions with high rates of hepatitis B
- Injection-drug users
- Men who have sex with men
- Individuals with an elevated result on the blood test ALT/AST of unknown cause
- Individuals with selected medical conditions who require immunosuppressive therapy
- Pregnant women
- Infants born to mothers who test positive for hepatitis B infection
- Household contacts and sex partners of hepatitis B–infected persons
- Individuals who are the source of blood or body fluid exposures to others (for example, a needlestick injury to a health care worker)
- Individuals infected with HIV
For hepatitis C:
- Individuals who were treated for a blood-clotting problem before 1987
- Individuals who are current or former injection-drug users, even if they injected only one time or many years ago
- Individuals who received a blood transfusion or organ transplant before July 1992
- Individuals who have undergone long-term hemodialysis treatment
- Individuals who have abnormal liver tests or liver disease
- Individuals who work in health care or public safety and were exposed to blood infected with hepatitis C through a needlestick or other sharp object injury
- Individuals infected with HIV
- Children born to mothers who have hepatitis C
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.”
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