Should We Be Concerned that John McCain Has a History of Skin Cancer?
In the beginning of September, John McCain will be the nominee of the Republican Party for President of the United States, the oldest major party candidate to run for a first term. Also unique to his candidacy is the well-documented publicly acknowleged history of a highly malignant and potentially life-threatening skin cancer, melanoma. Other presidents have had cancer; one, Grover Cleveland, surreptitiously and successfully treated it with radical surgery, but never has such a prior history been a potential issue in a presidential election.
A legitimate question arises as to what the American people need to know about McCain’s ability to complete his term unimpaired by illness, prior to his acceptance of the nomination. With respect to his melanoma, this will undoubtedly be debated in the forthcoming election if it is not pre-emptively and properly addressed. While one of us briefly discussed this in a recent HNN post, quoting a March 9th article in the New York Times by Lawrence K. Altman, M.D., this article provides an updated, in-depth assessment of the chances Senator McCain would be able to complete his term without a recurrence of cancer.
Dr. Altman’s prognostication--“for patients with a melanoma like Mr. McCain’s who remained free of the disease for the first five years after the diagnosis, the probability of recurrence was 14 percent during the next five years and death in 9 percent"-- is based on an article published in 1992.
Since then, as medical science has advanced, the accuracy of staging has improved (1). Even more recent literature (2) admits that even employing present day criteria, recurrence rates were calculated from older data. The statistics for recurrence and fatality for stage IIa disease are actually considerably lower. The paper cited by Dr. Altman included a number of patients whose lymph node metastases were not yet identified. Since then, the sensitivity for diagnosing metastatic disease has improved with the popular adoption of sentinel node biopsy and Positron Emission Tomographic (PET) scanning. Therefore, the recurrence and fatality rates cited in the earlier study included an undetermined but significant number of patients who actually had more advanced Stage III, not Stage IIa, melanoma. As testimony to its value as a diagnostic tool, there is high correlation between the projected incidence of sentinel node metastases from clinical Stage IIa melanoma, approximately 15-20%, with the historic recurrence rate before sentinel node biopsy was performed.
Today (and in 2000), the standard of care for the initial surgery for Stage IIa melanoma includes sentinel node biopsy, as was done for Senator McCain. Since his sentinel nodes showed no evidence of disease, his risk of recurrence and death from melanoma is considerably lower than Dr. Altman states, more on the order of 2-3 % recurrence and 1-2% fatality at five years. These prognostic projections are based on numerous studies from leading U.S. melanoma centers including M.D. Anderson Cancer Center in Houston and John Wayne Cancer Center in Santa Monica, CA (an additional list of references will be supplied upon request).
Senator McCain’s known melanoma history is as follows:
1993-A small melanoma in situ, the most benign form of the disease, was removed from the left shoulder by local excision.
2000- A melanoma in situ was removed by local excision from the left arm. Another melanoma, 2 centimeters (about the width of the fingertip, see second photo at left) in diameter and 0.22 centimeters deep, was removed from the left cheek by wide excision with extensive lymph node dissection and biopsy, with no evidence of metastasis. The classification of this melanoma is based on the maximal tumor thickness of 2.2 mm without ulceration (loss of the surface layer), designated as T2a in the current international cancer staging system.
2003- A melanoma in situ removed from the nose by local excision (lower right photo).
The other important question to address, in light of the fact that Senator McCain is applying for a four year contract as the most powerful man on the face of the earth, is what diagnostic testing needs to be done, prior to acceptance of the nomination, in order to provide voters with the greatest assurance that the candidate will survive his term of office?
The risk of recurrence is fairly low and as time passes, it will continue to decrease but never to zero. Melanoma is notorious for recurring years if not decades after its initial diagnosis. Therefore, regularly monitoring is essential.
Melanoma may recur locally or may also metastasize to other organs, most commonly the liver, lungs, bowels, bones and/or brain. Metastases are often asymptomatic and may sometimes only be located on screening imaging studies performed periodically, even in the absence of any symptoms or signs of clinical recurrence. Metastatic disease is associated with a very guarded prognosis, with more than a 50% chance of dying of melanoma within the first year after it is identified. Brain metastases, the second leading cause of death, are especially malignant, being found in 90 percent of patients who die of melanoma, with an average life expectancy of well less than half a year when symptomatic. These figures underscore the necessity for updated, accurate staging studies.
Had Senator McCain not been running for president, screening might be as simple as a careful annual physical examination and chest x-ray. In consideration of the gravity and importance of the office and ability to obtain reliable information with virtually no downside risk, a reasonable diagnostic recommendation in this case would be, at the minimum, the combination a whole body Fusion PET/CT scan and a brain MRI with gadolinium enhancement. A paper published in 2007 (3) suggests an increased yield using whole-body MRI, but this as yet has not been employed on a widespread basis. These tests are complimentary, with different areas of sensitivity; PET being a measure of function and MRI one of anatomy. Objectively documented presence of metastatic melanoma would forebode a poor prognosis. A negative result on these two examinations would provide voters a reasonable assurance of a presently disease-free state and of the ability to complete a four year term.
(1) Gershenwald JE, et al; Multi-Institutional Melanoma Lymphatic Mapping Experience: The Prognostic Value of Sentinel Lymph Node Status in 612 Stage I or II Melanoma Patients; J Clin Oncol 1999; 17: 976-983
(2) Gimotty PA, Botbyl J, Soong S, Guerry D, A Population-Based Validation of the American Joint Committee on Cancer Melanoma Staging System. J Clin Oncol 2005 Nov; 23: 8065-8075
(3) Schmidt GP, Kramer H, Reiser MF, Glaser C., Whole-body magnetic resonance imaging and positron emission tomography-computed tomography in oncology. Top Magn Reson Imaging, 2007 Jun; 18(3): 193-202
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Don Walters - 5/26/2008
I'm wondering if Dr. Lomazow or Dr. Whitman would care to comment on Mr. McCain's recent medical records display (not an actual release, reporters had 3 hours to look at them and weren't allowed to make copies). Most of the press is simply regurgitating what McCain's spin doctors are telling them, but a couple are actually bothering to look into the materials themselves. Here is a quote from a NY Times article:
"But the 1,173 pages of medical records did provide some important details about his cancer in 2000: Two pathologists at the Armed Forces Institute of Pathology who examined the melanoma specimen from Mr. McCain’s left temple in 2000 suggested that there were two melanomas on his temple, not one, as his doctors had said publicly at the time. Specifically, the Armed Forces Institute pathology report said that details about the lesion were “highly suggestive of a metastasis of malignant melanoma and may represent a satellite metastasis,” with satellite meaning one melanoma had spread to create another.
The Mayo Clinic in Scottsdale said it “cannot comment” on another institution’s medical opinion, and stood by its diagnosis and treatment of Mr. McCain’s melanoma. Mr. McCain’s melanoma is classified as Stage IIA, his campaign has said.
But two experts in the field who reviewed the pathology report released on Friday said it was unclear whether the melanoma on Mr. McCain’s temple had metastasized from another, or whether there was one new primary melanoma.
If the spread was through the nearby melanoma, that could suggest a greater risk, said Dr. Lynn M. Schuchter, a melanoma expert at the University of Pennsylvania, and Dr. Mohammed Kashani-Sabet, director of the Melanoma Center at the University of California, San Francisco."
Maarja Krusten - 5/25/2008
As a current employee of the federal government, I don't comment on some of the issues that other HNN readers do. As you recall, I belong to neither party, but am an Independent.
I do feel it's ok, however, for me to point out the correct German usage to Mr. Hughes, who strikes me as a very well-educated person who would not take offense at such a correction from me.
As I recall, Mr. Hughes is a veteran. One of the more interesting things for me to observe on HNN, which I first began reading around 2003 or 2004, is how those who once served (either as volunteers or conscripts) interact with those who did not.
I once heard Gen. Anthony Zinni (ret.) speak generally on the "leadership deficit" in the private and public sector but have not been able to find any transcripts for that speech or for similar speeches he has given elsewhere.
Andrew D. Todd - 5/25/2008
I doubt Mr. Hughes speaks German. More substantively, McCain's authority is naturally confined to those who accept his principles. Adenauer's authority did not extend to East Germany, nor to France. The Democrats do not have a leadership gap, and are not disposed to give McCain any authority. His authority is confined to the Republican Party.
The basic problem of the Republican Party is that most of its leading lights-- not the elected officials, but the people behind the elected officials-- have spent the last thirty or forty years in business, especially in entrepreneurial business, making money. They are the post-conscription generation. Practically none of them have experience even of peacetime soldiering, and the number who got to either Desert Storm or Bosnia is still smaller. What they did in their early twenties was to go to good colleges, the kind that don't accept "second chance" students, and then to either business school or law school. That's fine if you are a Libertarian, but Libertarians don't believe in armies and wars-- at least not at anything approaching the global level practiced by the present administration. The problem is that the "National Greatness" Republicans do not have leaders capable of being examples of what they preach. McCain is about the only surviving Republican politician who has any moral right to send young troops into battle.
The "New Class" is very big on Free Trade. Granted that things are cheap at Wal-Mart, but they aren't ten times cheaper, the spread for Mexican wages, or a hundred times cheaper, the spread for Chinese wages. That leaves a lot of room for politically connected lawyers and realtors to make money out of putting up new Wal-Marts. The long-term implication is that the Republican elite doesn't quite understand that they cannot treat American GI's like minimum wage workers: time 'em with a stopwatch to make 'em work faster, fire 'em when you don't need 'em, replace 'em with Mexicans as expedient, etc. McCain has gotten tricked into drinking the Free-Trade kool-aid supplied by his political backers, which, in Arizona, means people who make their living out of the difference between American wages and Mexican wages. His exchange with Obama over veterans benefits is indicative. Obama wanted a generous package, but McCain said it was too much because the troops might not re-enlist. The troops are all stop-lossed anyway, but the exchange gave the impression that McCain does not really care about the troops, but merely about what he can use them for.
If you want National Greatness, you have to have a comprehensive welfare state to go with it, more or less on the Swedish or Israeli model. Once you have done that, you can institute conscription to provide the necessary troops for National Greatness. Problem is, the Swedes and Israelis don't much like newly rich men, and they slap them down all the time, more or less by reflex. Ninety percent tax rates, and whatnot. Free Trade doesn't really go very well with National Greatness.
This "leadership deficit" isn't such a problem for the Democrats, because they want to get out of Iraq, not deeper into Iraq. Even so, they have more promising leadership material, mostly because they have been picking up so many people who were Independents or Liberal Republicans in 2000. James Webb (Annapolis; Navy Cross, Vietnam; Secretary of the Navy under Reagan) isn't a Republican anymore. He jumped the fence, and he's a Democrat now. He's been mentioned as a Vice-Presidential candidate, but I suspect Obama will need him more as Secretary of Defense. Then there's this man, Paul Hackett, from Cincinnati, who was over in Iraq. He ran for Congress as a Democrat, in a district which is demographically Republican, and did surprisingly well. People I know from Cincinnati are very impressed with him, and I expect James Webb can find a use for him.
Maarja Krusten - 5/25/2008
If you are going to refer to Konrad Adenauer by the German words used for him in his old age, use "der Alte" not "der Alt." Adenauer was known as "der Alte" which means "the old one" or in his case "the old man." In German, "er ist alt" means "he is old." "Er ist ein alter Mann" means he is an old man. But the old one is "der Alte" not "der Alt," as you wrote above.
Lawrence Brooks Hughes - 5/24/2008
If you're going to compare McCain to "Der Alt," you have to assume he will serve four terms, because if he should do so he would still be younger than Adenauer was at the end of his tenure as Chencellor... And then Der Alt lived on for another four years... For a running mate McCain should select a younger conservative such as former Sen. Don Nickles of Oklahoma, who is still under sixty, expert in several areas of the federal government, and very hard to lay a glove on in "Meet-the-Press" type inquisitions. McCain is certainly mindful he is likely picking the 45th president, and nobody would doubt the capacity of Nickles for that job.
Maarja Krusten - 5/22/2008
If anyone wants to discuss matters I did not discuss in my posts, such as the political aspects of Sen. McCain's candidacy, or anything else unrelated to my description of the death of my sister, please start a new thread rather than posting under my comments to Mr. Hughes about melanoma. That will ensure separation of threads and make it easier for readers to navigate the topics.
Don Walters - 5/21/2008
Look no further than AMERICA'S HOTTEST GOVERNOR!
Andrew D. Todd - 5/21/2008
The constitutional provisions for succession do not really solve the problem about McCain's age and health.
McCain is what one might call a "candidate of exhaustion." The Republican establishment didn't want him. They only settled for him after it became apparent that Condaleeza Rice was not acceptable; and Jeb Bush was not acceptable; and Mitt Romney was not acceptable; and Mike Huckabee was not acceptable, and would not meet their terms, to boot; and Ron Paul was not only unacceptable, and would not meet their terms, but was a goddamm apostate libertarian, besides. People cut McCain a bit of slack which they would not allow to anyone else, because he really is a Vietnam War Hero. He is the last thread holding the Republican party together. A candidate of exhaustion tends to be old because he reaches back to a time when his party was not embarrassed by its present problems. McCain's age is simply a byproduct of his being a candidate of exhaustion-- he couldn't be much younger, and still be an honor graduate of the "Hanoi Hilton." McCain couldn't have become a fully qualified aviator much before the age of twenty-five under 1960's standards, which means that he couldn't have become a Hanoi Hilton graduate much below the age of thirty. Starting in about 1971, the Air Force and Navy started using "smart bombs," which meant that the whole "Torpedo Eight" tradition of attacks pressed home with the utmost determination and mass casualties went away. There was room for him to be perhaps five years younger than he actually is, but no more.
One might compare McCain to Konrad Adenauer in Postwar Germany. Adenauer was the only available politician who had not gone into exile, or become a Nazi or a Communist, or been hanged in the aftermath of the July 20 plot. The unavoidable problem was that, from 1933-1945, the kinds of people who tended to become eminent Christian Democrats, all the doctors, lawyers, industrialists, etc., had all joined the Nazi party, or the "Allgemeine SS," and later had to be "denazified." The process of elimination insured that Adenauer would also be quite an old man, one who had been retired after losing elections in 1933. Because he was retired, the Gestapo was willing to take a comparatively lenient view of him. He was arrested a couple of times, but soon released, on the tacitly understood condition that he stay out of politics. As chancellor, Adenauer was able to survive because what he wanted people to do, was, first to keep the peace, with none of the brownshirt stuff; and second, to attend to their personal material interests, to enrich themselves; and he had an American subsidy to help the process along. A young man named Willy Brandt had just returned from exile in Scandinavia, but of course he had to put in twenty years as a journalist and local government official before becoming qualified for national office.
In the American political system, a candidate of exhaustion is going to have problems finding a running mate. Given the likelihood of succession, the vice-presidential candidate will be subject to unusually strict scrutiny, just as if he, himself, were running for the presidency. However, if such as candidate were available, the party would be running him as a presidential candidate, not a vice-presidential candidate. The objections to, say, Mitt Romney, as a vice-presidential candidate are substantially the same as those which made him unacceptable as a presidential candidate. Mitt Romney would have to run against the whole Yearning For Zion business, trying to convince people that, despite the inevitable internet rumors to the contrary, he was not like Warren Jeffs, and he did not aspire to use his power as president to have a harem of a thousand fourteen-year-old wives. So where does McCain go for a running mate?
Obama's strategy will presumably be to wait until McCain chooses someone, and then to use the internet to force attention on the Republican vice-presidential candidate, to force him to take stands on all kinds of issues, and generally keep him from hiding behind McCain.
Maarja Krusten - 5/20/2008
Thanks for the kind words about the loss of my twin sis. Her mind was very sharp right up to the end. She read a great deal (history -- focusing on World War II -- and biography) and was reading Rudy Guiliani's recently published book, Leadership, at the time she died. As it happens, she voted for John McCain in the 2000 Presidential primary. I certainly hope Sen. McCain is spared death due to melanoma. It's a terrible illness.
Lawrence Brooks Hughes - 5/20/2008
Sorry about the sad personal losses.
In the case of POTUS I think the 25th Amendment, ratified in 1967, generally spells out the process by which a bunch of doctors and cabinet officers can force the involuntary resignation of a disabled president, following which the vice-president would move up.
Maarja Krusten - 5/20/2008
I should have mentioned that in my sister's case, the melanoma started on a spot on her back, spread to her lungs, then her liver. She underwent radiation and chemo.
Posted on personal time
Maarja Krusten - 5/20/2008
A death from melanoma is not so quick and easy as to be covered simply by an expectation that the Vice President would succeed if a President dies.
What happens if a President is diagnosed with metastastic melanoma and has to start undergoing radiation and chemotherapy? What happens as the disease spreads to his lungs, liver, brain? At what point before he dies does he give up Presidential powers and resign? These are difficult questions.
I know something about this because my twin sister, Eva, died of melanoma in December 2002 at the age of 51. She was diagnosed with skin cancer in July 2001 and was dead within 18 months. She knew from the time she first was diagnosed (obviously at a later stage than Mr. McCain) that her illness was terminal and her remaining time most likely to be short. After her recovery from the initial surgery, she actually was able to return to work for a few months. As you can see below, a person diagnosed with melanoma has to decide how long he or she wants to continue to try working. In my sister's case, it was for quite some time.
My twin was a senior archivist in the National Archives' records declassification division, where she specialized in screening State Department records to determine declassification. She actually still was a federal employee when she died. (She received an award for her work from NARA in October 2002.) During the last few months before she died, she worked from home, drawing on her institutional memory to draft and send in by email various unclassified procedural and guidance materials for NARA, as she was able. She was able to stay in touch with the office through email and by using the telephone to partake in meetings and conferences.
Then U.S. Archivist John Carlin wrote of Eva Krusten after her death that "She was considered as committed a NARA employee as can be found, and gave guidance and assistance to anyone who needed it. Her colleagues truly enjoyed working with her and she was highly respected for her skills and work ethic. Her humor, compassion, and talent will be sorely missed here at the Archives."
So it's not as if you are perfectly well one minute and dead or totally incapacitated the next. The illness runs differently in different people, depending on how long it takes to spread to various organs and so forth. When to let go -- to say, I no longer can contribute to my workplace -- is not an easy decision. In my sister's case, she did work for NARA until a month before she died. It helped keep her spirits up and, as Gov. Carlin noted, she had a strong sense of commitment to her federal agency and a good work ethic.
Lawrence Brooks Hughes - 5/20/2008
If he dies in office the Vice-President moves up. So what? It's happened before and it will happen again. The chances are, if elected, he will not die in office, and we will get McCain for four years. What's the difference? The question only merits study if he picks a dreadful running mate, but he could not select anyone worse than Barack Obama! So, from every standpoint the exercise of poring over his medical records is a waste of time.
Don Walters - 5/19/2008
The article contains statements such as "Since his sentinel nodes showed no evidence of disease" and "melanoma... 0.22 centimeters deep, was removed by wide excision with extensive lymph node dissection and biopsy, with no evidence of metastasis", and "The classification of this melanoma is based on the maximal tumor thickness of 2.2 mm without ulceration". How do we know these statements are correct? Last I heard, Mr. McCain had not released his medical records.
It's raises questions that he had further surgery beyond his sentinel nodes. This is not normally done unless the sentinel node is positive. It would clear things up once and for all if Mr. McCain would release his records, INCLUDING pathology reports on his sentinel nodes. Until such time, articles like this seem like speculation.
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