Health of John McCain (2008)

Introduction Laws Sources Problems Invasive Melanoma Discussion A Plan Bibliography

The Invasive Melanoma of 2000

Melanoma is the most serious form of skin cancer. Senator McCain has had four melanomas diagnosed.

Three of the Senator's melanomas did not penetrate deeply into the skin. They were easily treated, and are discussed elsewhere.

One of Senator McCain's melanomas, however, penetrated into the deeper layers of skin. This "invasive" melanoma is discussed on this page. It is discussed outside of the problem list because of its complexity.

Contents of This Page

Discovery

The invasive melanoma was spotted on the left side of Senator McCain's temple on Aug. 2, 2000, during a routine examination (1) by the attending physician at the United States Capitol (2). The melanoma had escaped the eye of McCain's personal physician at Mayo Clinic Scottsdale (2).

The discovery of this melanoma occurred near the end of the Senator's unsuccessful year-long campaign for the Republican Presidential nomination in 1999-2000. Apparently he had noticed something amiss on his temple some time before August, evidenced by his remark: "I let it go too long" (3).

Simultaneously (one presumes), the Capitol physician also spotted a less serious melanoma on McCain's left arm (2). It was easily treated, and will not be further discussed on this page.

Editorial: That the melanoma escaped the eye of the senator's physician at the Mayo Clinic is a useful reminder that no method of cancer screening is perfect. Despite our best efforts as physicians, and our closest attention to our patients, cancers will inevitably slip through.

The Senator's statement suggests that, because of his campaign, he was "too busy" to attend to his health. This appears to have been a lesson learned. In the midst of his 2008 campaign, in July, he made time to see his dermatologist. It is hoped that, should he become President, he continues to make time for such follow-up.

Question: It has been stated that Senator McCain had not had care at the Mayo Clinic in the 27 months before the melanoma was discovered in August 2000 (4). Does this contradict the statement that the Mayo physician missed the melanoma?

The Senator underwent biopsies at the National Naval Medical Center in Bethesda, MD, the next day. That night he joined George W. Bush on stage after Gov. Bush accepted the Republican presidential nomination. The day after that, Aug. 4, Mr. McCain was told that the two spots were malignant (1).

When Senator McCain abruptly disappeared from the convention after his speech on Aug. 1, there were questions about his commitment to his one-time Republican primary rival, Gov. Bush (1).

But the Senator returned to the convention on Aug. 3, where he was photographed with a small bandage on his temple (1). On Aug. 10 he joined Gov. Bush on the campaign trail (1).

Editorial: The political fallout from so simple a medical procedure as a skin biopsy is a reminder of the enormous fallout likely to occur in connection with a major medical event.

Staging

The melanoma was 2.2 millimeters thick at its thickest part and was 2 centimeters across.

(A penny is 2 centimeters across. Two pennies, stacked atop each other, are between 2 to 3 millimeters thick.)

Editorial: The thickness of a melanoma is critical. A thickness of 2.2 mm is worrisome.

Question: A mass in the temple that approaches the size of two pennies (or even one penny) is pretty large. Despite being busy (see above), it is worrisome that the Senator allowed the mass to reach such a size before taking action.

If he had succeeded in being nominated for the Presidency in August 2000, would he then have made the decision to have the mass attended to? This seems unlikely, as it would surely have cast uncertainties over his fitness to be President and hurt him in the general election.

Would he have waited until after the election that November to have it attended to? That would have allowed the cancer three extra months to grow, and would have increased considerably his risk of dying from it.

In short, for Senator McCain in 2000, there was no good time to have his temple lesion attended to, so long as he was still in the Presidential race. Both he and his wife must surely have known the gamble they were taking by waiting. It is fine for a man to gamble with his own life, but it is another thing for him to gamble with the security and stability of the nation.

It is possible, of course, that the Senator and his wife were in denial. This would not be surprising, given that the Senator waited six months in 1993 before seeking care for a suspicious skin lesion that had been brought to his attention. The denial hypothesis, however, cannot be supported with any rigor. It would be hepful to know what the temple melanoma looked like before it was excised.

A melanoma 2.2 mm thick is class T3, according to the 1987 classification of the International Union Against Cancer.

Numerous tests, including CT scans, an MRI scan of the brain, and liver tests (including LDH), showed no evidence that the cancer had spread (4).

Editorial: With any cancer, it is critical to know if it has spread beyond the site where it arose. A cancer that has spread is more dangerous than one that has not.

However, a "minority report" offset the good news that the cancer was localized.

Two pathologists at the Armed Forces Institute of Pathology (AFIP) who examined the melanoma specimen suggested that there were two melanomas on Senator McCain's temple, not one. Specifically, the AFIP pathology report said that details about the lesion were "highly suggestive of a metastasis of malignant melanoma and may represent a satellite metastasis" (5).

In other words, the AFIP pathologists thought one melanoma had spread to create another.

Editorial: This is an important matter. If there was only one melanoma on the temple, the tumor would be far less advanced than if there were two, one of which was a satellite of the other.

The opinion of the AFIP pathologists cannot be lightly dismissed. The Armed Forces Institute of Pathology is probably the best institution in the world when it comes to looking at tissues under the microscope (which is how the assessment of Senator McCain's tumor would have been performed).

In contrast to Senator McCain's other three melanomas, the stage of the invasive melanoma (or melanomas?) has never been disclosed. The New York Times specifically requested clarification of the stage from McCain's campaign and from his physicians, but received no answer (5).

Question: Whenever a cancer is discovered, physicians give it a "stage" ranking, to indicate how advanced the cancer has become. Higher stages are worse. Stage rankings provide very useful information about the prognosis of a cancer, and drive the choice of treatment.

The Mayo Clinic's physicians disclosed that Senator McCain's three non-invasive melanomas were all stage zero -- the most favorable stage ranking there is.

By contrast, the stage ranking of the Senator's invasive melanoma has not been disclosed. It should be.

Editorial: Not disclosing the stage ranking of the invasive melanoma is inconsistent with a policy of being open about the Senator's past medical history. The stage is a tremendously important piece of information.

The possible reasons for its absence seem to be: (1) information has been held back, (2) there was no agreement on what the stage was, or (3) the tumor was never staged. The last of these options is unlikely, as it would be greatly at odds with standard medical practice.

Editorial: "Because doctors generally do not recommend extensive neck node dissection for Stage 2A, a number of melanoma experts have said they suspected that Mr. McCain's melanoma was Stage 3, which carries a bleaker prognosis" (5). The Senator did have dissection of lymph nodes in his neck. Moreover, in planning the operation, the intention was to "remove all of the lymph nodes in his neck that are at risk" (6).

Dr Daniel Vlock, a former melanoma researcher who no longer practices medicine, said news reports indicated McCain's invasive cancer was a "stage 2A" melanoma. But Vlock said that other parts of the record suggest the cancer was in "stage 3B," which has significantly lower five- and 10-year survival rates of 53% and 38%, respectively (7). (A summary of melanoma stages is available.)

Editorial: Pubmed shows that Dr. Vlock has published 16 articles about malignant melanoma, many of them clinical papers. It is reasonable to assume he knows his subject!

Planning the Operation

Dr. Denis Cortese, Mayo Clinic's president and chief executive, said in a recent interview that experts in all three of the clinic's sites discussed details of Mr. McCain's operation before it was performed. (2)

In a meeting attended by McCain, his wife, Cindy, and an unidentified "physician friend," surgeon Michael L. Hinni described how he was going to remove a large oval piece of tissue from the left side of the senator's face. He told them "it seems feasible to use this incision to remove all of the lymph nodes in his neck that are at risk, as he is going to incur the morbidity [damage] of the incision" anyway. (6)

The Operation

Dr. Hinni, an ear/nose/throat surgeon (6), operated on Senator McCain's left temple melanoma on Aug. 19, 2000, at the Mayo Clinic Scottsdale in Arizona (2).

The operation accomplished several tasks (4):

Removal of melanoma
"A 2 centimeter margin of normal skin was removed around the 2 centimeter melanoma, resulting in a 6 centimeter by 6 centimeter roughly circular wound on the left side of the Senator's face" (4). The cancer was "fully excised" (2).

Editorial: The bottom of a beer bottle is about 6 centimeters in diameter.
Identification of "sentinel" node
Editorial: Here is an explanation of a "sentinel node:" When a cancer arises in some location in the body, physicians want to find out if it has spread beyond the place it arose. Rather than look everywhere in the body for spread of the cancer, they prefer to concentrate their efforts on the places to which the cancer is most likely to spread.

The "sentinel" lymph node is one of these high-probability places. Lymph nodes are raisin-sized glands throughout the body that act like the filter in a vacuum cleaner: they trap anything unusual that flows through them. For any small region, "X," of the body, one lymph node is usually the primary filter assigned to region X. This is called the "sentinel" node for a cancer in region X, because it is the first place to which the cancer is likely to spread.

For Senator McCain's invasive melanoma, "region X" was his left lower temple.

Unfortunately, there is no rigid correspondence between a region X and the location of the lymph node that filters region X. In other words, the sentinel node for region X could vary from person to person. Thus, to find the sentinel node for region X, doctors must peform a few tests. They can, for example, inject radiation into region X, and use a Geiger-counter camera to find the lymph node to which the radiation first flows.

The Senator's doctors "injected a radioactive dye into the melanoma in a procedure known as a sentinel node biopsy hours before surgery. The doctors waited for the dye to flow in the lymph fluid to the node in the neck to which the cancer is statistically most likely to spread first." (2)

In the operating room, the surgeons "used a gamma counter -- an instrument like a Geiger counter -- to identify the node, and removed it. Pathologists quickly froze the tissue while Mr. McCain was on the operating table, looked at it through a microscope and did not detect cancerous cells." (2)

"But this kind of biopsy is not 100 percent reliable for melanoma, partly because the chemical stains that help pathologists identify breast and other cancers in frozen sections do not work as well on melanomas. Also, the cancer could have spread to a nonsentinel node." (2)

Removal of key lymph nodes (and parotid gland)
So, with Mr. McCain's advance permission (2), the surgeons followed what was then an accepted practice: they "removed the surrounding nodes as part of the sentinel operation. The operation to dissect the lymph nodes in the face and neck can be tricky as the surgeon works to avoid injuring the nerve that controls various facial movements and expressions." (2)

Assumption: From this, it appears that lymph nodes in the neck were removed. It would have been preferable to hear this from the surgeon directly.
"The underlying parotid salivary gland was also removed to assure a clear deep margin, to protect facial nerves from injury, and to remove the sentinel and other lymph nodes that were inside the parotid gland" (4).

Editorial: The parotid is the major salivary-producing gland; there is one in each cheek. Reference (4) made the embarassing mistake of calling the parotid glands "Parodid" glands. That mistake is corrected above. (Worse, reference (8) called it the "carotid salivary gland"!)

Assumption: By "underlying," Dr. Hinni might have meant just the part of the gland that was exposed by the operation. Reference (6) reports that only "portion of the parotid salivary gland" was removed.

It is unclear how many lymph nodes were removed. One source says 38 (6). Another, citing Dr. Hinni, says "during the reconstructive surgery to close the wound, 33 lymph nodes were removed, a relatively large number, because they were already exposed and Dr. Hinni felt it a `prudent' course" (5).

Question: How many lymph nodes were removed?
Reconstruction of the left temple region.
To safely remove all of the cancer, with a wide margin, and to remove the lymph nodes, a relatively large incision was required (4). The incision apparently extended into the neck (2). Senator McCain's surgeon described it as "a wound requiring sizeable reconstruction" (4).

The surgeon continued: "This explains why the large incision was made -- it was necessary so that a flap of skin and soft tissue consistent with the color and texture of the Senator's facial skin could be elevated and advanced/rotated into the wound" (4). The large opening in McCain's face was filled with a flap of skin that was cut from behind his ear (6).

Ultimately, the left side of the Senator's jaw took on a puffy appearance. His surgeon has stated: "To answer what appears to be numerous questions about the prominence of the Senator's left jaw: this is a result of an absence of soft tissue on the face in front of his ear that makes the masseter (the chewing muscle) over the jaw appear more prominent. To be clear, the swelling is not due to any evidence of cancer" (4) (5)

The operation lasted five and a half hours (2). Reference (9) shows an impressive photograph of the left side of Senator McCain's face not long after the operation. The scar extends downward at least the line of the jaw.

Sequelae

"None of Senator McCain's lymph nodes showed any evidence of metastatic disease" (4). "The final pathology analysis showed no evidence of spread of the melanoma, his staff said at the time. Mr. McCain ... has said he did not need chemotherapy or radiation" (2).

Editorial: It was very good news to find no cancer in the removed lymph nodes. Comments about chemotherapy and radiation are below.

Question: It is still unclear what stage cancer this was. The statement, "The final pathology analysis showed no evidence of spread of the melanoma," still admits of uncertainty. Specifically, if there were two camps of pathologists pre-operatively, one seeing a single melanoma and the other seeing two melanomas, then it's entirely possible that the statement from the Senator's staff simply ignored a still-unrefuted claim of the two-melanoma camp.

Editorial: It is tempting to assume that the cancer was "only" stage 2 because the Senator did not get chemotherapy or radiation treatments. An oncologist tells me, however, that "we have no proven adjuvant for melanoma," meaning that chemotherapy and radiation usually do not benefit the patient, even when the cancer has advanced to stage 3. (Interferon was used for a time, but ultimately proved to have no long term benefit.) Thus, even if the cancer had been stage 3, it would have been reasonable to withhold chemotherapy and radiation.

Follow-Up

According to Senator McCain's physicians, "To summarize, we continue to find no evidence of metastasis or recurrence of the invasive melanoma as we approach the eighth anniversary of that operation. This was most recently confirmed with his comprehensive examination and tests in March 2008 and with Dr. Connolly's skin examination on May 12, 2008. The prognosis for Senator McCain is good because the time of greatest risk for recurrence of invasive melanoma is within the first few years after the surgery" (10).

The Senator has been followed closely for a recurrence of the cancer. The exact protocol has not been disclosed, but it is said that he has had "innumerable CAT scans and blood analyses" (6).

Footnotes

1. Alvarez, Lizette. "McCain Discloses New Case Of Malignant Melanoma." NYTimes.com. 2000 August 17.
2. Altman, Lawrence K. "On the Campaign Trail, Few Mentions of McCain's Bout With Melanoma." New York Times. 2008 March 9.
3. Gupta, Sanjay. "Fit to Lead." CNN. Special Investigations Unit. Broadcast 2008 October 11. Note: I have some questions about bias in this source. They claimed that Senator McCain's temple melanoma was the size of a dime and the thickness of a nickel. It was actually larger then a penny (which is larger than a dime) and thicker than a nickel. In addition, they devoted much air time to Senator Obama's smoking history, without once mentioning that Senator McCain smoked two packs of cigarettes per day for about 25 years.
4. Hinni, Michael L. Statement in Trastek.
5. Altman, Lawrence K.; Bumiller E. "McCain's Health Is Called Robust by His Doctors." New York Times. 2008 May 24.
6. Shear, Michael D.; Brown, David. "McCain's Medical Records Indicate He Is Cancer-Free, Generally Healthy." Washington Post. 2008 May 24, page A03.
7. Nasaw, Daniel. "US election: Doctors call on McCain to release details of bout with skin cancer." Guardian.co.uk. 2008 Sept. 18.
8. CNN.com. "McCain in 'excellent health,' doctor says." 2008 May 23.
9. Gupta, Sanjay. "McCain in 'excellent health,' doctor says." (Video report.) CNN.com. 2008 May 23. [Note: to see the video, click on the VIDEO tab, located next to the READ tab.]
10. Eckstein, John D. Statement in Trastek.