On the Campaign Trail, Few Mentions of McCain’s Bout With Melanoma

http://www.nytimes.com/2008/03/09/us/polit...agewanted=print

March 9, 2008
On the Campaign Trail, Few Mentions of McCain’s Bout With Melanoma
By LAWRENCE K. ALTMAN, M.D. Along with his signature bright white hair, the most striking aspects of Senator John McCain’s physical appearance are his puffy left cheek and the scar that runs down the back of his neck.

The marks are cosmetic reminders of the melanoma surgery he underwent in August 2000. Mr. McCain, the presumptive Republican presidential nominee, sometimes tells audiences that he has “more scars than Frankenstein.”

The operation was performed mainly to determine whether the melanoma, a potentially fatal form of skin cancer, had spread from his left temple to a key lymph node in his neck; a preliminary pathology test at the time showed that it had not.

But because such a test cannot be definitive, the surgeons, with Mr. McCain’s advance permission, removed the surrounding lymph nodes and part of the parotid gland, which produces saliva, in the same operation, which lasted five and a half hours.

The final pathology analysis showed no evidence of spread of the melanoma, his staff said at the time. Mr. McCain, of Arizona, has said he did not need chemotherapy or radiation.

In 1999, during Mr. McCain’s first race for president, he gave the public an extraordinary look at his medical history — 1,500 pages of medical and psychiatric records that were amassed as part of a United States Navy project to gauge the health of former prisoners of war. This reporter, who is a physician, interviewed the senator’s doctors in 1999 with his permission.

But this time around, Mr. McCain has yet to make his full medical records or his physicians available to reporters. At least three times since March 2007, campaign officials have told The New York Times that they would provide the detailed information about his current state of health, but they have not done so. The campaign now says it expects to release the information in April.

So Mr. McCain’s prognosis for the recurrence of melanoma can be gauged only by talking to experts not connected with his case. Those experts say his prospects appear favorable.

The melanoma removed in 2000 was Stage IIa on a standard classification that makes Stage IV the most serious. For Stage IIa melanoma, the survival rate 10 years after diagnosis is about 65 percent. But the outlook is much better for patients like Mr. McCain, who have already survived more than seven years.

For patients with a melanoma like Mr. McCain’s who remained free of the disease for the first five years after diagnosis, the probability of recurrence during the next five years was 14 percent and death 9 percent, a study published in 1992 found.

No spread has been detected in the three or four dermatologic checkups Mr. McCain has undergone each year since 2000, stress tests show no evidence of heart disease, and “his doctors consider him in very good health,” his campaign staff said in a recent statement.

The campaign also said Mr. McCain regularly took Vytorin to lower his cholesterol, a baby aspirin to help prevent heart attacks, a multivitamin and, occasionally, Claritin or Flonase for allergies.

Mr. McCain has proved resilient in the past, surviving serious injuries that he sustained when his airplane was shot down over Vietnam and then when he was captured, and sometimes tortured, as a prisoner of war for five and a half years.

Now he is hoping to be the oldest man ever elected to a first term as president. Even if the melanoma returns, he would not be the first sitting president to have had cancer.

From what information Mr. McCain has disclosed, he is at increased risk for melanoma and other skin cancers because of his medical history, fair skin and prolonged sun exposure at a young age — long before the wide use of sunscreen.

Since the 2008 campaign began, doctors not connected with Mr. McCain’s case have expressed intense interest in the extent of the face and neck surgery that he underwent on Aug. 19, 2000, at the Mayo Clinic Scottsdale in Arizona.

Some of these doctors have noted in e-mail messages and in comments to reporters that the surgery appeared to be so extensive that they were surprised his melanoma was not more serious — perhaps Stage III, which would give him a bleaker prognosis. These doctors said they would be surprised to learn that such an operation would be performed without evidence that the melanoma had spread.

But a number of melanoma experts said in interviews that such an operation was understandable according to the medical standards of 2000 and that the extensive surgery did not necessarily imply Stage III melanoma.

“It was not out of line,” said one of the experts, Dr. Richard L. Shapiro, a melanoma surgeon at New York University. Dr. Shapiro added that he would feel more comfortable in making a judgment if he saw a full pathology report.

“It was a complex problem,” he said, “that was handled very skillfully by a team of experts.”

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.

In trying to discover whether the melanoma had spread from his temple, Mr. McCain’s doctors made an incision down the side of his face and partly removed the lymph nodes in his neck, the campaign said in the statement.

“No spread of melanoma was found in any of these locations,” the campaign said. “However, this preventative procedure had cosmetic side effects for Senator McCain, including swelling at the site of the incision. Thus, the large scar and attendant swelling that Senator McCain has on the left side of his face is not the result of the melanoma itself, which was small and localized, but rather of the more extensive surgical procedure utilized out of a high degree of caution.”

Mr. McCain has had four melanomas.

In 1993, he waited more than six months before seeking care after a Navy doctor recommended that he consult a dermatologist for a lesion on his left shoulder that turned out to be his first melanoma. It was excised and has not recurred.

Pathology tests showed that the two other melanomas — detected on his upper left arm in 2000 and on his nose in 2002 — were of the least dangerous kind, in situ. In that type the malignant cells are confined to the outer layer of skin.

The most serious melanoma was spotted on his temple in 2000 by the attending physician at the United States Capitol after it had escaped the eye of Mr. McCain’s personal physician at Mayo Clinic Scottsdale. (The Capitol physician also spotted another melanoma that was in situ.)

The melanoma on Mr. McCain’s left temple was 2 centimeters in diameter and 0.22 centimeters deep, and was fully excised with wide margins, 2 centimeters in each direction, his campaign staff said.

To determine whether the cancer had spread to lymph nodes in his neck, the Mayo 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.

Then they 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.

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.

So Mr. McCain’s surgeons, following what was then an accepted practice, 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.

In Mr. McCain’s case, the Mayo Clinic team of surgeons reconstructed the skin and soft tissue overlying the left temple, face and neck by pulling up skin to close the wound.

Doctors advise melanoma patients to have regular checkups to detect new skin cancers and the spread of old ones because melanomas can be quirky. Mr. McCain’s staff has not said what tests his doctors have used to monitor his case.

Most recurrences of melanoma occur in the first few years after detection. Survival figures for melanomas are often measured in 10-year periods rather than the 5-year periods for many other cancers.

“With melanoma, a patient is never completely clear,” said Dr. Shapiro, the N.Y.U. expert.

If melanomas do recur, standard treatment options are limited for many to surgery and a difficult form of chemotherapy. The chances of long-term survival diminish.

Now, on the campaign trail, Mr. McCain appears to take care to shield himself from the sun, slathering on powerful sunscreen before outdoor events, finding spots of shade from which to speak and sometimes wearing baseball caps while outside.

Mr. McCain is occasionally asked on the campaign trail about his age. But he is almost never asked about his health.

Michael Cooper contributed reporting.

 

See the pattern yet? This is the 2nd hit piece against McCain by the NYT. They're doing their part for the Democratic nominee.

So much for a free press. And so much for whining about Fox News being biased.

 

^^^ it's tiny, but great dirt on Obama.

 

^^^ Talking heads like Chuck Schumer? Hillary's been on plenty. Or maybe you're talking about Susan Estrich?

 

The right wing talking heads are rather conspicuous. But they have a LOT of democrats and so-called liberals on, too.

You do know that Greta Van Sustren came to Fox from CNN? At CNN, she was one of the biggest apologists for Clinton during his impeachment. Fox had Paula Zahn, who's now at CNN. So not even all the hosts are right wing.

It's not that I have a particular interest in defending Fox as "The Truth" or anything. It's part of a well balanced news diet.

For example, if you want to know anything about what McCain is up to, you'll get 5 minutes per hour on Fox instead of 1 minute on the other channels. Believe it or not, McCain is newsworthy.

 

<div class='quotetop'>QUOTE (Denny Crane @ Mar 10 2008, 08:07 PM) <{POST_SNAPBACK}></div><div class='quotemain'>The right wing talking heads are rather conspicuous. But they have a LOT of democrats and so-called liberals on, too.

You do know that Greta Van Sustren came to Fox from CNN? At CNN, she was one of the biggest apologists for Clinton during his impeachment. Fox had Paula Zahn, who's now at CNN. So not even all the hosts are right wing.

It's not that I have a particular interest in defending Fox as "The Truth" or anything. It's part of a well balanced news diet.

For example, if you want to know anything about what McCain is up to, you'll get 5 minutes per hour on Fox instead of 1 minute on the other channels. Believe it or not, McCain is newsworthy.</div>

Juan Williams works at the Washington Post and NPR. Mara Liason is also from NPR.