John McCain. The New York Times, and malignant melanoma

Malignant melanoma(MM) is the deadliest skin cancer. One in four people diagnosed with the disease end up dying from it. It is the most prevalent cancer for women age 25-29, and second most common for ages 30-34. If caught in its early stages, MM can be easily fought. Once it spreads to most distant sites, lymph nodes, or other organs, the survival rate drops. Take for instance those with lymph node involvement(Stage III), the average 5-year survival is around 50%. Stage IV patients with brain metastisis have less than year median survival rate.

I know a great deal about MM. In 1993 I had one of these cancers diagnosed. Then in 1994 I had three more removed. I was fortunate through 2006. A detailing of my more recent struggles with MM can be found here and here. I'm stage IV now with brain mets.

Lawrence K. Altman M.D. writes a lengthy article in New York Times. The article beginning about the puffiness in the Senator's face and the noticeable scars.

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.

First the operation was done with the purpose(drop the word mainly) to determine if the MM had spread. Been there done that myself only last summer.

The puffiness is a common side effect from having lymph node surgery. I had the same area operated on last year and the puffiness will always be there.

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.

Two comments on the above. Dr. Altman is being a little wordy, patients, United States Senators or sarcastic Florida bloggers alike, sign a recent consent before having surgery. We all give advance permission.

The most common therapy for Stage III melanoma is immuneotherapy involving interferon. This in order to stimulate the patient's immune system.

I underwent this beginning last October. The most common side effect of this treatment is chills, and fever. Some people weather interferon better than others, I was able to partake in most activities I like including covering a golf tournament while being treated. Others go through a year of hell.

The Times goes on to say Sen. McCain hasn't released his medical records of late. He did back in 1999, before running for the Republican nomination in 2000. So Dr. Altman writes-

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.

330 plus words into the article the author comes out and says the odds are favorable for Sen. McCain. I'll let others judge if this article is a NY Times 'hit piece' or not. The article headline, 'On the Campaign Trail, Few Mentions of McCain’s Bout With Melanoma', would make readers think we're learning of some dark, dangerous health secret about the Senator. It takes over 300 words, or about a page, to learn McCain is past the most dangerous time for a Stage II MM patient.

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.

A MM as far along as McCain, is considered to be almost out of danger for the chance of the disease spread. Still a Stage II patient needs to have regular dermatologist checkups(I go 3 times a year) and a annual checkup with the oncologist. A blood screening and chest x-ray are the tests a Stage II patient will undergo yearly.

I went 13 years disease free. In my case, a new MM was discovered last fall and it was the cause of the disease spreading in my body. I had five melanoma in all. A patient with multiple MM isn't common. But......

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.

In situ melanomas almost never spread. Called Stage 0 melanomas, they are totally within the outer most layer of skin and very superficial.

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.

A .22 depth melanoma, also known as a Clark Level II, is about the same depth as three of the five melanomas I've had diagnosed(.2 to .26)in the 1990's. The MM being excised with wide margins is standard procedure for this stage of melanoma. Based on the depth of his MM only, He is a Stage IA patient.

I'm just making some educated guesses, based on my 14 plus years experience as a Melanoma patient. Without knowing the Senator's detailed health history, you could conclude the Senator is pretty safe from further trouble with MM. I'd bet McCain takes his checkups seriously.

Dr. Altman on the other hand has to raise fears, only because we don't know all that happened in 2000.

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.

I've had friends who had lymph nodes removed, but no disease was found. Everyone, myself plus the author of the article and the nameless doctors with their fears, is guessing. The article is educational about malignant melanoma. If read in depth, it can teach people that the disease is hardly a death sentence.

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.

Everything said above is true. A recurrence of any cancer makes diminishes long-term survival.

No one with Stage IV mm is going to run for President, first of all because the treatment needed for the disease is too time consuming. A Stage III patient could run, if the diagnosis was in the past. People have lived for many years with that level of disease.

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

If the press, including the NYT is so concerned about McCain's MM history, they should be badgering the candidate.(I'd side with the Senator if he told them to get lost. Who wants uneducated or educated reporters digging through your personal health history to make ill informed medical diagnosis without seeing the patient)If no one is asking, the media has only themselves to blame.