In today’s New York Times, Dr. Lawrence K. Altman, M.D. examines the known medical records of all four presidential and vice presidential candidates. For purposes of considering Republican vice presidential candidate Sarah Palin’s qualifications as possibly next the president of the United States, should something happen to John McCain, only medical information on McCain is outlined below.
Mr. McCain’s difficulty raising his arms and his sometimes awkward gait are remnants of severe, untreated injuries he suffered in Vietnam. Mr. McCain, a Navy pilot, broke both arms and his right knee when his jet was shot down over North Vietnam in 1967. He experienced additional wounds while being tortured during his five and a half years as a prisoner of war. Mr. McCain may eventually need joint replacements, according to his doctor at the Mayo Clinic in Scottsdale, Ariz.
Mr. McCain has released more details about his health than the other three nominees, though he has done so in a phased way and has apparently not agreed to any extensive interviews about his health. A handful of reporters were allowed to view his records during his bid for the 2000 Republican presidential nomination. Another group of reporters were permitted to see newer records last May. By not allowing reporters to interview him or his doctors extensively about his entire medical history, he has made it impossible to get a complete picture of his diagnoses and treatment.
In 1999, early in his first run for the presidency, Mr. McCain allowed a small number of reporters, including me, to review an estimated 1,500 pages of his medical records without photocopying or recording the information.
In doing so, Mr. McCain gave the public its broadest look at the psychological profile of a presidential candidate. He released psychological records about him that were amassed as part of a Navy project to gauge the health of former prisoners of war. Assessments were based on standard psychological tests and what Mr. McCain told his doctors after his release. The records mentioned that in 1968, about eight months after his capture and after some particularly brutal beatings from his North Vietnamese captors, Mr. McCain attempted suicide, trying to hang himself with his shirt.
The records and his doctors, whom I interviewed with the senator’s permission in 1999, said he had never been given a diagnosis of a mental health disorder or treated at the project’s center for a mental health disorder.
The records also showed that a surgeon removed a melanoma from Mr. McCain’s left shoulder in 1993. Melanomas can be a far more deadly form of skin cancer than the more common basal cell and other types.
In early August 2000, just as Mr. McCain’s rival George W. Bush was about to receive the Republican presidential nomination, Dr. John F. Eisold, the attending physician at the United States Capitol, detected two more melanomas, Mr. McCain’s second and third.
One on Mr. McCain’s left arm was determined to be the least risky type, in situ. But the one on his left temple was dangerous.
A few days after detection of the melanomas, Mr. McCain sought care for them at the Mayo Clinic in Scottsdale. Mr. McCain’s campaign said this year that the left-temple melanoma was 2.2 millimeters at its thickest part and graded as Stage IIA on a scale in which Stage IV is the worst. Stage II meant that the melanoma had not spread into the lymph nodes. The number of melanomas is less significant than the thickness measured in the pathology assessment of any one of them.
Mr. McCain underwent extensive surgery on his face and neck for the melanoma on Aug. 19, 2000. Surgeons removed more than 30 lymph nodes, and pathologists then determined that all of them were cancer free.
In March 2007, as Mr. McCain was making his second bid for the Republican nomination, The Times began asking his campaign for permission to speak with the senator and his doctors, citing the history of such interviews.
On May 6, 2008, Jill Hazelbaker, a McCain spokeswoman, denied the requests, writing in an e-mail message that The Times was “not at the top of the list” and including a link to a Times editorial that had criticized Mr. McCain for not disclosing health information and Senator Hillary Rodham Clinton of New York for not disclosing financial records.
On May 23, Mr. McCain allowed a small pool of journalists, including three doctor-reporters, though none from The Times, to spend three hours reviewing a newer set of his Mayo Clinic records. That set, 1,173 pages, included records from 2000 to 2008 but none of the records made available in 1999. Again, the campaign did not allow the journalists to photocopy any documents.
Mr. McCain’s Mayo Clinic doctors answered selected reporters’ questions by telephone, but only for 45 minutes instead of the scheduled two hours. The McCain campaign did not allow New York Times reporters to ask questions in the teleconference.
The clinic doctors said that Mr. McCain was in good health and that no medical reason precluded him from fulfilling all the duties of president.
The doctors said that a fourth melanoma they detected on the left side of his nose in 2002 was also in situ, the least dangerous type. All four melanomas that Mr. McCain experienced were primary, or new, and there was no evidence that any of them had spread, the doctors said.
However, the reporters’ summary cited a report dated Aug. 9, 2000, from two pathologists at the Armed Forces Institute of Pathology in Washington who examined a biopsy of the melanoma taken from Mr. McCain’s left temple a few days earlier.
The Armed Forces pathologists suggested that the left-temple melanoma had spread from another melanoma, known as a metastasis or satellite lesion. “The vertical orientation of this lesion,” the report said, “with only focal epidermal involvement above it is highly suggestive of a metastasis of malignant melanoma and may represent a satellite metastasis of S00-9572-A,” which is the “skin, left temple, lateral” biopsy.
The pool report was by nature unable to provide a complete portrait of Mr. McCain’s recent medical history. It left several questions, including about the number of biopsies and when they were done. On Aug. 18, 2000, Dr. John D. Eckstein, Mr. McCain’s personal physician at the Mayo Clinic in Scottsdale, noted in Mr. McCain’s records that there were two biopsies of the left temple. Dr. Eckstein’s note did not say where and when the biopsies were performed. The Armed Forces report cited one biopsy, so presumably a second was performed in Scottsdale. The Armed Forces pathologists said a melanoma had developed over a skin scar whose origin was unclear.
A skin lesion, not one of the four melanomas, had been removed from Mr. McCain’s left temple in 1996 and interpreted as being benign; some experts have speculated that it might have been misdiagnosed, and thus the origin of the 2000 melanoma.
The Armed Forces pathologists did not speak in the teleconference in May 2008, and questions raised by their report have remained unanswered. The selected reporters did not ask about that report, and the Mayo Clinic doctors did not discuss it. A complete Mayo pathology report was apparently not included in the pool summary.
In interviews, several melanoma experts questioned why the Mayo Clinic doctors had performed such extensive surgery, because the operation was usually reserved for treatment of Stage III melanoma, not Stage IIA.
On Aug. 18, 2000, the day before Mr. McCain’s operation, his surgeon, Dr. Michael L. Hinni, wrote in the records that he planned to do the extensive operation because of the size and location of Mr. McCain’s melanoma. In the teleconference in May 2008, Dr. Hinni explained that because the melanoma was two centimeters across he had to make “a 6-by-6-centimeter island of skin, a fairly sizable wound” to remove it.
It is not known whether the Mayo Clinic in Scottsdale asked pathologists outside the Mayo system for an independent review.
If Mr. McCain’s 2000 left-temple melanoma was a metastasis, as the Armed Forces pathologists’ report suggested, it would be classified as Stage III. The reclassification would change his statistical odds for survival at 10 years from about 60 percent to 36 percent, according to a published study.
The greatest risk of recurrence of melanoma is in the first few years after detection. His age, his sex and the presence of the melanoma on his face increase the risk.
The fact that Mr. McCain has had no recurrence for eight years is in his favor. But cancer experts see the 10th anniversary as an important statistical benchmark, and that would not occur until 2010.
In May, his dermatologist at the Mayo Clinic, Dr. Suzanne M. Connolly, said in the teleconference that though there was no way to predict with certainty Mr. McCain’s chance of a recurrence, she judged it to be less than 10 percent. But melanoma is known to be quirkier than most cancers; doctors cite occasional cases in which melanomas come back after 15 or 20 years.
Melanomas can spread to various areas in the body, including the skin and any internal organ. In general, such spreading means the melanoma would not be curable. Treatment would depend in part on what organ or tissues are involved and could include additional surgery, chemotherapy, biologics, vaccines and radiation.
Many such treatments can be debilitating and impair an individual’s physical and mental stamina. If the patient was the president, the location of a recurrence and its treatment could raise the need to invoke the 25th Amendment, elevating the vice president to president, at least temporarily.
On the trail, Mr. McCain has played down concerns about his age by pointing to the vigor of his mother and her twin sister at age 96. Mr. McCain’s father died in 1981 at age 70 after a heart attack.
In the May teleconference, Dr. Eckstein said that he had not detected any memory deficits in Mr. McCain and that the senator had not reported any. Dr. Eckstein did not report whether Mr. McCain had taken any baseline cognitive tests.
In making his medical information public, Mr. McCain released his confidentiality in the traditional patient-doctor relationship.
For its part, the Mayo Clinic says it agreed to yield control over all of Mr. McCain’s medical information to his campaign and to refer all questions to the campaign. Pool reporters inspected the records at a hotel near the clinic, which sent the records there under security. In the teleconference, the doctors answered questions by telephone at the clinic with no reporters present.
Dr. Eckstein, Mr. McCain’s doctor, said he understood that the campaign had released all the McCain records to the pool reporters. But a spokeswoman at the Mayo Clinic in Scottsdale, asked if the institution could verify that the campaign had released all the records to the reporters, said she did not know whether the doctors had checked to be sure.
Last week, The Times contacted the McCain campaign to fill in gaps in the medical records. Ms. Hazelbaker, the McCain spokeswoman, wrote in an e-mail message: “As you know, we disclosed over 1,200 pages of Senator McCain’s medical history to Dr. Altman’s colleagues in the press earlier this year. We also arranged a Mayo Clinic briefing with three of Senator McCain’s physicians that Dr. Altman listened to by phone. Additionally, we released a detailed document outlining his most recent physical and lab test results. It was an unprecedented level of disclosure, and Dr. Altman can look at the public document on our Web site if he wishes to do so.”