Health of John McCain (2008)

• Which Mayo Clinics?
• Openness during Senate campaigns
• Who excised 1993 melanoma?
• Proof that renal cysts are benign
• Treadmill protocol
• Orthostatic symptoms?
• End-organ hypertensive effects?
• Urinary bleeding -- when?
• Cause of drooping left eyelid?
• Lung abnormalities?
• Melanoma surveillance 1998-2000
• Late discovery of invasive melanoma
• Stage of invasive melanoma
• How many lymph nodes were removed?
• Final staging?

There are several major ways in which a medical condition could reduce job performance:

In the discussions that follow, it will be helpful to remember the indirect burdens that disease can bring -- even for a President, who has a medical staff at his beck and call.

• Appearance of a new melanoma.
• Recurrence of the 2000 invasive melanoma.

A new melanoma would not necessarily be a threat to life, but it would interfere with the President's job: at the least, it would certainly trigger an intensive search to see if it had already spread. There would no doubt be long discussions on how to spin the news, and the press and the administration would certainly engage in essentially non-productive discussions of the President's treatment and prognosis (3).

The best known method to discover a new melanoma is frequent skin examinations by a dermatologist who knows his case well. This is the cornerstone of Senator McCain's melanoma care today.

Senator McCain and his campaign imply that he would continue his frequent skin checkups if he became President. There is actually reason to doubt this, as he deferred his skin checkups while running for President in 2000 (4). The deferral is probably why the melanoma discovered on his temple in 2000 was so far advanced. Thus, if elected, a President McCain should have the results of his skin examinations disclosed publicly, at the time they occur (5). The public could then serve as a nagging parent should he fall behind in his check-ups.

Unfortunately, simple skin examinations are wholly inadequate for detecting a recurrence of the 2000 melanoma. If the 2000 melanoma returned, it would not likely return in the skin. It would more likely return in a deep organ, such as the brain or liver. Skin examinations would obviously not detect brain or liver tumors.

Thus, skin examinations will not detect an old melanoma that has spread to an internal organ, or a new melanoma that arises outside the skin, or a new skin melanoma that spreads to an internal organ before arousing suspicion.

The Senator's continuing survival since 2000 reduces the odds of his old melanoma appearing in his brain. This is fortunate, because the absolute odds are quite high:

Metastatic spread of tumour cells detached from melanoma into the central nervous system (CNS) occurs ... in 10 to 40% of melanoma patients in clinical studies and up to 90% in autopsy studies. Headache is the most common presenting symptom, but brain metastases should be suspected in all melanoma patients with new neurologic findings. Magnetic resonance imaging is the best diagnostic technique for detecting CNS metastases. Median survival of melanoma patients with CNS metastases ranges between 2 and 8 months. (7)

Brain tumors present an insidious threat because of their potential to subtly warp thinking processes -- an obvious concern in a decision-maker.

Even if treated, residual effects -- from the tumor or its treatment -- might forever afterwards cast doubt on the President's decision-making. A canny politician would, therefore, realize that his political career would end the moment a brain tumor is discovered, no matter what the probability of successful treatment. Thus, to prolong his hold on power, it would be in the President's best interest to delay for as long as possible the recognition of such a tumor. The nation's interests are the opposite.

These realities are a conflict of interest. Like all conflicts of interest, this should be a red flag for voters. The Senator's physicians should outline what steps they plan to take, if any, to ensure they catch a brain tumor early. They should outline this before the election, so the voters can decide if it is adequate. It is too much to ask the voters to trust the President's physicians. Once their patient becomes President, patient-physician confidentiality means the President's physicians can say to the public only what the President asks them to. Public trust comes second to their obligations to their patient. And even if public trust did come first, the electorate does not know these physicians. They are not subject to Senate confirmation.

The medical surveillance plan for a President McCain should regularly include, at a minimum, a neurological examination conducted by a physician (preferably a neurologist) and imaging of the brain (e.g. by MRI). These studies should be performed now, especially because the Senator's drooping left upper eyelid is a neurological finding compatible with a tumor in the brain; it warrants investigation.

If caught early, the eye harboring a melanoma can be saved.

In medicine, odds on the order of 10 percent are considered high, and justify very aggressive medical surveillance.

Using references from the medical literature, Alam (10) estimates the current risk of Senator McCain dying from his 2000 invasive melanoma as 6% per year. The method used is not rigorous, but it usefully highlights a fact missing from current discussions of the Senator's health, namely, the risk of his cancer returning is still significant.

According to the Framingham equation, Senator McCain has a 27% chance of having a fatal heart attack in the next 10 years (11). His Framingham worksheet is available.

Use of the Duke treadmill score is problematic. It requires knowing which treadmill protocol was used during the Senator's stress tests (12). In the most optimistic case, if we assume the "Bruce" protocol was used, then Senator McCain has about a 10% chance of dying from heart disease in the next 10 years. If one of the less-strenuous treadmill protocols were used, his predicted risk of cardiovascular death would be higher. His Duke nomogram image is available.

Senator McCain is acquitting himself well, from a cognitive standpoint, in his campaign. His physician reports no evidence of short term memory loss. His function today, however, is no guarantee of his function tomorrow. He has several risk factors for dementia:

• Advanced age.
• History of head trauma producing unconsciousness.
• History of heavy, though unspecified, past alcohol consumption.

Lesser, but still abnormal, degrees of cognitive loss could pose grave threats to the success of a Presidency. Neurologists have difficulty defining these lesser degrees of loss, which go by the name of "mild cognitive impairment" (MCI).

Mild cognitive impairment is distressingly common in older Americans. Given the Senator's good performance during the campaign, it is unlikely that he has MCI today. Too little is known about MCI to determine his risk for MCI in the next few years.

Untreated OSA has the potential to significantly influence a Presidency (14), as the example of William Howard Taft proves (15). Chronically unrefreshing sleep can influence judgment, temper, and cognition itself.

Snoring is a cardinal sign of obstructive sleep apnea. If Senator McCain snores, he should be tested for OSA.

Sen. John McCain's 5 1/2 years as a prisoner of war in North Vietnam undoubtedly changed the course of his life. But now that he is 71 [72 at inauguration], that remote trauma seems unlikely to shorten his life span or to lead to mental or physical conditions that are not already apparent. That is the implication of a body of research on the lifetime effects of captivity and war trauma and the anecdotal experience of the small group of naval aviators imprisoned with McCain at the notorious "Hanoi Hilton." (16)

There is little value, however, in trying to predict whether a President McCain would be at risk for LOSS. The psychological demands of the Presidency, and the pschological make-up of someone who is elected President, are sufficiently unique that such a person cannot be expected to fit into the groups of people in whom studies of LOSS have been conducted.

This belief is commonly held, but it is clearly false. Richard Nixon is the clearest counter-example. His three modern Presidential campaigns (1960, 1968, 1972) subjected him to an extraordinary amount of public scrutiny. Yet, in the end he proved mentally unfit as President. It has recently been disclosed that he consulted a psychiatrist over a period of years in the 1950s (17).

Moreover, Litwin assumes a constancy of brain function. The brain of a 72 year old may not be the same brain two or three years hence.

Litwin should also have considered serious medical illnesses that can be completely asymptomatic, even in an active campaigner. The best example is a non-flow-limiting coronary plaque prone to rupture.

• In the event I am diagnosed with cancer in the brain, I will, within three days, resign the office.
• In the event I am advised by physicians to undergo cancer chemotherapy, I will transfer power to the Vice President. In the event the treatment does not render me cancer-free, I shall not seek restoration to the Presidency.
• Should I suffer an illness or injury in which my physicians recommend oxygen therapy, I will transfer power to the Vice President until at least the time oxygen is no longer recommended.
• In all cases of illness, I will authorize my physicians to freely disclose any medical matters that would render me unfit for duty under US Air Force Instruction 48-123 volume 3 attachment 4 (18) or succssor.

First, there is the possibility that his invasive melanoma could recur, either killing him, making him severely ill, or requiring treatment that would make him ill. We will conservatively estimate the odds of this at 2% per year.

Second, there is the possibility of a heart attack or a stroke. The risk predictions vary for Senator McCain's specific history. We will put him at a lower than average risk for a man of his age, and say the risk of cardiovascular death is 2% per year.

Third, there is the normal risk of death that anyone faces at a given age. Normally, cardiovascular deaths account for about half of all deaths in older persons. We will be generous to the Senator again, and put his risk of non-cardiovascular, non-melanoma death at only 1% per year. (19)

Fourth, there is the possibility that mild cognitive impairment may begin to occur. There is not enough information, however, to predict the odds of this, so we will call it zero.

Overall, therefore, the annual numerical risk appears to be at least 2% (melanoma) + 2% (cardiovascular) + 1% (general) = 5%. Quantitatively inclined readers should note that it is fair to consider these as independent causes, and simply sum them (20).

When compounded over 4 years, a 5% annual risk works out to a 19% chance of something medically bad occurring during a McCain presidency. This is a very conservative estimate.

As it stands today, the McCain campaign offers too much trust, and not enough verify.

The Senator should be applauded for making his medical records available for inspection, especially if they are his complete medical records. But he should be vigorously condemned for his tactic of forcing the inspection to be cursory and hurried.

Senator McCain forces us to place a great deal of trust in his physicians. They are perhaps fine people, but let us not forget that, at the Mayo Clinic, by their own sanctimonious admission, "the needs of the patient come first" (23). In this situation, the Mayo Clinic should put the nation first.

All physicians are aware of their dual responsibility to the public health and to their patients' health. Thus, there is no ethical conflict for the Mayo Clinic to speak freely and completely about the Senator's health, should the Senator allow it. In fact, the Mayo Clinic should have insisted on such liberty before agreeing to make any statement on McCain's behalf.

No statement from the Mayo physicians shows that they were allowed to speak freely. In fact, it is clear they were not. There was no discussion of the AFIP report. There has been no clarification on the staging of the 2000 invasive melanoma. If the Mayo Clinic assembled members from all three of its centers to discuss McCain's case in 2000, then it was clearly not as straightforward a case as the public disclosure would have us believe.

The Mayo Clinic has essentially operated as an arm of Senator McCain's campaign, wrapping itself in a misleading cloak of high-sounding moral principle. Mayo should have told the McCain campaign they would say nothing at all, unless they were allowed to speak freely. Most importantly, the Mayo Clinic should have disclosed the ground rules under which its disclosures were made. Only by knowing the ground rules could the public be assured that Mayo was not being complicit in a cover-up.