Many holes in disclosure of nominees’ health

Several questions left
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.

iIn 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.

Mr. McCain has kidney stones and takes a statin for high cholesterol but has no evidence of significant heart disease, his doctors said.

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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. It was certainly more significant than the one-page doctor’s note Obama released, though I have little hope The Times will report it that way.”

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