John McCain a "dead man walking"? Not so fast

Less than a month ago, I got a bit perturbed by some vile rhetoric written by a left-wing blogger named Matt Stoller, who referred to John McCain as a "crazy, cancer-ridden dishonest madman." As you recall, I administered a bit of not-so-Respectful Insolence to him. It wasn't so much because I like John McCain. Indeed, I've pretty much decided that McCain is a lost cause, a shadow of his former self. I would have voted for him in 2000, but in the last eight years he's let his ambition to become President utterly destroy whatever honor he had left, a truly sad thing to see given his previous service to this country. That being said, as a cancer surgeon, I do not like to see cancer survivors disparaged in the manner that Stoller did, even when that cancer survivor is John McCain, and I get especially annoyed at the attitude that science doesn't matter that Mr. Stoller demonstrated in abundance when he criticized climate scientists for "tut-tutting people not to jump to conclusions that specific storms or hurricanes are related to climate change."

I despise an attitude like that. Science matters, and distorting science, be it climate change or about cancer, is not only unnecessary but dangerous. I also despise an attitude that uses a patient's disease as an insult.

That's why, when I saw another blogger going down the Stoller path into tinfoil hat territory, I decided that it was time to deliver more than a little not-so-Respectful Insolence. On the other hand, to be fair, I will point out that this blogger at least avoids the nasty use of "cancer-ridden" as an insult; so I guess maybe her post is not quite as bad as Mr. Stoller.

It's pretty bad, though. Real tinfoil hat material. I'd say it's not as bad when it comes to the contempt for cancer patients but beats Stoller hands down for wild conspiracy-mongering that would be more at home on a 9/11 Truther website than anyplace else. Grassy knoll, anyone?

This blogger also demonstrates a good bit of the arrogance of ignorance in the form of a charmingly entitled post John McCain: Dead Man Walking? If ever you want evidence that such obtuseness is not confined to just right wing bloggers, this is it. Once again, we get the whole "John McCain is dying of cancer" rant, again without a shred of evidence and with only a minimal (if that) understanding of melanoma, the form of skin cancer that McCain has survived. The blogger, going by the 'nym of Maggie Jochild," starts out with a sad story of cancer, where she actually gives good advice, although it's irritating that he seems to think that working at a cancer center without any medical training in any way qualifies her to comment any more than anyone else:

I am not a doctor and have no medical training, but at that time I worked in a major cancer clinic and I saw skin cancer daily. I bent over her ankle, peered at the spot and said "I dunno. I think it's probably some kind of freckle, but you should have it checked out by somebody who's competent, not me." She said she planned to -- she was in the medical field, and responsible. Her own mother had died of cancer when Dusty was five, and it had been a loss she'd never quite overcome, in part because her mother lied to her about her terminal condition and promised she'd be coming back from the hospital when she went in to die.

Not long after I returned to Texas, Dusty called me and said it was melanoma. She was fair-skinned, had always been diligent about using sunscreen, but it had occurred anyhow. She began rigorous treatment. I never saw her again. She was dead within the year, leaving Tom without his mother at age five, just as Dusty had grown up.

Whenever you see someone preface remarks about a medical condition with "I am not a doctor and have no medical training," it's a pretty good indication that that someone doesn't know what she's talking about. Yes, melanoma is a potentially horrible tumor, but it's also potentially very curable in many cases. It can be especially bad because it's not uncommon in younger people. It is the most common cancer in women between age 25-29 and second only to breast cancer for women aged 30-34, and melanoma can be metastatic at the time of diagnosis of even a small primary tumor. It really sucks to encounter young patients like this with melanoma, which can cut people down in their prime. The only truly effective treatment for melanoma is complete surgical resection because melanoma more or less laughs at most chemotherapy. There are, however, biological treatments; unfortunately, they are only mildly effective and fraught with unpleasant side effects. Even so, that doesn't excuse Maggie's descent into the arrogance of ignorance:

Last week, when I got the letter from Robert Greenwald talking about John McCain's refusal to release his medical records to fair scrutiny, the fact that there are 1,000 pages of them (I create medical records for a living, 1,000 pages is EXTREME), and the news that he has had malignant melanoma, deep primaries with removal of lymph nodes, my immediate thought was "Then he's dying." If he were to be elected, he'd have an almost 2 out of 3 chance of having a recurrence if he doesn't have one already. This is not the kind of cancer you count on escaping from. This is not Stage II, as it has been reported: Stage II by definition does not have lymph node involvement. By definition, it must be either Stage III or Stage IV.

Wrong, wrong, wrong, wrong. It was not stage III or IV. I discussed this before, although not in a lot of detail. First, I have to point out that what McCain's status is with regard to his melanoma is an entirely separate issue from whether or not his campaign should release more of his medical records. Actually, I'm a bit conflicted on that issue. He did a fine job releasing his records in 2000 but has been a bit secretive in 2008. Given that observation, I can't help but observe that a lot of conspiracy-mongering about McCain's health emanating from some corners of the blogosophere is, to a large extent, his own damned fault for not being more transparent in disclosing his medical records. Withholding anything only feeds the paranoia of bloggers like Stoller and Jochild. Be that as it may, misinformation about melanoma being used as a way of painting McCain as a "dead man walking" irritates me almost as much as using "cancer-ridden" as an insult. The arrogance of ignorance strikes again.

Maggie needs to learn one thing: Just because they removed John McCain's cervical lymph nodes were removed does not mean that those lymph nodes contained melanoma. Let's review a little bit about how melanoma is staged. A good brief explanation can be found here. In brief, melanoma staging depends on three main factors: depth of invasion of the skin; presence or absence of tumor in regional lymph nodes; and presence or absence of distant metastases. True, there are other factors that factor into the equation, such as the presence or absence of ulceration of the primary tumor; the presence or absence of "satellite" lesions (small melanomas near the primary); or the presence or absence of in-transit metastases, also known as regional dermal metastases. This latter form of metastases are small deposits of melanoma that travel up the lymphatics and lodge in lymph vessels, where they grow into tumor deposits. In fact, regional dermal metastases can be a very serious problem. Sometimes they are the only manifestation of melanoma and keep popping up just as fast as surgeons can cut them off. Sometimes they will grow and coalesce to take over an entire limb, with no way to cut them all off. Amputation won't do much good, because tumor is in the lymphatics and will inevitably recur in the stump.

John McCain didn't have any of these things.

In fact, what John McCain had was not stage III or stage IV melanoma, which would have required either lymph node metastases, ulceration of his tumor, or, in the case of stage IV, distant metastases to be diagnosed. He had stage IIA melanoma. That means he must have had a tumor that had no lymph node involvement and either 1.01-2 mm thick with ulceration or 2.01-4 mm without ulceration. Here's a description of his operation:

• In August 2000, following a 27 month absence from care at Mayo Clinic, Senator McCain was diagnosed with a melanoma that was 2.2 millimeters thick at its thickest part and was 2 centimeters across.  This melanoma was located on the left lower temple region of the face.
• Prior to surgery, numerous tests were performed, including CT scans, an MRI scan of the brain, liver tests that included LDH, and there was no evidence that the cancer had spread.
• A comprehensive surgical procedure was done that included sentinel lymph node biopsy, removal of the cutaneous melanoma and key lymph nodes, and reconstruction of his left temple region. 
• A 2 centimeter margin of normal skin was removed around the 2 centimeter melanoma, resulting in a 6 centimeter by 6 centimeter roughly circular wound on the left side of the Senator's face.  The underlying Parotid salivary gland was also removed to assure a clear deep margin, to protect facial nerves from injury and to remove the sentinel and other lymph nodes that were inside the Parotid gland.  None of Senator McCain's lymph nodes showed any evidence of metastatic disease.
• The large incision was necessary to safely remove all cancer with an appropriate margin, resulting in a wound requiring sizeable reconstruction.  This explains why the large incision was madeââ¬"it was necessary so that a flap of skin and soft tissue consistent with the color and texture of the Senator's facial skin could be elevated and advanced/rotated into the wound. 
• To answer what appears to be numerous questions about the prominence of the Senator's left jaw: this is a result of an absence of soft tissue on the face in front of his ear that makes the masseter (the chewing muscle) over the jaw appear more prominent.  To be clear, the swelling is not due to any evidence of cancer.

I must admit, I was initially a bit confused over the surgical strategy. A sentinel lymph node (SLN) biopsy is the standard of care today. This procedure involves the injection of radioactive dye and/or blue dye (usually both), which gets taken up in the lymphatics and lodges in the first draining lymph node. Using a Gamma probe and visual examination for blue dye, the surgeon identifies that lymph node (or nodes) and removes it. If it has no tumor in it, it is a quite accurate indication that none of the other lymph nodes have cancer in it. In fact, the SLN biopsy was quite a step forward in melanoma surgery because it spares many patients lymph node dissection, which can be a very morbid operation depending upon the lymph node basin. Indeed, before the era of SLN biopsy, I remember endless debates at surgical conferences over whether elective lymph node dissection should be done at the time of melanoma resection or whether it should be delayed until there was a clinically suspicious lymph node detected by physical examination in that lymph node basin. My memory may not be correct, but I seem to recall that by 2000 there was enough confidence in SLN biopsy in melanoma that it was being used routinely without automatically doing a full lymph node dissection, but it's also possible that at the time for head and neck melanoma not all melanoma surgeons had full confidence in the technique yet. Doing SLN biopsies for head and neck cancers is often a lot more difficult than for melanomas on the trunk or extremities, which will usually drain to the axillary or inguinal lymph nodes. Moreover, it is that extensive surgery for what was apparently stage II disease has continued to contribute to the impression that McCain's melanoma must have been more extensive. Dermatologists and surgeons look at that operation through the prism of today's standard of care and wonder why McCain underwent such an extensive operation, rather than considering the standard of care eight years ago, a time when the standard of care for the management of lymph nodes in melanoma was rapidly evolving.

Surprise, surprise, though, It turns out that Maggie got her information from Matt Stoller, who demonstrates once again an uncanny knack for diving right into the deep end of the ignorance pool with a resounding belly flop that splashes the stupidity around, drenching everyone unfortunate enough to be in the vicinity:

I just got back from a dermatologist for a check-up (growing up in Miami with outdoor summers requires this), and I asked her about McCain and skin cancer. He's had various types of the disease and I wanted to get a sense of whether he's really in danger or if this is one of those treatable forms of cancer. And she told me that basically, some skin cancers are not that bad, but malignant melanoma - the kind McCain has had in two separate places - is not one of those. It's bad. Real bad. And unlike most cancers, it doesn't really go away, even after years in remission. Sam Donaldson had it on his ankle, and thirteen years later it returned in the same spot. McCain has had it on two separate 'primaries' (not recurrences, which aren't as bad), and you can clearly see the post-surgical scars of having his lymph nodes checked (and partially removed). This is not a healthy guy, this is a 72 year old man with a fairly high likelihood of serious illness and death within the next few years.

That's sort of true in that melanoma is one of the tumors that are notorious for recurring late. I'd even have grave concerns myself if McCain had just undergone the surgery for his melanoma this year, because, even though his prognosis would be relatively good, his chances of recurrence and/or death in the next five years would still be significant. However, 2008 is not right after McCain's melanoma surgery. It's eight years later, and his chances of recurrence are considerably lower because of how long he's survived. The longer a melanoma patient survives without a recurrence, the less likely a recurrence becomes. Not surprisingly, Stoller's assessment is also wrong in other ways. For example, recurrent melanoma does not necessarily portend a better prognosis than new primary melanomas. In fact, each new primary is usually treated independently for purposes of prognosis, being treated in essence the same prognosis as if the patient had never had melanoma before. Moreover, in general, second melanomas tend to be thinner than the original melanoma. For McCain, other than his melanoma resected in 2000, all of his other melanomas were in situ melanomas, which meant that they had not invaded yet--a very favorable prognosis, with virtually 100% survival. If McCain ever succumbs to melanoma, it won't be because of his in situ lesions. In contrast, recurrences may or may not portend a worse prognosis, depending on the type of recurrence. An in-transit metastasis is not good but also not horrific; a lymph node recurrence is bad--it's an automatic stage III at least; a recurrence as a distant metastasis is an almost certain death sentence eventually, although it should be pointed out that even some stage IV melanomas can be "cured" for long term survival by surgical resection. Indeed, stage IV melanoma is one of the few cancers that can sometimes be cured with surgery, and five year survivals are between 7-19%.

One thing you also have to remember here is that dermatologists usually don't take care of melanoma, at least not definitively. They diagnose it; they biopsy suspicious lesions; and they often do the initial excision. For small, thin melanomas that only require excision and do not require evaluation of the lymph nodes, they will often do the definitive therapy, and they also usually do the long-term followup with frequent skin examinations to spot recurrences or new skin cancers after the definitive resection of a melanoma. All of these are critical functions and require a fair amount of skill, but for any but the smallest, thinnest melanomas, the evaluation of lymph nodes and determination of final care of the patient generally falls not to dermatologist, but to a surgical oncologist or general surgeon with enough experience in melanoma to be competent dealing with it and, after that, medical oncologists. That a dermatologist apparently told Stoller this is only marginally meaningful. Some dermatologists are very knowledgeable about melanoma; others may not be as up on the latest in treatment.

Given all this background, you know what really bothers me about bloggers like Matt Stoller or Maggie Jochild? It's that their examinations of reasonable questions about whether John McCain's melanoma is a health factor that is sufficiently worrisome in a Presidential candidate that it should be a major factor in deciding whether or not to vote for him is so outrageously over-the-top, so full of paranoid conspiracy theories, that they taint the whole issue with the putrid stench of fetid wingnuttery every bit as irrational as anything found over at WorldNetDaily. By being so eager to label McCain a "cancer-ridden madman" secretly dying of cancer and plotting to give Sarah Palin the Presidency after he dies, they make even reasonable questions about McCain's health sound bat shit crazy. Reasonable people can disagree over how important this particular issue is, informed by rational consideration of life expectancy tables and factoring in the relatively small chance of melanoma recurrence in the next four years, but reasonable discussion and disagreement are not at all what these two bloggers are about. That can be seen by examining the way that Maggie outdoes even Matt Stoller in doing a cannon ball into the deep end of the paranoia pool:

If he is in fact a Dead Man Walking, then the choice of Sarah Palin as Vice President also becomes more than a Hail Mary pass intended to destroy any bounce from the wildly successful Democratic Convention. It becomes reckless in the extreme: Choosing an heir apparent who lies, engages in petty revenge, wants to know how to ban books, faithfully attends a church which believes dinosaurs were around 4000 years ago and Jews are punished by God for not believing in Jesus, has less foreign policy experience than a Delta flight attendant, doesn't know what the Bush Doctrine is, and has less than two years experience governing a state with a population less than that of Wichita, Kansas or Raleigh, North Carolina.

We know that the secret cabal, the Council for National Policy, who hopes to replace American democracy with religious rule (THEIR religion, not yours), are the people who investigated Sarah Palin and "chose" her for McCain as his VP. Since he accepted their decision, fundamentalist organizations have thrown themselves behind his campaign in a way they had not before. It raises the question of a deal. What would a dying man have to offer power brokers in order to have their backing for the U.S. Presidency?

Quite the deathbed request that would be.

I don't like Sarah Palin any better than any other blogger around ScienceBlogs. Choosing her as his running mate was a brilliantly cynical move on McCain's part, given that Palin is utterly unqualified to be President if McCain were to die or be incapacitated in office, which based on McCain's age alone is a more likely scenario than it is for the average newly elected President. She's only qualified to be Vice President if we go back to the days when the Vice President did nothing other than break ties in the Senate and wait around until the President dies--but then only as long as McCain remains healthy. But this whole "secret cabal" thing is so over the top loony that I've only rarely seen its like. Maggie really does sound like a 9/11 Truther here. Don't get me wrong; I'm actually more or less down with her about Palin's inexperience and religious extremism, but this whole thing about a "dying" John McCain offering this secret cabal their choice of VP nominees in order to secure their support, knowing he is dying and that he would be handing the Presidency over to their hand-picked candidate is just plain loony.

I just hope Maggie has her bunker ready. The Black Helicopters from Haliburton are coming for her on the orders of Dick Cheney and the religious cabal in order to prevent them from forestalling the election of Sarah Palin--oops, I mean John McCain--and the subsequent onset of The Rapture and the Second Coming of Jesus. After all, the secret religion-industrial complex cabal can't have anyone out there letting everyone know The Truth about the McCain/Palin conspiracy.

After Maggie Jochild is safely silenced, they'll go after Matt Stoller.