I often plow through pages of biopsy results when I meet a skin cancer patient for the first time. It takes a seasoned professional to understand the pathologist's interpretations of a skin lesion and to apply that information to the patient standing before you. By combining the report and the clinical picture in front of me, I am able to categorize my patient into various risk levels for skin cancer recurrence. As much of this judgment is based on the reading and interpretation of the dermatopathologist, I've developed close relationships with several excellent pathologists. Even so, when their readings are ambiguous or their interpretation doesn't coincide with what I see in front of me, I am professionally obligated to ask for a second reading from an independent pathologist.
Given that analyzing biopsy results can be challenging even for someone who does this on a regular basis, I am not surprised that the reporters who were given access to Senator McCain's medical records were completely baffled by the 1173 pages of doctors' notes and test results. Dr. Lawrence Altman argues in the New York Times that this limited access to the Senator's medical records prevents Americans from fully understanding the potential health risks that may limit the Senator's ability to fulfill his duties should he be elected our next president. The short time the records were open for examination has raised critical questions concerning inconsistencies in medical opinions about the severity of his melanoma.
According to his medical records, Senator McCain has suffered from numerous common types of skin cancer, including basal cell carcinoma and squamous cell carcinoma, as well as 4 potentially lethal melanomas. The lesion on his left temple that was diagnosed in 2000 and is clearly visible in this video was the most severe and has raised the most questions regarding the accuracy of the diagnosis and appropriateness of his treatment. In particular, there is confusion about whether this melanoma was a new tumor or a recurrence of an earlier lesion biopsied in the same area in 1996 and originally read as benign. The report in 2000 of the Armed Forces pathologists about this left temple lesion suggested a recurrent melanoma, stating "The vertical orientation of this lesion, 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.
It is important to determine whether this left temple lesion is a primary tumor or a metastasis in order to appropriately treat the lesion and provide an accurate prognosis. A new melanoma of 2.2 mm in depth would be stage IIa on a I-IV stage scale while a recurrent lesion would be a stage III. Reclassifying the tumor, would change Senator McCain's statistical survival at 10 years from about 60 percent to 36 percent at the time of diagnosis, according to a published study. A recurrent lesion would also prompt surgeons to be more aggressive and remove the entire basin of 30 draining lymph nodes, as was done in Senator McCain's case, rather than simply check the most likely affected sentinel lymph node. It is unclear from the McCain's surgeon's reports why such an aggressive course of action, which is usually reserved for metastatic melanoma, was taken in the Senator's case if there was no evidence of melanoma in the sentinel node.
Should metastatic melanoma recur, appropriate treatment often requires further surgery and debilitating chemotherapy which would make it difficult for even the most dedicated individual to perform daily functions. The public should be aware of medical information which may indicate a greater chance that a candidate may be affected by a serious illness which could limit his capacity to lead. I strongly encourage Senator McCain to alleviate the confusion over these biopsy reports and melanoma surgery. The public would be even more encouraged if he let independent pathologists review the slides from his skin biopsies and lymph node dissections. The senator and the public deserve a second opinion on his medical fitness to serve prior to making a decision on November 4th.