A reader writes:

Being a Dermatology Physician Assistant and a cancer survivor, I recently reviewed John McCain’s medical records (which were made public earlier this year after he was the Republican nominee) about his melanoma, the type of skin cancer that is very frequently fatal. He has had 4, possibly 5 melanomas. The most serious one was on his left temple, in 2000. It was considered a deep melanoma (2.2 mm– which is very risky). There was also another melanoma in the same area, which could have likely been a metastasis from the bigger melanoma on the temple, there is no way to know. They had to take out all his lymph nodes on that side of his head and neck, that is why his cheek looks so misshapen. That thickness of melanoma (whether or not it is in the lymph nodes) usually gets about 1 year of interferon (a form of chemotherapy), which would have been standard of care. But, since this happened right at the time of the 2000 election conventions, McCain opted not to have the chemo.

He has had another melanoma appear on his nose in 2002, again, no real way to tell that this was not a metastasis, or a new melanoma. The other 2 melanomas were prior to 2000. Frankly, I’m surprised that he has survived this long. Melanoma is very unpredictable and aggressive. With his history of multiple melanoma episodes, as well as other types of skin cancers and pre-cancers, this means McCain’s immune system is poor. Melanoma can metastasize to any part of the body including the brain. It lurks until it starts to cause problems in whatever organ it starts to grow in. The only way to know if it spread is when it invades something and causes that organ to malfunction. There are no blood tests or other screening tests to catch metastasis “early” other than frequent skin checks and that would only find it again on the skin. When melanoma spreads, there is not any good treatments to stop it. So, I think that it is a very real possibility that John McCain will have more melanoma.

I try to inform all of my patients each day of the risks of melanoma and I spend my work days hunting for melanomas at the earlier superficial stage that can be treated. McCain’s is in the deeper, more dangerous, category. At least in dermatology, we don’t worry too much about the melanoma’s less than 1 mm. His was 2.2 mm. It was likely an aggressive one, because it seems that it was not observed at his derm exam, then his family doctor found it during an interim appointment. I am sure that a dermatologist would have seen it and biopsied it given his history. So, it probably grew extremely quickly in several month’s time since McCain would have been seen by derm at least every 6 months. This reminds me of one my patients– she had a melanoma removed on her shoulder with clear margins, her lymph nodes were negative. On her first follow up visit in 3 months she had no visible sign of any recurrence. 1 month later she came in because she had some unusual bumps appearing in the area. She had metastases locally, and when they checked a PET scan, she had melanoma throughout her body. She only lived a few more months.

Here is an article that appeared soon after the medical records were released (and I have also read the actual medical reports that were released).