Kennedy's Chances of Survival and McCain's
Recently, it has been all too frequent an occurrence to have to assess the survival chances of prominent individuals with cancer. Ted Kennedy’s recent diagnosis is the latest and his prognosis cannot be sugar coated. While the exact stage of his “malignant glioma” has not been revealed, a rough estimate on a credible website succinctly notes “of 10,000 Americans diagnosed each year with malignant gliomas, about half are alive 1 year after diagnosis, and 25% after two years.” Glioma has been classified into four grades, grade one being the most benign and grade four, also known as glioblastoma multiforme, the most malignant.
It is unwise for a physician to make specific comments on a patient without access to details of the case. There are, though, some signs and facts that can be commented upon in a generalized way. Senator Kennedy’s tumor is in the parietal lobe of his dominant hemisphere, the one controlling speech. The parietal lobe is concerned primarily with sensation, but some visual pathways course thorough it and some areas are adjacent to the speech area and control, among other functions, the ability to read and calculate. This would generally hamper the ability to provide a surgical palliation (safely removing as much tumor tissue as possible in order to delay the spread). Surgery to cure malignant glioma has not proven to be successful. Also, the fact that the senator had a normal brain MRI less than a year ago in conjunction with his carotid surgery suggests that the tumor is of an aggressive nature.
Malignant brain tumors when first diagnosed are often associated with swelling of surrounding tissue, known as edema, from breakdown of the blood-brain barrier. Edema usually responds quite well to corticosteroids and often there is a temporary but dramatic improvement in symptoms after initiation of treatment. Steroids have minimal, if any, effect on malignant gliomas themselves and the inexorable growth of residual tumor tissue, with steadily progressive decline, often rapidly supervenes. Seizures can usually be well-controlled with medications. The combination of chemotherapy, brain irradiation and medication often affects cognitive function in a mild way, though the major problem will be direct extension of the tumor throughout the brain. All in all, Senator Kennedy and his team of physicians are confronted by an extremely formidable opponent.
With respect to other recent cancer-related political news, a case summary with respect to his melanoma has just been released by Senator McCain’s doctors. The summary and the results of reviews of the extensive medical records examined on site by reporters, some of whom were doctors, fails to address the issue of testing the senator should have prior to his acceptance of the nomination. This is precisely the subject of my previous post.
To reiterate with added emphasis, Senator McCain has a small but significant chance of occult metastatic disease. A regimen of skin examination and bloodwork every three months described by his doctors is grossly insufficient to provide the best assurance of a disease free state. Even though the odds of finding metastatic disease are as small as they are, the gravity of the office and the devastating prognosis associated with widespread disease makes it, in the opinion of this neurologist, imperative to have these tests performed and their results publicly revealed prior to acceptance of the nomination. To be blunt, if he has metastatic melanoma, he should not run.
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Steven Lomazow - 6/3/2008
Dear C Wilburs,
Thanks for your comments.
The answer to your first question is easy- as little as possible.
The scenario of the POTUS having brain cancer needs to be avoided to the utmost probability- the consequences are far too important not to afford the voting public the best assurance that they are supporting a candidate with the best possible chance to finish his term.
This is not 1944, when common knowledge of FDR's condition brought about a "dump Wallace" campaign.
Here there are reasonable prospective actions, and they need to be exercised to the fullest.
Even if there is a 1% chance that John McCain has metastatic melanoma at present, the testing outlined is justified.
The outline published by his doctors is not adequate.
Steven Lomazow, M.D.
Steven Lomazow - 6/3/2008
Dear Ms Reyes,
Thanks for your comments.
One purpose of medicine is to avoid problems in the future.
Even if there is only a 1% chance of the Senator having metastatic melanoma, the lack of risk in confirning this is justified in this case.
The scenario of the POTUS having brain cancer and having to be replaced by the VP is unlikely but real. All measures need to be done to avoid it. The testing I recommended will give the best assurance.
If he was running for dog catcher, perhaps a less stringent standard could be used- but that is not the case.
with best wishes,
Steven Lomazow, M.D.
C Wilbers - 5/28/2008
Since Dr. Lomazow admits that the chance of occult metastatic disease from melanoma is small, I wonder how much risk of mortality he is willing to accept in his presidential candidate? Based on Senator McCain's age and sex, and latest mortality statistics on the CDC web site, he has an approxmiately 12% chance of dying by age 75, not taking into account his history of melanoma. Consider that McCain's 5-year risk of melanoma recurrence and melanoma-related death, at the time of diagnosis, were in the range of 2-3% and 1-2% respectively (if we accept these stats from Dr. Lomazow's previous article). Further consider that McCain's melanoma-related odds have improved substantially by surviving 8 years without evidence of recurrent disease under standard dermatological surveillance, and that at least one paper has suggested an improved prognosis may exist in patients with multiple primary melanomas. Further consider the resolution limits of PET/CT and brain MRI which cannot detect microscopic metastases, and so can never certify anyone as "disease free." In light of all this, if Dr. Lomazow wants to disqualify John McCain for presidential office, he has better grounds to do it on the basis of age-related mortality discrimination than on the basis of melanoma-related mortality discrimination.
Furthermore, as a physician, Dr. Lamazow should recommend a PET/CT and brain MRI for his patient only if it is in the patient's best medical interest. Dr. Lamazow is not John McCain's physician. He has not made the case that these procedures are in McCain's best health interest, and should not impugn the professionalism of McCain's physicians with a publicly-stated clinical opinion. Given the low pre-test probability of these tests being positive related to melanoma, any findings on these tests are statistically more likely to be false positive, resulting in further unnecessary medical work-up and further unwarranted public scrutiny of McCain's health. Negative findings may also be falsely reassuring since occult microscopic metastasis could still present with clinical disease at any time, and a negative PET/CT and brain MRI would not affect the odds of that occurrence in the least. Such false reassurance could even tempt McCain to ignore real symptoms heralding metastatic disease, and thus delay testing at a critical point in time.
I submit that supposed public interest, or in this case physician-facilitated public paranoia about cancer, should not trump solid patient-specific, evidence-based clinical judgement by McCain's physicians. If McCain has chosen his physician team wisely, their expert advice for monitoring and maintaining his health WILL serve the public interest PRECISELY by optimally serving McCain's personal health without any regard for the pronouncements of medical/political pundits like Dr. Lamazow.
Nancy REYES - 5/26/2008
Medical reality check:
Senator Kennedy's cancer, alas, is a very malignant glioma.
McCain has a different cancer; melanoma, which has a higher cure rate.
Melanomas metastasize two ways: blood borne and via lymph nodes. Since he had a radical neck dissection looking for metastatic lymph nodes, and yet was classified as IIA (No local nodes by definition) we can assume the cancer was localized.
A small percentage have late metastases, but that five percent chance is low. Since McCain was checked by the Mayo clinic, your criticism that he was not properly checked out is absurd.
The chance of McCain developing a new cancerous mole or a cancer in another organ system may occur, but then it could occur in Senator Obama, who has a family history of cancer.