John McCain and his Brain Tumor

Today we are once again faced with a noted individual fighting a serious illness. Oceans of ink will be spent discussing the Senator’s battle with his cancer.

Typically, there is often a great deal of false optimism that occurs in these settings, because we simply cannot accept that people die of cancer.

To begin, let me be extremely clear that I wish Senator McCain the best. He is at the Mayo clinic, so I’m completely confident that he will be receiving the best possible care.

However, let’s discuss this disease a little more objectively, in order to get a better handle on what the Senator faces.

Glioblastoma is an extremely aggressive form of brain tumor. What causes it is unknown, although this is the tumor that has been falsely linked to cell phone use in the past.

In the ideal case, a patient will have the tumor surgically removed, and then receive a drug called Temodar at the same time as receiving radiation therapy.

Let’s address each of these in turn.

SURGERY

It is customary, when discussing the surgery of a famous individual with cancer, to hear the surgeons quoted as, “they got it all”.

Now, in some situations, say, an early breast cancer, that can be completely accurate. However, when one is discussing a glioblastoma, that is simply never true.

What they really mean, at best, is that the surgeons removed all they could see. The nature of glioblastoma, however, is that it spreads through the brain tissue, and removal of all of it is virtually impossible.

That’s why additional treatment is necessary.

RADIATION THERAPY

Radiation treatments have been a mainstay in the treatment of glioblastoma for decades. Unfortunately, the success has been limited.

Typically, someone treated with surgery only lived 6 months, on average. Radiation could extend that to nine months, occasionally a year. It is a dismal disease.

The other problem with radiation was that we treated a very large portion of the brain to very high doses. That meant, that in the few longer term survivors, they often suffered brain damage (brain necrosis) or dementia.

Today, our techniques are far superior, and we can accurately spare more of the normal brain, but that’s not the problem with this disease.

The problem is, this tumor can tolerate radiation better than the normal brain can. In fact, in autopsy studies, it was not uncommon to see an area of the normal brain, which had been destroyed by radiation contain completely healthy tumor.

CHEMOTHERAPY

One of the greatest advances in the treatment of this disease was the discovery of the drug Temodar (Temozolomide). The use of this drug, along with radiation, and for several years afterwards, doubled the survival time from nine months to 18 months.

It may not seem like much, but believe me, as someone who has treated his fair share of these tumors, this was an amazing advance.

However, the prognosis is still dismal. I saw several numbers quoted in the media today saying that there are 5-10% long term survivors (5-10 years). However, these patients may be ones with a special sub type that has a mutation which makes them respond better to therapy.

PROGNOSIS

As a rule, the younger you are, being female, having a smaller tumor and having it all removed means better survival. Being an 80 year old male, Senator McCain has at least two strikes against him.

Let’s not forget when Ted Kennedy was diagnosed with this tumor. He went to Duke to receive “the best care”. He died in about 18 months, as expected.

Now, why do I insist on hanging crepe here?

It’s because when famous people get these diseases, we insist on assuming they will have miraculous powers of recovery. But that is simply untrue.

And worse, it produces a sense of false hope in other patients currently battling this disease.

Remember Cardinal Bernardin and his pancreatic cancer? After his first surgery it was announced that the cancer had “only” spread to 2 lymph nodes and the surgeons “got it all”.

Yet, every oncologist worth their salt knew that it was only a matter of time till it would recur, which it did about one year later.

There’s little doubt that the Senator will battle this disease the best he can, helped by the best that modern medicine can offer, however, we should not hold out false optimism that he will beat this because of the amazing challenges he has overcome in his life.

As a military man, I believe the Senator would agree that sometimes the opposition is simply too great to overcome.

I sincerely wish you the best Senator. I hope that, at the very least, the time you have remaining is of a high quality, and that when the time inevitably comes, your passing is peaceful and with dignity.

I have always wished that for all my patients.

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