McCain Releases Medical Records

Yale University Prevention Research Center director Dr. David Katz was online Friday, May 23 at noon ET to discuss the medical records released Thursday by Sen. John McCain and what they indicate about the Republican presidential candidate's present and future health.

The transcript follows.

Katz is an associate professor (adjunct) at the Yale School of Public Health, and director of Yale University's Prevention Research Center. He is the founder and president of the non-profit Turn the Tide Foundation, devoted to reversing trends in obesity and related chronic disease. He has authored 11 books; writes a monthly nutrition column for O, the Oprah Magazine, a weekly health column for the New York Times Syndicate and a daily blog for Prevention Magazine; and is a medical consulting to ABC News.

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washingtonpost.com: What would treatment be like were Sen. McCain's cancer to recur, and how would it potentially impact his performance as president?

Dr. David Katz: If melanoma were to show up in a new spot, it would be resected (removed with minor surgery). Because the senator is being screened carefully, it will likely be caught early -- and the surgery should be curative.

The bigger worry is a recurrence of the prior melanoma -- that would signify a metastatic condition, very refractory to treatment. But at eight years out from his last surgery, the risk of that is below 10 percent.

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Dallas: What about what McCain's medical disclosure may not be telling us? His temper reminds me a great deal of my grandparents -- who, disturbed by their declining memory and thought, lashed out at family and friends about the slightest thing.

Dr. David Katz: I think this is an excellent point. No matter our health, our faculties do decline with age. I too have noticed some very subtle indications that Sen. McCain's wit may show some signs of his age.

The significance of that is for you to decide. There is, perhaps, a trade-off between the mental acuity of youth, and the wisdom of age.

By the way, I do have a political opinion, but I'm trying to keep it out of the way for purposes of this discussion and walk the middle path!

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Helena, Mont.: Were you able to see the actual records, or are you just going by what reporters have said are in the records?

Dr. David Katz: Sen. McCain's medical record is a chart 1,700 pages long; I have not reviewed that. I have access to much the same information as you, so my contributions here are more about interpretation of information than they are about privileged information.

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New York: The Post printed a comment about Sen. McCain having no long-term affects from being a prisoner of war. Is that even necessary to discuss? Are we not hyperanalyzing to the extreme in today's world? How about the hundreds of thousands of World War II prisoners of war who lived productive lives, whether they did or did not have psychological scars? Are we becoming a nation of over analytical wimps?

Dr. David Katz: There's a nice living to be made as an over-analytical wimp!...

But be that as it may- the psychological trauma of war is very significant, and far more prevalent than we tend to acknowledge. So scrutiny of this issue makes sense. But because Sen. McCain has served in the U.S. Senate for years -- a job that requires many of the same aptitudes as the presidency, and perhaps an even greater ability to work and play well with others -- I would agree that in this case going to his remote past to look for concerns does seem to be dredging.

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San Francisco: What's the typical life expectancy of a man McCain's age, and how would it be affected by the abuse he suffered as a POW? What's the likelihood of Alzheimer's disease or other mental decline? At 72, McCain would be the oldest person to ever become president. Reagan's mental health declined in his second term.

Dr. David Katz: Average life span for men in the U.S. is roughly 75. The fact that Senator McCain is a senator, has money, influence, and privilege; a family; excellent medical care -- all mitigate in his favor. These are factors that would, all things being equal, tend to extend his life expectancy. His past traumas, and the melanoma, would mitigate the other way -- lowering his life expectancy.

Either way, it's worth noting that were Sen. McCain to live the average male life expectancy in the U.S., he would not survive his first term.

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Columbia, Md.: Was there any mention of the large mass on the left side of his face? I've never seen mention of it; photogs seem to shoot McCain from the right, and I have to wonder what he's hiding. The mass wasn't there during the last campaign.

Dr. David Katz: To my knowledge, this disfiguration is a consequence of exploratory surgery at the time of his most advanced melanoma. I have not examined the senator, but images I have seen suggest to me this disfiguration has been stable for several years at least.

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washingtonpost.com: As a long-term smoker who recently quit, what sorts of health concerns could there be for Sen. Obama in the next four to eight years?

Dr. David Katz: The risks of heart disease and emphysema start to drop off almost immediately with smoking cessation, so these risks are lower now that the senator has quit. The risk of lung cancer will remain elevated for some years, but this is not a risk likely to manifest for decades anyway. Sen. Obama's age is a defense of his health, just as Sen. McCain's is a vulnerability.

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Dallas: On the issue of health records for a presidential candidate, do you think if the voters had known that FDR was so feeble and sickly that they would not have given him a fourth term? Also, JFK's health records show that he had some problems, and that his medications might have altered his mental capacity. Any truth to that? Overall, isn't it best to let voters know about the health of their candidates so they can judge if each can serve their term?

Dr. David Katz: This, to me, seems the central question: who should know what about the health of a presidential candidate? We could argue that everyone should know everything -- but if that is so, why not generalize? Aren't passengers entitled to know the health record of every pilot of every plane we fly in? After all, we're putting our lives in that person's hands.

Our society seems to have embraced the principle that the President of the United States is a uniquely public property. The trouble is, the person occupying that position is still a person -- and perhaps entitled to some privacy as such.

My view is this: as with any job description, the POTUS position should make explicit the information that must be disclosed. Candidates could then decide in advance if they are comfortable with standing that naked in front of a crowd. If no, they don't have to run.

I think the requirement for transparency should extend to relevant information likely to impact suitability for the job. It should stop short of salacious curiosity- a realm into which we sojourn all too readily. Actuaries could do a good job of drawing the dividing line.

As for FDR's last term -- his health might well have been a factor, and perhaps should have been.

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Bethesda, Md.: Speaking of smoking, pictures from the '70s show McCain with cigarettes. Is there any information about how long he smoked and when he quit?

Dr. David Katz: In between answering questions, I'm looking to see if I can get this information; I don't have it readily available.

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Seattle: Does McCain melanoma make him more predisposed to other types of cancer, such as colon or prostate cancer? Also, what indications of such health problems would show up in his records that would not be readily apparent?

Dr. David Katz: To some degree, yes, although the association is indirect. His record shows he has, in fact, had colonic polyps.

With regard to cancers we can screen for effectively, the senator is in good shape since he is getting very meticulous medical attention. But we don't have screening tests for all varieties of cancer, so in some cases there would be no warning until the disease were found. The senator is free of any cancer at this time according to his medical record.

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Stamford, Conn.: Re: Life expectancy -- you replied to San Francisco that average life expectancy for men is 75, but isn't that life expectancy at birth, whereas the relevant issue is "what is his further life expectancy at his present age"? As a historian who works with demographic data, I know there can be a significant difference between life expectancy at birth and life expectancy at a given age; I would expect a 72-year-old man in the present-day U.S. to have a further life expectancy of more than three years.

Dr. David Katz: Very good point -- I am giving brief and simple answers. But life expectancy is projected from birth, and that average is brought down by people who die very young. The years of expected survival at a given age vary from that figure.

See if you can track down a good source for the average years of remaining life for a 72-year-old male in the U.S., and fill us in!

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Seattle: Seventeen hundred pages, three hours, no doctors and only five reporters? What sort of analytic review can you do on medical records under those circumstances?

Dr. David Katz:1173 pages, actually, I think. It's a lot of pages in any event.

Very limited -- but note that medical records include a lot of daily progress notes that don't alter the big picture. The key points of a very extensive medical record can often be summarized pretty readily. The main items are: what conditions has the senator had, what treatments has he received, what conditions does he have now, and what risk factors does he have for major chronic diseases? Most of this information is now on display.

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Rolla, Mo.: I'm afraid the McCain age issue will boil down to those who think he's doddering old fool and those who think it's no issue whatsoever. What are the real issues, if any, for an otherwise healthy 72- to 80-year-old man in the office of presidency?

Dr. David Katz: With regard to health-- yours, mine, or Sen. McCain's -- there is what we know for sure, and what we project. Those projections are based on probabilities. I am 45, but could be struck by lightening tomorrow while the Senator lives to be 110. It's just not very likely...

Age is one of the most potent and universal predictors of health outcomes, since it catches up with us all eventually. Age does make survival a consideration; McCain would have to live to be 80 to get through two terms, for instance. A long way from impossible, but not a guarantee even for someone in good health with good luck. Age, on average, slows mental acuity, reduces memory, reduces daily tolerance for hours of work, dims vision, reduces auditory acuity -- and so on. It is certainly a relevant consideration. The question for everyone is: how relevant, as compared to other salient considerations?

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Harrisburg, Pa.: The office of president appears to place much stress on a person. Does John McCain appear physically prepared to endure the possibility of great stress?

Dr. David Katz: I would simply remind everyone that serving as a US Senator, and running for president, are not exactly a walk in the park- and he seems to be able to tolerate those activities.

From a distance, it appears to me that running for president is more stressful than being president -- although we'd have to ask Carter, Clinton and the Bush's to know for sure.

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Annapolis, Md.: Is it standard practice to release medical records during a presidential campaign? Do most candidates just release them to the media, or do they control access and copying? What was the reason for the controlled access in McCain's situation?

Dr. David Katz: Medical records are privileged information, and I do not believe there is any official requirement for release unique to a presidential campaign. The Senator realized, however, that not releasing his records was a potential liability. So he chose to release them, but in a manner carefully controlled by his people.

As per an earlier reply, I believe we need, and should have, standard and official health reporting requirements for any presidential candidate so the playing field is level, and there are no surprises.

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Anonymous: Does John McCain have any lingering health issues from his imprisonment in Vietnam? Hopefully he has healed from them all. I ask because it obviously was a physically traumatic experience and I believe he suffered broken bones from the crash and the overall experience. Did he regain full function once the bones healed and he recovered from any malnutrition? This is not a question for you, but especially if John McCain becomes president, I believe the government of Vietnam should offer an apology for this mistreatment.

Dr. David Katz: I would again invoke his long service in the Senate and note that the rigors of service as a senator, and as president, are similar if not the same. So I think we already have evidence that the relevant health concerns are new ones -- such as the melanoma -- rather than residues of old traumas.

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Absurd Farce?: Let me get this straight: A dozen or so reporters hand-chosen by the McCain campaign are getting a few hours of access to 400 pages of doctor scribbles and medication names? In fact, the organization that brought a doctor to the medical record viewing in 2000 hasn't even been allowed back in. Why don't news outlets protest the whole silly exercise, and simply say that as a profession, the job is to inform the public, and that means bringing in some actual experts who can evaluate these documents -- and if they can't do that, then sorry, they can't report that McCain opened up his medical records. Why is that so hard to do?

Dr. David Katz: A valid point. Again, I think we should establish standard medical reporting requirements for a presidential candidate. At present, we don't have any- so what the Senator is disclosing is entirely at his discretion.

That said, there are relatively few, salient elements in a lengthy medical record -- and those items are being disclosed. So unless there is willful deceit going on, I think we are getting a reasonable bird's eye view of the Senator's health.

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Seattle: How do you detect mental-status changes, like Alzheimer's, at an early onset? That's a deal-breaker for a lot of people of McCain's age; if we can't tell when he goes senile, how can we hold him accountable for being senile?

Dr. David Katz: There is standardized cognitive testing to detect very early stages of dementia, or "senility." But in the portion of the Senator's record made public, this is not included. Mental status and cognitive testing could be a standard requirement in the medical evaluation of any presidential candidate- then we'd know. At present, it is not. So we will be taking our chances...

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Washington: Would a victim of physical torture like McCain normally have received a mental health examination by the military upon release from captivity? Are these records included in the dump?

Dr. David Katz: I don't know the standard military protocol in this situation. But even if included, it would be years out of date. No, this is not included in the information made public.

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Fairfax, Va.: Because Sen McCain is well into his 70s, should we be worried about "senior moments," or not? It could be problematic in someone with so much responsibility.

Dr. David Katz: The reason we even have the term "senior moment" is because we've all recognized that memory tends to become a bit less reliable as we age, even if we age well. Yes, it could be problematic. But again, it's worth noting that Sen. McCain is, in fact, Sen. McCain -- and is functioning in that rather high-responsibility job.

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Bethesda, Md.: "Running for president is more stressful than being president." Perhaps, but the campaign process, even this time, doesn't last as long. Look at before-and-after pictures for the past few presidents, and it sure looks like the job ages people more than just the passage of time.

Dr. David Katz: Yes -- in fact, the rigors of both may add up and accelerate aging. I agree that a presidency appears to add more than its fair share of gray hairs to the presidential head!

The interplay between the rigors of the job and age is a relevant concern; hence this topic and dialogue.

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Washington: Is McCain going to let any insurance company doctors evaluate his medical records? Is he going to let anybody with any medical skills evaluate his records?

Dr. David Katz: To my knowledge, for the moment, what you see is what we get.

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Dr. David Katz: Good dialogue, folks; thanks for letting me join in. More questions than answers, but at least we're all thinking!

Best wishes to all.

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