Prepared By Mayo Clinic At The Request Of Senator John McC ain Victor F. T rastek, M.D., C E O, Mayo Clinic In A rizona: We have been asked by Senator McCain to provide medical information pertaining to his care at Mayo Clinic. I would like to reiterate that patient privacy is integral to Mayo's core value that the needs of the patient come first, and we are releasing this information at the request of Senator McCain. Also, to be clear about the issue of the timing of the May 23rd press conference, the release of the Senator's medical information is a combination of two factors: scheduling and making certain that the release included the most recent medical information. The Senator had physician visits at Mayo Clinic as recently as earlier this month. Consequently, the date of May 23rd was the earliest possible time that could be scheduled following his last visit, given the calendars of the campaign staff as well as his three Mayo Clinic physicians, and also taking into consideration the minimum amount of time necessary to have complete information regarding his most recent medical evaluations. At Mayo Clinic, we practice medicine with a coordinated team approach, with our physicians working closely together on behalf of the patients we serve. The following three physicians comprise the team that has been primarily responsible for caring for Senator McCain over the past several years at Mayo Clinic: Dr. John Eckstein is a physician in our Internal Medicine Division and has been caring for Dr. Michael Hinni is a surgeon in our Otolaryngology/Head and Neck Surgery Department. Dr. Hinni specializes in surgical oncology of the head and neck. He performed Senator McCain's left lower temple melanoma surgery in August 2000. Dr. Suzanne Connolly is a specialist in our Dermatology department, with extensive clinical experience. She is Senator McCain's dermatologist. John D. Eckstein, M.D., Internal Medicine, Mayo Clinic: (bio & photo: I will begin with a synopsis of the Senator's general health, based on his most recent comprehensive evaluation in March 2008 and a subsequent follow up visit and tests earlier this month. At the present time, Senator McCain enjoys excellent health and displays extraordinary energy. While it is impossible to predict any person's future health, today I can find no medical reason or problems that would preclude Senator McCain from fulfilling all the duties and obligations of President of the United States. Senator McCain has been a patient at Mayo Clinic since 1992. He had periodic comprehensive physical examinations during the 1990's and annual examinations since August 2000. In this review of Senator McCain's health status, the issues we will address include the following: 1) Skin Cancer 2) Urologic History 3) Cardiovascular Fitness 4) Orthopedic Status and 5) Medications 1) Skin Cancer: Regarding his past skin issues, the Senator has received skin care at Mayo Clinic in Arizona since August, 2000. Four malignant melanomas were surgically removed in the past. Three of these were "in situ" melanomas, meaning they were limited to the top layers of the skin and were not invasive. These three early melanomas – on his left shoulder, left arm and left nasal sidewall, were removed in 1993, 2000 and 2002, respectively. A fourth melanoma that was invasive was removed from his left lower temple in 2000. Each melanoma was a new primary melanoma and did not represent a recurrence of any previous melanoma. There was and is no evidence of recurrence or metastasis—meaning spread—of the invasive melanoma nearly eight years after surgery. Other less serious skin cancers have been removed over the years without complication. These have been non-melanoma basal cell and squamous cell cancers. Many questions have been asked about the removal of the invasive melanoma from Senator McCain's left lower temple in August 2000. Dr. Hinni, who performed the surgery, will explain in detail the surgical procedure. To summarize, we continue to find no evidence of metastasis or recurrence of the invasive melanoma as we approach the eighth anniversary of that operation. This was most recently confirmed with his comprehensive examination and tests in March 2008 and with Dr. Connolly's skin examination on May 12, 2008. The prognosis for Senator McCain is good because the time of greatest risk for recurrence of invasive melanoma is within the first few years after the surgery. Michael L. Hinni, M.D., Otolaryngology/Head And Neck Surgery, Mayo Clinic: (bio & photo: The following is a summary of the surgical procedure that I performed on Senator McCain in 2000. In August 2000, following a 27 month absence from care at Mayo Clinic, Senator McCain was diagnosed with a melanoma that was 2.2 millimeters thick at its thickest part and was 2 centimeters across. This melanoma was located on the left lower temple region of the face. Prior to surgery, numerous tests were performed, including CT scans, an MRI scan of the brain, liver tests that included LDH, and there was no evidence that the cancer had spread. A comprehensive surgical procedure was done that included sentinel lymph node biopsy, removal of the cutaneous melanoma and key lymph nodes, and reconstruction of his left temple region. A 2 centimeter margin of normal skin was removed around the 2 centimeter melanoma, resulting in a 6 centimeter by 6 centimeter roughly circular wound on the left side of the Senator's face. The underlying Parotid salivary gland was also removed to assure a clear deep margin, to protect facial nerves from injury and to remove the sentinel and other lymph nodes that were inside the Parotid gland. None of Senator McCain's lymph nodes showed any evidence of metastatic disease. The large incision was necessary to safely remove all cancer with an appropriate margin, and resulted in a wound requiring sizeable reconstruction. This explains why the large incision was made—it was necessary so that a flap of skin and soft tissue consistent with the color and texture of the Senator's facial skin could be elevated and advanced/rotated into the wound. To answer what appears to be numerous questions about the prominence of the Senator's left jaw: this is a result of an absence of soft tissue on the face in front of his ear that makes the masseter (the chewing muscle) over the jaw appear more prominent. To be clear, the swelling is not due to any evidence of cancer. Suzanne M. Connolly, M.D., Dermatology, Mayo Clinic: (bio & photo: I will summarize the skin issues associated with Senator McCain's care at Mayo Clinic. First, I'd like to provide some background on melanoma, because it is often misunderstood. The current estimate is that 1 in 58 Americans will develop malignant melanoma in their Melanoma is a potentially serious form of skin cancer and its incidence continues to rise. In 2008, it is estimated that there will be 116,500 new cases of melanoma—more than 54,000 that are not invasive (in situ) and more than 62,000 that are invasive. Although the exact cause of melanoma is not known, avoiding excessive exposure to ultraviolet light is the most effective prevention for all skin cancers, including melanoma. Risk factors for developing melanoma include many moles that are benign or atypical, a previous melanoma, immunosuppressed state, fair skin and light eyes, excessive exposure to ultraviolet light, and a family history of melanoma. In speaking specifically about Senator McCain, his risk factors include light skin, light eyes and a history of excessive sun exposure. Senator McCain has no known family history of melanoma. He has few moles and he has no known history of atypical moles. As far as his skin care at Mayo Clinic is concerned: As Dr. Eckstein has already noted, the Senator had 3 primary non-invasive melanomas, called melanoma in situ, stage zero. These developed on sun-exposed skin. Two were removed here at Mayo; one was removed elsewhere in 1993. These 3 melanomas were excised and there is no evidence of any recurrence of melanoma at any He did have an invasive primary melanoma on the left lower temple, for which he underwent the extensive surgical procedure as outlined by Dr. Hinni. As Dr. Eckstein and Dr. Hinni stated above, there has been no evidence of recurrence of the invasive melanoma on the left lower temple that was removed in 2000. I would repeat again that the period of greatest risk for metastatic disease from that melanoma was within the first few years. o The Senator has no evidence of melanoma. o He continues to monitor his skin carefully. o He comes in for a skin examination every 3-4 months. o He not only practices good habits of sun safety but also advocates them publicly. I will touch on a few additional aspects of Senator McCain's health. 2) Urologic History: He has small kidney stones in his right kidney and a number of small benign cysts in both kidneys. Neither of these issues impacts his kidney function. He had 4 bladder stones which were fragmented with laser in August 2001 and at the same time some benign enlarged prostate tissue was surgically removed. Since then, he has normal urination and has not passed a kidney stone. He takes medication to help prevent future kidney stones. He has no evidence of heart or other cardiovascular disease. He walked the Grand Canyon rim-to-rim in August 2006 without problems, and continues to hike whenever his schedule permits. His current stress echocardiogram is normal at a high level of exercise. There is no evidence of decreased blood supply to any part of his heart muscle. In the past he had slightly abnormal lipids, and now takes medication. He was a Navy pilot in Vietnam, and his plane was shot down in October of 1967. He broke both arms and a leg after ejecting from his plane. He was a prisoner of war in Hanoi for 5.5 years. As a POW, he was beaten and tortured repeatedly, and suffered fractures of both shoulders. Because he received no treatment for his fractures, all fractures healed with significantly reduced range of motion of his shoulders, arms and right knee. He does not complain of bone or joint pain and does not take pain medication. o Simvastatin, which is a cholesterol lowering medicine o Hydrochlorothiazide, for kidney stone prevention and Amiloride to preserve potassium o Aspirin, for blood clot prevention o Zyrtec, an anti-histamine as necessary for nasal allergies o Ambien CR, as necessary for sleep when traveling o A multiple vitamin tablet. Basal Cell Carcinoma – most common type of skin cancer which most commonly develops on sun exposed skin. They are more common in fair skinned individuals and tend to grow slowly. They have a very low likelihood of metastasizing (spreading to other parts of the body) but can be locally invasive. Treatment is associated with a very high cure rate. Squamous Cell Carcinoma – second most common type of skin cancer which is primarily found on sun exposed skin in fair-skinned people. This form of skin cancer can metastasize (spread to other parts of the body), but early treatment is associated with a very high cure rate ( >95%). Melanoma – a form of skin cancer which develops from the melanocytes (pigment cells) in the skin. It can be mixed shades of tan, brown, black but also pink, red or white. If treated early, it is curable. Actinic K eratosis – small, rough, scaly spots are found on light exposed skin especially in fair skinned individuals and represent cells damaged by sun exposure. They have potential to progress to skin cancer of the squamous type. They can be treated by a number of topical approaches. Seborrheic K eratosis – benign lesions that never turn into cancer. Do not require treatment; they may be treated for cosmetic reasons or if they are irritated. Metastasis the process by which cancer spreads from the place at which it first arose as a

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