Justice Ruth Bader Ginsburg continues to be in the news as questions mount over her health and ability to serve on the US Supreme Court. Most recently, she underwent, “Surgery to remove two malignant nodules from her left lung, the Supreme Court says.”

Yet a week ago, she was the picture of health and vigor, announcing, “My health is fine, ribs are almost repaired.” These two announcements, a week apart, don’t pass the smell test. Much like Hillary Clinton’s excellent health and fitness to serve as president despite her falls, double vision, and coughing spells

As a physician, allow me to play doctor here, with the required caveat that I am not Justice Ginsburg’s physician, have not met or diagnosed her, and am only relying on reports from our scrupulously honest and accurate American journalists.

Am I playing armchair doctor? Perhaps. Just as 60,000 mental health professionals signed a petition stating,

We, the undersigned mental health professionals, believe in our professional judgment that Donald Trump manifests a serious mental illness that renders him psychologically incapable of competently discharging the duties of President of the United States.

Mental health is a bit more nebulous than cancer. We all have elements of many personality disorders, but that doesn’t make us mentally ill. Trump’s bravado and swagger may offend the sensibilities of New England liberals who view his tweets as psychopathology, rather than Trump’s pathway around an obstructive and hostile mainstream media.

Let’s look at Justice Ginsburg’s recent well publicized medical history. She had surgery, “To remove two malignant nodules from her left lung.” These were found, “[i]ncidentally during tests she received while being treated for rib fractures sustained in a fall last month.” In other words, during an x-ray or other scan after her fall.

This means her recent lung surgery was scheduled in advance. So much for her assertion that, “My health is fine.” I suppose it’s a Clintonesque parsing of what the meaning of “fine” or “health” is.

As both nodules, “were found to be malignant during an initial evaluation,” she, “underwent a pulmonary lobectomy.” This means removing one of her five lung lobes via thoracic surgery, certainly not a small undertaking, especially in a frail 85-year-old.

We don’t know what the two nodules were specifically other than that they were both malignant, or cancerous. There are two types of malignancy – primary and metastatic. Primary means that the cancer originated in the lung, or typical lung cancer. Metastatic means they traveled from some other primary cancer elsewhere in the body.

Justice Ginsburg has a history of other cancers, “The justice had colon cancer in 1999 and pancreatic cancer in 2009.” Odds favor that her lung nodules represent metastases from her other cancers rather than a third new cancer originating in her lungs.

It’s not impossible for her to have primary lung cancer on top of her other two cancers, but unlikely, as she does not have a history of smoking. As these removed nodules were examined histologically, I’m certain her doctors know the answer. At some point we will too. 

The National Cancer Institute tells us where primary cancers metastasize to, at least the most common sites. Both colon and pancreatic cancer frequently spread to the lungs. This makes sense as the entire blood stream passes through the lungs with each trip through the body.

Cancer is staged, which helps provide treatment options and prognosis. There are four stages. Stage four, the highest stage, “Means that the cancer has spread to other organs or parts of the body. It may also be called advanced or metastatic cancer.”

If this is indeed the case, it is devastating news for Justice Ginsburg and her family. The prognosis for advanced cancer is poor.

For pancreatic cancer, the American Cancer Society tells us, “Stage 4 pancreatic cancer has a 5-year survival rate of about 1 percent.”

For colon cancer, the prognosis is better, with a 12 percent 5-year survival rate for stage 4 disease.

Justice Ginsburg’s rib fractures may have been fortuitous as the x-rays found her lung nodules. Eventually they would be found if she developed shortness of breath or began coughing up blood, but by that time they may not have been surgically removable.

She fractured her ribs due to a fall. An 85-year-old falling is not unusual and in fact, falls are the leading cause of injury and death in older Americans. What else might have led to her fall?

Cancers occasionally metastasize to the brain, which could affect balance. When she fell, she almost certainly had imaging of her head, for this reason and to rule out a brain hemorrhage such as a subdural hematoma.

Ronald Reagan, in 1989, suffered a subdural hematoma after falling from a horse.

Cardiac issues can also lead to falls. Justice Ginsburg had a coronary artery stent placed in 2014.

All in all, Justice Ginsburg has some significant health issues. The media, not surprisingly, tries to downplay this by promoting the “RBG Workout”. Her trainer wrote a book telling fitness buffs, “How she stays strong and you can too.”

Good for her. Fitness is beneficial at any age and I commend her for regular workouts. The fawning media takes it to another level however. A Politico writer wrote, “I Did Ruth Bader Ginsburg's Workout. It Nearly Broke Me.” I feel sorry for the writer. He looks like a young healthy millennial and if he can’t keep up with an 85-year-old two time cancer survivor, perhaps he needs more gym time himself.

Finally, her surgery, a lobectomy, is no walk in the park. It is, “A major surgical procedure, complications are fairly common.” Bleeding, infection, breathing issues, and so on, particularly in an elderly person.

I wish Justice Ginsburg well as she has a multitude of serious medical problems and the odds are stacked against her. Her medical battles are connected to the political battle over her replacement. Look how the Left attacked Justice Kavanaugh, and he was replacing swing-vote Anthony Kennedy. When President Trump nominates a constitutionalist to replace a very liberal justice, the battle will make the Kavanaugh confirmation process look like a tea party.

Based on her medical problems, as best as we can determine from news reports, her retirement may be sooner rather than later. That 53-47 Senate may be as important as ever for President Trump, reinforcing that in the 2018 midterms, the Senate was the primary target. Trump’s replacement nominee may need every vote. Fasten your seat belts for the upcoming fireworks.

Image credit: NBC screen grab

Brian C Joondeph, MD, MPS, a Denver based physician and writer. Follow him on Facebook,  LinkedIn and Twitter.