I go on long runs each day, pounding out all the scenarios of what might happen with each stride, trying to outpace this monster that has suddenly and wholly invaded our lives. I call our father and fill him in, because my sister asks me to.
"Jesus," my father says. "Well, keep me posted."
My mother copes the way she usually does, talking to my stepfather and her close friends, cataloguing with them over and over again her worst and most terrible fears. She has this tiny, apocalyptic habit of going straight to the worse case scenario in most situations, sometimes before she has the whole story, and then, once she's gathered all the information, she can either accept the worst or work her way back down to whatever manageable outcome has occurred. I guess this way she will be relieved if anything less than the worst happens; my sister and I are still trying to figure that one out. We function differently, particularly with this situation, and neither of us will go to cancer until we have no other choice, when there are hard facts on paper to point to and try to make sense of.
When Dr. Jones calls to say it is malignant, my mind goes blurry. I hear the call itself, how my sister's phone rings to the tune of "Hey Jude," …don't make it bad, take a sad song and make it better…. and how the notes hover above us and cling to the air. They float down and settle over us after a time, long after the phone is hung up, along with a perverted sense of relief. At least we know, even if it is the last thing we want to. I grab my sister, pull her into me and tell her she and Mom are the most important people in my life and I am going to do whatever it takes to help her through this.
"I know," she says and this is all she can say for awhile. "I know."
The woman who rents us the cabin, a thin, red headed sweetheart with the disposition of someone who bakes muffins for churches and schools, comes over to check on us not long after the phone call. She and her husband live in the house across the way.
"It's cancer," my mother says as she opens the door.
"Fuck," the sweet woman says. She pushes her too-big 80s style glasses back on her nose and I watch the pink scrunchie in her hair move back and forth as she shakes her head, holding one hand over her mouth. She hugs my mother, saying, "Stay as long as you need to. Just tell us what you need."
My mother starts a round of phone calls after the sweet woman leaves. She stands outside on the porch while she does it, just beyond the open sliding glass door. My sister and I are still sitting shell-shocked on the couch, listening.
"Hi," my mother says again and again, as the sun bounces off the water beyond her, bits of light coming through the thick rows of trees. "It's cancer."
She has made four or five calls when my sister says, "I need to get out of here. I need a cigarette." I balk for a moment, and she shoots me a look. "I already have cancer," she says. "And I deserve a goddamn cigarette."
Her boyfriend breaks little during this time, once or twice that I can recall. He and I drive to the video store on the night she is diagnosed -- I don't know what we are renting or why it is just the two of us in the car, but there we are. He has tears in his eyes, although I can barely see them behind his glasses and the baseball cap pulled down firmly over his forehead. The rest of his face is hidden as it usually is in the fall and winter, behind a full, bushy beard.
"I knew it was cancer," he says. "I could tell from the skin on her breast, it was all dimpled and strange, and all the books said that was cancer, they called it 'peau d'orange' like an orange peel. I should have been juicing, I should have been doing something."
"You couldn't have stopped it," I say to him. "You can't blame yourself."
He says nothing, and we sit for a while in the parking lot at the Blockbuster, staring out into the black night. He drops me off at the cabin later and returns in a few hours with a backseat full of thick, hard backed natural health remedy books, several penned by the fanatic, and a juicer, all of which he has retrieved from the storage shed out on the land. He hauls the juicer and a few of the books into the cabin, along with bag after bag of organic fruits and vegetables from the local market.
"It's the cancer-mobile," he announces as he comes through the door with his cures in hand. "Cabbage, I bought lots of cabbage. My dad had all these growths on his body and they disappeared after only two weeks of eating a head of cabbage everyday." We cheer some at his enthusiasm, despite ourselves. We know he is only doing what he knows to in the middle of this chaos, and in that moment, we allow him as much.
We spend a long Monday in doctor's offices a few days after the biopsy comes back malignant-- we being half my family (my stepfather has arrived, along with my aunt, who lives in Seattle) and my mother's friend Jan. Jan is a naturopath and a nurse, with a round, soft face that calls to mind Mother Earth. She has a calm, comforting way about her, with wide eyes that blink while giving away nothing and a low voice like a melody. She is there to support my mother and to help us through the medical jargon of it all.
We go to Dr. Ben Chue first, an oncologist at The Seattle Treatment and Wellness Center. The center is known for touting cutting edge western medicine while supplementing those treatments with eastern philosophies, such as acupuncture, naturopathic support and positive visualization. We chose Dr. Chue because we've gotten his name from several people, including Dr. Jones, who says he is a genius, a maverick in the area of cancer treatment.
"I hope he's brilliant and a babe," I say to my sister on the way there. "Because I'm pretty sure part of the reason you got cancer is that so I can land myself a hot doctor."
"Oh, you're getting a husband out of this, I'll tell you that much," she says.
The nurses and techs smile at us in the waiting room beforehand, explaining that not everyone is going to fit into Dr. Chue's office and that my sister will have to choose who she wants with her when it is time.
"Everyone," my sister says, and the receptionists and techs and nurses keep smiling and explain that it will be very full in there and my sister says again, "Everyone," and they sigh and grumble and wave their hands for us to follow them.
We sit at a long table in the conference room at the Wellness Center and wait for Dr. Chue. My mother is poised to take furious notes on a yellow pad, my aunt plays solitaire, my stepfather looks dazed and sad, my sister's boyfriend is quiet and Jan reviews the list of questions she has compiled. My sister is sitting straight-backed, brave and clear-eyed. I try to act similarly, while staring at the photo collages of past patients hanging on the walls. They are smiling widely with their doctors, but their bald heads and gaunt faces made their mouths seem ominous to me and I focus instead on the white board at the front of the room, trying to decipher the not-quite-erased words left there that have spelled out someone else's fate. All I can see is the curve of a letter here, a line of fading emphasis there. Nothing that makes any sense.
Dr. Chue is a tiny, Chinese man with clear braces, chapped lips and tiny feet clad in pointed loafers. He is not going to be my husband. He is friendly, if not reserved and clinical, asking my sister questions about the lump and her lifestyle, including her drinking habits. When she tells him she drinks socially, he says, "What's socially, a case a day?" and we laugh, relieved that the brilliant doctor also has a sense of humor.
He takes my sister to another room to examine her and when they return, he pitches his treatment to us, using the white board to detail the particulars of my sister's tumor. He makes circles and draws arrows going in and out of the circles, clusters of dots with the tip of his pen to stand in for groups of cells gone haywire, dividing rapidly, causing cancer. Here are the bad things about my sister's cancer: it is estrogen positive, which makes for a more aggressive tumor, she is young, which makes for a more aggressive tumor and it has tested positive for an antibody called HER2-Nu, which makes for a pathologically aggressive tumor. The HER2-Nu antibody provides her tumor the benefit of angiogenesis, wherein it can sprout its own blood vessels to more efficiently attract cells and grow exponentially faster than a normal tumor. He explains that pathologically aggressive tumors of this kind are usually treated in the following way; chemo, mastectomy, more chemo, radiation.
But wait, here are the good things: my sister is young and that makes her body more able to withstand chemotherapy and there is an experimental drug called Herceptin that was designed specifically for HER2-Nu positive tumors and trials have shown it increases survival rates for women with the antibody dramatically enough that they surpass women who aren't HER2-Nu positive. Most doctors only use this drug when cancer reoccurs, but Dr. Chue believes in using it as a first line of defense.
He goes on to tells us that he also uses unique chemotherapy drugs, explaining that chemo was developed after World War I, when it was discovered that the bone marrow of soldiers exposed to mustard gas was destroyed. Doctors began to investigate why this might have happened, and in 1942, 'nitrogen mustard' was used in a hospital in the US to treat lymphoma patients. Most of the drugs still commonly used are not so far off from their chemical warfare predecessors (evil sounding ones, like Adriomyacin, a.ka. 'The Red Devil,' which causes heart problems and the thinning of membranes) and these are not the drugs Dr. Chue likes to use. He's come up with his own chemo cocktail; part Taxol (extracted from the yew tree), part carboplatin and part Herceptin. He says the synergistic effect of using these three drugs in tandem has produced some of his most fantastic results. He also administers the treatment differently, using what is called "fractionated" chemotherapy, where patients are given the drugs once a week at a lowered dosage instead of a high dose every two or three. In this way, they receive the same amount of drugs as a traditional chemo cycle but the blast to their systems is much less extreme.
People didn't think fractionated chemo would work, and when he started doing it nearly a decade ago, he tells us his colleagues had nothing but negative things to say about Dr. Chue. "So many bad things they said about me. But not now, now other doctors are doing things the same way. Some patients can even work the whole time during fractionated chemo, some don't even lose their hair." He makes chemo sound like a mild miracle flu; feel bad for a few days and come out the other end cancer-free. As he talks and gives us more and more positive points to focus on, I feel everyone in the room, except Ted, sit up a little straighter.
"With this combination of drugs, we can shrink that tumor down to a few cells, even to nothing. I've done it before, and although you have a very aggressive, fast growing disease, we can arrest it and nearly eradicate it. You may not need a mastectomy when we are finished, you may not need radiation, but all of those things depend on how the tumor responds to the chemo. We do what's called the sandwich method, shrinking the tumor first with chemo, then you will have surgery, which we will follow with more chemo. Your treatment should start next week, however. There is no time to wait." I see Ted stiffen at this suggestion and hear my mother say we have to talk about it, that we are seeing a surgeon later in the day to get more information.
I am nodding along at this point, still brave and clear-eyed like my sister. While they all talk about potential treatment schedules and the details of Dr. Chue's availability, I happen to glance down at my sister's file, which sits open on the conference table. On top is the referral letter Dr. Jones wrote to Dr. Chue. In it, she urges him to take Kari on as a patient and in closing, writes, "I hope you will help this lovely young woman." Nothing about me is clear-eyed or brave after that and the whole room goes wet. I keep my eyes on the floor so that no one will know I can't handle what is happening.
We stumble out of Dr. Chue's office and into the car and then into the surgeon's building drunk on Chue's chemo cocktails, full of hope and the idea that my sister will come out of all this practically unscathed. We can feel it already; she isn't really even going to be sick.
"Can you imagine, he could shrink it to nothing?" my mother says as we sit waiting in a small room while the surgeon finishes examining my sister. Jan has gone in with her as she doesn't want to be alone, and a few minutes later, Jan and my sister come back into the room without the surgeon.
"It's not good," my sister says, putting her face into her hands. "She took one look and ran out to call Dr. Chue. I'm learning that doctors rushing out of rooms to call other doctors is a very, very bad thing."
"She saw something," Jan says, "that Chue might have missed."
The surgeon reappears with a tired look on her face. She is a heavier woman in her late 40s, with dark skin and short dark hair dyed copper on the ends. She is wearing a flower patterned blue flowing skirt and a black and blue sweater. She has come in to meet with us on her day off as a favor to Dr. Jones. She smiles faintly at us and turns to post Kari's mammograms and MRIs on the light screen. She points at the tumor on the films and then sits down at the table in front of a plastic model of a breast. She opens it up and points to the ducts, explaining that Kari has "poorly differentiated" ductal carcinoma, which means it is spreading rapidly.
"Also, I've left a message for Dr. Chue, as I believe you actually have a case of inflammatory breast cancer, judging from the skin on your breast. It's thick, red and bumpy, which indicates that the cancer cells are blocking the lymphatic vessels there. In these kinds of cases," she goes on, while passing out sheets of paper outlining a course of treatment, "there is only one course of treatment. Chemotherapy occurs first, then a mastectomy, followed by more chemotherapy and then radiation."
We all sit quiet and stunned.
"This is a rare form of the disease, and there is no option other than to treat it as aggressively as we can."
"But we just came from Dr. Chue's and he said there might be a possibility of lumpectomy-" my sister says.
The surgeon shook her head. "He didn't diagnose it as inflammatory, and although it is a clinical diagnosis, meaning there is no way to test for this particular strain of the disease, I have little doubt that is what's happening here. The cancer has already involved your skin, and mastectomy is the only option."
"What is the prognosis?" my mother says.
"You'd have to talk to Dr. Chue about that," she says, and looks away. We sit in silence, the only sound my sister's choked sobs. Her face has gone a blotchy, red-pink. I reach over and hold her hand.
"I'll leave you all to discuss this," the surgeon says. She gets up and leaves the room. She came highly recommended, she is renowned in the Northwest for her treatment of advanced breast cancer. My sister has advanced breast cancer.
"I'm so sorry," I say to the door as it closes behind the doctor. I grip my sister's hand and hold on as long as she will let me.
We have nothing to say to one another as we drive back towards the city, nothing to do but listen to the sound of my sister alternatively sobbing and howling into Ted's shirt. Jan holds my hand in the car, squeezing it hard enough that it goes numb before we drop her and my aunt off; Jan is flying back to Portland and my aunt is taking her to the airport. It is still early evening as we head downtown, towards the ferry. My stepfather suggests we have something to eat before getting on the boat back to Poulsbo. No one really answers him.
"The cutter had no time for hellos," he says. "Nothing. Not even her name. All she had time to tell us was what she was going to cut."
"She wasn't that bad," I say. My mother is in the front seat, staring at her lap. I am alone in the first backseat, my sister and her boyfriend behind me in the second backseat of my stepfather's large Suburban.
"Yes, she was," he says. "I mean you don't even introduce yourself before you deliver that kind of news? I think we need to leave death at the restaurant tonight. Like right now."
This is one of my stepfather's signature phrases, borrowed from a Lebanese man he used to work with when he sold insurance. It's an odd one for him, considering he usually could care less about eating and isn't prone to philosophizing or using metaphors. He's a little like Tim the Tool Man from Home Improvement, in that he might overhear something, a joke or a story and by the time he's relayed it to you, he's forgotten the punch line or substituted a bird for a dog in the scenario. But "leaving death at the restaurant" is one we all appreciate as he
evokes the phrase whenever he feels any of us have gotten too serious about life, usually when my mother or I are analyzing a situation to death.
"Ok," I say.
"Fine," my mother says softly.
We sit down to dinner in an overpriced seafood restaurant with wood paneled booths and waiters in short white coats and black bow ties. I go outside to call my father, because I've told my sister I'd keep him informed. "It's bad, Dad," I say. "Really bad. They are talking about chemo and a mastectomy, for sure, then probably radiation. Maybe you should come up."
"Jesus," my father says. "Well, keep me posted. We should probably wait until things settle before we come up there." I don't have the strength to tell him that his daughter might need him here as soon as possible. It is something he should innately know, just like so many other things.
I go back inside and order a glass of wine. So does my sister and Ted. My mother and stepfather don't drink, so they watch us have one glass, then two. I don't know what I eat, I don't know that there is ever food in front of me. My mother says, "Is that all you are having?" and I snap at her, say I'm not exactly hungry.
At some point between the wine and the food, Ted says we don't really know yet if Kari needs a mastectomy. As with modern cancer treatment, the fanatic is also against mastectomies. He calls them the "butchering of women," and Ted has detailed for us in the last few days that not so many decades ago, the procedure once included the removal of the woman's chest muscle, sometimes her entire arm. The way the fanatic and Ted present it, every surgeon in America can't wait to needlessly hack off a woman's breasts.
"What are you talking about?" I say, trying to control the sudden rage that is taking over my body. We all know what he believes, and he knows what we think about what he believes. I feel my skin go hot and my hands start to shake. "We have to do what the doctors say."
"I think she should get another opinion," he says, so quietly I can barely hear him.
"I can't do this with you two at each other," my sister says and starts to cry, which of course, make my mother and I start as well. "I can't take it, I can't."
"I'm sorry," I say to her, then to Ted, "We're not against you, we're not. We just want what's best for Kari."
He nods, says nothing.
I look back down at my plate. My mother pats my arm and sighs.
"I am not equipped," I whisper to her, and I mean it. The weight of what is happening is starting to sink in. I have been overwhelmed at certain times in my life, but before, there was always a way to organize myself, wrap my arms around something and deal with it; problem solve until the problem goes away. But this? What in my life has prepared me for this? I know little of illness and even less of death. I can't keep houseplants alive and have never had a pet. I've never had to take care of anyone but myself my entire life. How am I going to do this for my sister?
"Yes, you are," she says. She pauses and looks across the table at Kari, who is gazing past all of us, like she can see through the walls and down the street, into another place and time. "We are all equipped," she says, squeezing my forearm. "It's just that none of us wants to be."
