I’ve been in the medical profession since I was twenty-two. I’ve worked for doctors. I know how they operate. I know they never call on the same day with good news. I know they never deliver bad news over the phone.
Good news can wait until morning, you see. Good news can be given on the phone. It’s the bad news you get urgent phone calls at night for, bad news that requires meeting face to face.
So when Nick came out of his bedroom, white-faced and shaking, and told me his doctor had just called and wanted to see him back in her office as soon as possible, I knew something was wrong.
Nick knew it, too.
Neither of us spoke as we got ready to leave. I turned off the oven, leaving a pizza half-baked on the center rack. Nick put his shoes back on and wordlessly handed me his keys. I drove us to the oncology clinic.
We were halfway there before Nick finally said, “So what do you think it could be? A relapse?”
That was my worst fear – and, also, exactly what I thought it had to be. What else but a recurrence of his cancer could be bad enough that she wouldn’t tell him over the phone? I explored the other possibilities in my mind, looking for one I could latch onto. “I don’t know… Maybe your scans were inconclusive; maybe there was a mistake made in the lab; maybe she just needs to run one of the tests again.”
“Why wouldn’t she have just told me that? We could have scheduled an appointment over the phone.”
“Well, maybe… maybe your blood counts are down and you need a transfusion, or… or she wants to change one of your prescriptions or… something…” I was grasping at straws, and it was obvious.
“Yeah, maybe…” Nick muttered. I could tell he didn’t believe the bullshit coming out of my mouth any more than I did.
I shut up after that, and we rode the rest of the way to the clinic in silence.
We got a parking spot close to the entrance, since the deck was almost empty. It was after hours, I realized, and most of the medical practices housed in this building were probably closed. My footsteps echoed through the vast, concrete space as I got out of the car and walked around to Nick’s side. He grunted in pain as he struggled out of the passenger seat. I offered him my hand and helped pull him into a standing position, then slid my arm around his waist and left it there as we slowly made our way into the office building. He walked slightly hunched over, like an old man, and I knew that his back had to be killing him, from the spinal tap and the bone marrow biopsy and, possibly, something more serious. This just reaffirmed my suspicions: Dr. Subramanien wouldn’t make him come back here, after the painful procedures she’d already put him through that day, unless it was serious.
She met us in the waiting room of the fifth floor clinic. All of the chairs were empty, and the receptionist had gone home for the evening. It was just us. “Nick, thank you for coming in,” she said, touching his shoulder lightly, nodding at me in greeting. Neither gesture hid the grim look on her face. “I apologize for bringing you back here this evening, but I didn’t want to discuss this over the phone.”
Nick didn’t waste any time with a greeting. “What is it?” he asked.
The doctor pressed her thin lips together, then beckoned to us. “Let’s go into my office to talk.” She led us back to her office, which was much smaller than the conference room where we’d met to discuss Nick’s options for the stem cell transplant. “Please, have a seat.” She motioned to the two chairs facing her desk, while she walked around to sit behind it. Nick and I sat down.
“I’m sorry to have to tell you this, but it’s not good news,” she began, and even though I’d known it wouldn’t be, hearing the words was still like a kick to the stomach. “The lab analysis on the fluid sample obtained during your lumbar puncture today shows cancer cells in your cerebrospinal fluid.”
“So it’s back,” Nick said, in a low, dead sort of voice. “It’s spread.”
Dr. Subramanien nodded. “I’m afraid so. It’s not uncommon for your form of lymphoma to relapse in the central nervous system, and as of right now, it appears to be isolated to the spinal fluid. I put a rush on your other test results after seeing the CSF analysis. The CT and PET scans show no signs of solid tumors in the brain, spinal cord, or other organs, and your bone marrow looks clear.”
I let out my breath slowly, thinking, So it hasn’t spread everywhere. Maybe it’s not so bad, then…
But her next words destroyed this delusion. “Unfortunately, cancer in the spinal fluid is difficult to treat. Your best option is a combination of chemotherapy and radiation to the whole brain and spinal cord.”
“More chemo.” The flat tone of disgust Nick used gave me an anxious feeling I couldn’t quite explain.
“We would give you methotrexate-”
“The same drug I had before?” Nick interrupted, glaring across the desk at her. “The drug that didn’t work?”
“-injected directly into the spinal fluid,” Dr. Subramanien continued smoothly, only to be cut off by Nick again.
“Which means more spinal taps, right?” He slumped lower in his chair, looking defeated, and I felt his pain, felt absolutely sick at the thought of putting him through that again.
“That’s one way of administering the intrathecal chemo, yes. Another option is an Ommaya reservoir, which is a type of catheter that’s implanted under the scalp, so that the drug can be delivered into the cerebrospinal fluid inside one of the ventricles in your brain.”
I saw Nick blink. His face had been very white, but all of a sudden, it started getting red. “My brain?” he repeated, his nostrils flaring. “You wanna put a tube in my brain now? It’s not enough that I had one sticking out the side of my neck, or that I still have this thing in my chest-” He put his hand over the portacath. “-but now you’re talking about one in my head?”
I could tell he was starting to lose it, and I reached out and laid a hand on his arm, saying, “Nick…”
He shook my hand off without looking at me, his eyes still fixed on Dr. Subramanien in a death-stare. Very calmly, she replied, “It would just look like a small lump on the top of your head, not much different from your portacath.”
Nick ran his hand over the top of his head, his fingers raking through the new growth of hair, and stared down at the desktop. Dr. Subramanien seemed to sense his frustration and stopped talking, allowing him the time to think in silence. I knew how overwhelmed he must feel, from the devastating news and the treatment options to consider. Neither of us wanted to be in this situation, dealing with this disease again, facing what we both thought we’d put behind us. But, of course, it was his illness, his body, and while the doctor could give suggestions, and I could offer support, Nick would have to be the one to make the decisions.
“No,” he said suddenly, looking up.
“No what?” I asked, before I could help myself.
He still refused to look at me. “No more chemo,” he mumbled, dropping his eyes again. “No more spinal taps… no more tubes sticking out of me. I don’t wanna deal with any of that shit again. I’m done.”
My stomach lurched, like I was about to throw up, and my heart started beating faster. “What are you saying, Nick? You can’t just give up… You’ve got to try to treat this!”
“Try?” He snorted derisively, glancing at me briefly before looking away again. “Why? She said herself it was hard to treat!” he cried, flinging a hand towards the doctor.
“But… what about radiation?” I looked desperately at Dr. Subramanien, silently begging her to step in and talk some sense into him.
“Radiation without chemotherapy isn’t as effective with this kind of metastasis,” she said quietly. “Craniospinal radiation also has potentially serious side effects – fatigue, headaches, nausea, hair loss, and the risk of cognitive impairment or secondary tumors. As a palliative measure, it can help relieve symptoms associated with cancer in the spine, but it’s not likely to get rid of the cancer completely on its own.”
“How likely is it that the chemo will get rid of the cancer completely?” asked Nick in a low voice, still staring down at the desk. “I mean, realistically… what are my odds of beating this?”
“You must understand that every case is different,” Dr. Subramanien explained, “and odds are only a predictor, not a guarantee.”
“Yeah, yeah, I get it. So what are they?”
I had done the research; I knew the odds weren’t in his favor. But it still shocked me to hear Dr. Subramanien say, “I’m afraid that, even with treatment, your prognosis is rather poor at this stage. In clinical studies, adults with your type of lymphoma who have relapsed in the central nervous system have a one-year survival rate of about twenty-five percent.”
I sucked in a huge breath and held it, feeling it rattle around in my lungs as I struggled to keep my composure. Beside me, Nick was silent and still, as he absorbed the same information. Twenty-five percent… a one in four chance that he would make it even another year.
“And if I decide not to do treatment?” Nick’s voice had returned to an emotionless monotone; he spoke as if he were already dead. “How long do I have then?”
Dr. Subramanien shook her head. “There’s really no way to know that; I can’t put a time limit on-”
“Please, I need to know!” Nick insisted, his voice rising sharply. He leaned forward, looking directly at the doctor again. “How long?”
She pressed her lips together and folded her hands on the desk top. “On average… six months.”
Nick nodded once and lowered his head. I wondered what on earth was going through it. My own thoughts were racing too fast to even put into words; it was like the rug had just been swept out from under me, and I was struggling to find my balance. I felt nothing but total devastation in the wake of the conversation I’d just witnessed.
I don’t really remember what else was said in the doctor’s office that evening. My brain was still reeling with shock over it all: Dr. Subramanian’s grim diagnosis… Nick’s impassive acceptance of it… his refusal to pursue the treatment options she’d offered…
I do know that she wrote him two prescriptions, one for a painkiller, the other, a steroid, to help control swelling and other symptoms he’d have down the road. But I couldn’t bear to look that far ahead yet, to even think about what was going to happen to him. Nick and I walked out of the office hand in hand, but neither of us spoke, and I drove us back to his condo in a trance.
In the days that followed, I researched treatment options, read studies, looked into clinical trials, even called oncologists I knew back home to ask for second opinions. But even though I searched high and low for some magic muffin that would cure Nick’s cancer, I didn’t find anything much different from what Dr. Subramanien had already told us, and Nick shot down every one of my suggestions.
“I read this study that mentioned allogeneic stem cell transplants as an option for people who have relapsed after an autologous one,” I mentioned to him one day. “That might work; I mean, Leslie’s a match, and her baby is due any day now, right, so once she recovers from having the baby, she could still donate…”
But Nick just shook his head, stubborn as ever. “No. No way in hell am I putting myself through that again. The first one was bad enough.”
“You’d rather die?”
“I’d rather enjoy what’s left of my life. I don’t wanna spent the rest of my time lying in a hospital, puking my guts out, and feeling like total shit. If I’ve only got six months either way, I might as well make the most of them.”
“But Nick, you don’t know that; Dr. Subramanien even said so; she said every case is different…”
No matter what I said to try and change it, Nick’s mind was made up, and he couldn’t be convinced otherwise. And so, I found myself facing the hard reality he had already started to accept.
Nick was going to die, and there was nothing I could do to save him.
***
