Violation (25 page)

Seattle Review,
2007

I had to quit softball when I hurt my back, and I finally quit volleyball after two dislocated thumbs and a rotator cuff injury. I still miss softball acutely and think often of those hot, loud nights in the little gym, setting and dreaming of the spike. I don't miss co-ed pickup games.

     
Chemo World

SEVERAL YEARS AGO, I BEGAN WORKING ON A SMALL
oncology unit at Providence Portland Medical Center in Portland, Oregon. The unit, known as 5-K, is shaped like a T and can hold twenty patients at a time. Its small size, the closely knit team, the long relationships with returning patients, felt exactly right. Nurses who come to 5-K usually stay a long time. The work is complex, challenging, intimate. To do it well requires me to be at my best. There is, too, the vague pleasure of feeling competent in a place where most people can't imagine working. The world of cancer is a world unto itself. Double doors at each end shut out the rest of the hospital in a kind of quarantine—keeping germs out but also keeping the cancer in.

So many people in my circle of family and friends have had cancer that not to be one of them feels strange at times. On 5-K, this circle has expanded to include many strangers. Sometimes it seems as if everyone has cancer, that having cancer is normal, and we're all just used to it. I know a lot of healthy survivors, but often the magnitude of the disease asserts itself. My mother's early death from breast cancer raises my risk of the disease significantly, so I have a mammogram every year. Last year, the technician took my films and left me in my drafty gown. She came back a few minutes later and said I needed to go down the hall for an ultrasound as well. She couldn't explain why; I'm sure she didn't really know. The ultrasound technician would only tell me there was a “shadow,” and then she left with her own set of pictures. I waited in the
dim, cramped room; I waited in a quivering fear that had a life of its own. When the young physician arrived, I almost tackled him.

“Look,” I said. “Look, I work on 5-K. You tell me what the hell is going on, right now.”

“Oh, we're not thinking a malignancy,” he said, surprised. I wanted to hit him. I wanted to yell: You tell me that
first.

CANCER
IS A
catchword for a group of diseases defined by the cell in which they originate. Different cancers have different courses, prognoses, and treatments; they are different diseases. Some are fast and some are slow, some are relatively easy to treat and others almost impossible. They all involve abnormal cells without a useful function, cells that are not orderly and are not controlled by the normal mechanisms that manage cell growth. Tumors can double in size in two to three months. By the time of diagnosis, many have metastasized to new sites. The cancer is loose, it has broken free, and the second-generation tumors are often genetically evolved, with new properties. With each move, the cells become more primitive, evolving into a kind of ur-cell. There are cancers called “unknown primary”—the cells are so plain their origin can't be identified. These are cells as psychopaths: twisted, clever, self-destructive, taking victims down along the way.

The number of cells involved is difficult to grasp. By the time cancer is detected, many millions of abnormal cells are present, and they are usually dividing rapidly. Treatment is a matter of killing as many of these abnormal cells as possible, as fast as possible, without killing the patient in the bargain. Most oncologists are reluctant to use the word
cure
, and tend to speak of cancer as a chronic disease. The goal of treatment is remission, a state in which the cancer can't be detected. Remission doesn't mean there is no cancer in the body. Animal studies suggest that millions of cancer cells remain hidden in the person considered “cancer free.”

The immune surveillance theory of cancer holds that in a way we all
do
have cancer, that a healthy immune system fights off rogue cells as they appear. (New research indicates that cancer in
turn can shut off crucial parts of the immune system, actively dismantling what might attack it.) A person's immune system may be able to eliminate those remaining cells one by one, the way one fights a cold, and the remission will be durable. As with other chronic diseases, in theory cancer patients could simply continue to take anticancer drugs their entire lives—if the drugs were not so toxic.

5-K IS ON
the same floor as the Robert W. Franz Cancer Research Center, and at any given time almost every cancer treatment is represented there.
^1
1
Patients are receiving various kinds of immunotherapy and chemotherapy, having radiation treatments, and recovering from surgery. There is often at least one person having a stem-cell transplant. Others are there because of the kinds of problems that tend to accompany cancer and its treatments, like infections. 5-K is a regional center for peripheral stem-cell transplants and one of only a few dozen centers for high-dose Interleukin-2 (IL-2) therapy in the United States.
^2
2

When I first started in the unit, I was told by more than one nurse, “If you can work on 5-K, you can work anywhere.” As a population, 5-K patients are sicker than most in the hospital, skirting the edge of instability and crisis repeatedly. They may stay for weeks at a time and return again and again over a period of years. Quite a few die there. Assignments on the three daily nursing shifts are doled out partly according to the level of care each patient requires and partly on the level of training of the nurses. My training as a 5-K floor nurse took more than a year and will never stop; it includes special instruction in chemotherapy, transplants, immunotherapy, and cardiac monitoring, and studying for my national certification as an oncology nurse.

In the time I've worked there, we've had a wedding, a number
of birthday parties, some anniversaries, many deaths, many emergencies, several resuscitations, the occasional family fight. There is no cancer demographic, no particular population: this is everyone, from everywhere. This is the musician who hauls her IV pole down five flights so she can play the grand piano. This is the young man covered in tattoos who was turned away from two emergency rooms for lack of money before he came to Providence and was diagnosed with leukemia. This is the young Mexican father who has no papers and has been treated without cost for years. This is the ice-skating instructor who had been a Sweetheart of Sigma Chi, the avid hiker who can no longer walk, the lawyer who likes to have whole pizzas delivered to his room from the joint down the street. They range in age from eighteen into the nineties, are all races, many nationalities, all degrees of wealth and lack of it.

Christa, a forty-four-year-old woman now in remission, told me that when she was first diagnosed with lymphoma, everything happened terribly fast. “I was carried along in this urgent wave,” she said. “People kept talking about getting second opinions, but it was so urgent I was just swept along.” People with cancer are overwhelmed first by fear, then by information, then by noise and change, and finally by continual tiny losses that etch away at their sense of self like water on a stone. Modesty is one of the first things to go, and privacy hardly exists. People sometimes are admitted to the unit directly from the doctor's office, having just heard the news. There's no time to pack a bag; they are literally stripped before the day is done. I remember a man who buried his wife on December 22, and on Christmas Eve was admitted to 5-K, having been diagnosed with leukemia that morning. He sat up in bed with an unfocused, sagging shock in his face, barely answering my questions. He was facing a brand new life, which had arrived without warning.

I think this is why most of my 5-K patients prefer watching
Animal Planet
to anything else on television. They doze, they watch TV, and they chat desultorily with relatives, many of whom essentially move in for the duration. (We provide beds for them; after a
few days, the small hospital rooms are draped with drying laundry, suitcases, family photos, and knitting.) The patients walk the halls in varying degrees of boredom, anxiety, or persistence. Because of their low resistance to infection, many are strongly encouraged not to wander outside the unit's small range. Most wear hospital gowns, women sometimes in nice pajamas or clutching a robe, men sometimes without shirts, all with the same gray slipper socks. They push their IV poles and look at one another: the thinning hair, the fuzzy heads, the bald heads, the occasional surgical mask, the gaunt faces, the reflections of themselves. You can tell which visitors are new: they are the ones who stop to read the inspirational posters with the careful concentration of schoolchildren. The veterans are in the kitchen, making a new pot of coffee.

I read the charts. I know what some of the code words mean, the scan results, the markers. One nurse sometimes wears a pin that says
CANCER SUCKS
. This is one way to put it. The very idea of what we do here, so peculiarly intimate, so daringly rude—the things we ask are so unfair, the disease itself such effrontery—and it is usually at this moment of reflection that my pager goes off and interrupts me. I don't have the right to know what I know about others, to see what I see of their secrets—how can anyone?—so I try to hold my knowledge as lightly as a fine glass vase, bound to break.

For many weeks, we cared for a young woman, a born-again Christian with non-Hodgkin's lymphoma. She came to 5-K for a stem-cell transplant. She was admitted to the large room usually reserved for transplants, the one equipped with special air filters to reduce contaminants. The night she finished the high-dose chemotherapy that starts the process, she was a bit nauseated but still feeling all right. Her room was madly decorated with drawings and dolls and quilts and flashing Christmas tree lights and signs and pillows. I slid quietly in and out of her room all evening, hanging and adjusting a blood transfusion, listening to her heart and lungs, checking the pump that delivered anti-nausea medication, testing her urine to make sure the drugs hadn't damaged her bladder.
A group of friends arrived with a keyboard and a few guitars, and she sat cross-legged on the end of her bed, holding her face in her hands, while they sang to her. Hardly a word was said for hours, except in prayer.

That's one kind of day. Here's another: a forty-one-year-old woman diagnosed with lung cancer. She was athletic and had never smoked. She and the husband, who clearly adored her, had a toddler. After a month of arduous chemotherapy, her oncologist, Dr. Jeffrey Menashe, came to her hospital room for a talk. He is a tall, lean man and dresses in a pressed white shirt and dark tie when he visits his patients on 5-K. I listened while he told her ever so gently that the treatment hadn't worked. There is a new drug under investigation, he said. I can't make any promises, he said.

“I'll do it,” she said, and the tears were sliding down her face, dripping off her cheeks. “I'll do anything to live.”

I ASKED CHRISTA
, who had lymphoma, what she remembered about being told she would need chemotherapy. “Oh, just the word ‘chemo'—just the
idea
of chemo,” she said. “You've heard the most frightening things.”

Just that word, chemo: an insider's word, diminutive, familiar.
Chemotherapy
actually means any treatment with medicine, but in modern parlance it means only one thing—the cytotoxic drugs. And what a word—the root, chem, has the same Greek source as the word alchemy: the search for a means of prolonging life, a universal cure for disease. The search for transmutation. My friend Sylvia, who survived Hodgkin's disease, said of her chemotherapy, “It's like going to a foreign country you've heard a lot of bad things about and never wanted to visit. And then you have to go there.” After Sylvia said that, I began to call it Chemo World.

Cytotoxic
means
cell-killing
; these drugs destroy fast-growing cells of all types. They are still the cornerstone of cancer treatment, used before, during, and after surgery, radiation, and other treatments. There are many dozens of cytotoxic drugs of several classes on the market, and more are being released all the time.
To kill fast-growing cells in a living body in order to return it to health is a little like using buckshot to kill a cockroach on the picture window. Cytotoxic drugs can be teratogenic (causing fetal malformations), mutagenic (causing genetic mutations), and, yes, carcinogenic. They also sometimes kill cancer, so most of us view them with trepidation and hungry hope. Jeffrey Menashe imagines a day in his lifetime when we are done with cytotoxic drugs. He says, “The whole discipline of oncology was built up around the fact that you have a class of drugs that is so toxic you need a discipline to manage it, which isn't true of any other kind of drug.”

Most cells of the body multiply by division; they are magnificent duplicating machines. When more cells of a certain kind are needed, some of that type create enough material, genetic and otherwise, for two cells, and then they divide—that simple, that miraculous. One of the hallmarks of cancer is that the cells continue dividing without cease, without regard to physical space, available nutrition, or any of the other controls that limit normal cell growth. They just keep multiplying—growing and dividing and growing again.

Cytotoxic drugs are classed by how they affect cells. Certain drugs are “cell-cycle specific,” meaning they only kill cells at a specific phase in their growth cycle; others are nonspecific. One type of drug inhibits DNA repair and synthesis; another interrupts cell metabolism in a specific phase; yet another breaks the DNA helix strand in any phase. Some drugs are thought to kill in proportion to the dose—the more drug administered, the more cells are killed—and have a “kill rate” for just what proportion of cells they destroy.