The words “vasogenic edema” stumped me momentarily, but after looking up the phrase, I took it to mean swelling. The tumor had been there for some time, I surmised, and growing, and was surrounded by dead cells and fluid, together with blood from a “prior hemorrhage,” all that was clear enough, however dismaying. I wondered if the “prior hemorrhage” had been responsible for Margaret’s difficulties with using the fingers of her right hand. Remembering John Gunther, I knew an astrocytoma was bad news, a glioblastoma was fatal news, and there was a difference between “primary” brain tumors—that is, those formed in the brain but which do not travel elsewhere—and metastatic brain tumors, which have been formed by cancer cells traveling from elsewhere in the body and are very bad news indeed. “Mass effect” I understood vaguely. As the tumor grew it pushed away the healthy brain tissue to make room for itself, but what really caught my eye was the size of the tumor: “3.5 x 2.7 x 3.4 cm in size.”
At first I thought I had misread it and mistaken millimeters for centimeters, but I read it again, and there was no doubt which it was. I had attended school in Switzerland, but those of us there who were British or American still clung to our own archaic system of measurement since it would be needed for our college or university entrance test, so even at this late stage of my life my mind did not easily visualize objects, distance, temperature, weight, or volume measured in metric units. My mind still functioned in pints and inches, not liters and centimeters.
I pulled out a ruler, measured off three and a half centimeters, and my stomach lurched as I came to grips with the fact that the tumor in Margaret’s brain was not much less in volume than a ping-pong ball. This was a large mass to imagine growing in the tightly packed interior of Margaret’s skull.
I skimmed through the rest of the report, most of it describing the results as “unremarkable,” only to notice under “Lungs/Pleura” a brief note of “a 7mm nodule in the left lower lobe,” a “6mm nodule in the right lower lobe,” a “questionable 7mm nodule in posterior of the right lung base,” and “a 7 x 9mm cystic lesion” in the pancreas. These were presumably “the couple of spots of concern” the doctor had mentioned as we were leaving. I paused to consider the possibility that Margaret’s problem might be more widespread than her brain tumor, frightening though that thought was.
The first question, of course, was whether or not to share all this with Margaret, but it seemed obvious to me that she already had enough to deal with at the moment. She had to absorb the news that she had a malignant brain tumor, as well as the idea of having a brain biopsy that entailed drilling a hole through her skull the day after tomorrow. It was difficult to know whether she had heard the neurosurgeon’s remark about the presence of other tumors in her body, or if that had simply not registered in the shock of learning about the malignant brain tumor. Either way, there did not seem anything to be gained by reading her the radiologist’s report or explaining what it meant in detail, even had I been equipped to do so.
I slipped the radiologist’s report to the bottom of the pile of papers on my desk (and with some degree of guilt shelved it at the back of my mind for the moment) and began to fill out the forms—previous medical history, current medications, insurance information—all of which was soon going to become second nature to me over the next year, so much so that I took to carrying the information around with me in a special briefcase, together with my reading glasses and a ballpoint pen, to speed up the process of filling out forms on a clipboard in innumerable doctor’s and hospital waiting rooms.
I thought what we needed was a second opinion, but we needed it fast—the neurosurgeon’s reaction to Margaret’s brain scan made it clear that delay was not an option. When I had been diagnosed with prostate cancer in 1994, Margaret and I sought out second opinions from surgeons in New York City, Boston, and Baltimore, but there was time to spare, nobody suggested that a week or two one way or the other would make any difference, prostate cancer is usually slow-growing. When I finally chose Johns Hopkins in Baltimore it was on the recommendation of numerous friends, one of whom declared passionately that he would “lie down in the street in front of traffic” to stop me from going anywhere else. Despite this offer of self-sacrifice I had always believed since that I made the wrong choice, that Memorial Sloan Kettering Cancer Center in New York City would have been better by far (admittedly this comes under the category of not crying over spilled milk), but I could not complain that we didn’t get an opinion from enough eminent urologists before reaching a decision. Getting a second opinion from distinguished specialists of any kind is usually a long, slow process; it’s hard enough to even get an appointment with one, let alone travel to Boston to see whoever is reputed to be the best neurosurgeon at Massachusetts General Hospital, or to Rochester, Minnesota, to see his or her counterpart at the Mayo Clinic. Nor are specialists necessarily sympathetic to “doctor-shopping,” even if we had the time to do it. Besides, while almost every man over the age of fifty has a recommendation to make about a urologist, not many people have a favorite neurosurgeon.
As I looked through the scribbled notes of people I needed to call, a name on one slip of paper caught my attention: Dr. Alain C. J. de Lotbinière. Margaret’s diagnosis had altogether erased from my mind the fact that I was scheduled to speak about Hero, my biography of Lawrence of Arabia, at a book club dinner being held at the Kittle House, a restaurant in Chappaqua, New York, on Monday evening next week, an event that had been arranged months ago. The invitation had come from Dr. de Lotbinière. Whatever was going to happen, it was clear to me that I was probably not going to be giving a talk about T. E. Lawrence Monday night.
No author likes to cancel an event at the last moment that was arranged months in advance. It happens, of course, in our part of the country everybody understands that events scheduled during the winter are dependent on the weather—a snowstorm that shuts down the Taconic Parkway cancels all obligations—but perhaps because my mother was an actress the tradition that “the show must go on” had a certain resonance for me. Come to that, Margaret was not someone who would normally let bad weather or illness cancel her plans. I was fairly sure that if I asked her she would tell me to carry on, but who could foresee what we might be doing four days from now?
I picked up the telephone to call the organizer of the event, remembering as I did so that Dr. de Lotbinière—and his father—had attended the same boarding school that I did in Switzerland, indeed that had been the reason I accepted his invitation to speak about Lawrence to his group in the first place, even though my biography of him had been published six years ago. Among those who attended Le Rosey “the old school tie” remained figuratively and literally a strong bond, not something to be taken lightly. Apart from “sportsmanship,” one of the basic principles that had been drummed into us in several languages at Le Rosey was that when a Roséen said he was going to do something, he must do it.
I had several numbers for Alain de Lotbinière, but I remembered that he had told me to use that of his cell phone if I needed to reach him. He answered at the first ring, in a sonorous, low-pitched, polite, and even soothing voice, with no more than the slightest suggestion that he was, at the very least, trilingual, but then so are most people who have gone to a boarding school in Switzerland. After he had told me how much he was looking forward to Monday night I told him, with some embarrassment, that I was calling to say that I could not be there. Why? he asked, without any trace of the impatience he must surely have felt at my canceling my appearance at an event that had been planned so far in advance. I explained that Margaret had been diagnosed with a malignant brain tumor, and that I would surely have other things on my mind this coming Monday than Lawrence’s hopes for the Middle East in 1919.
Yes, he replied in the same calm, soothing voice, of course he could understand that. The other members would be disappointed, but many of them were doctors, they would understand. We could put Lawrence off to a later date, when Mrs. Korda’s problem had been resolved. I ex
plained that as yet we had no idea of what was in store for her, or how we would deal with it.
That was only to be expected, he said, and perhaps he could be of some help—he was himself, as it happened, a neurosurgeon of some experience. It came back to me quite suddenly that of course I knew that. It had not seemed to me important at the time, but I recalled that Alain de Lotbinière’s emails came from Brain & Spine Surgeons of New York, in White Plains. He was not just a neurosurgeon, but a distinguished one, medical director of the Cancer Treatment and Wellness Center at Northern Westchester Hospital, an associate professor of neurosurgery at Yale University Hospital for seventeen years, with a string of initials after his name. I had looked him up when he first called, then promptly put it out of my mind since I had not imagined that either of us would be in need of a brain surgeon.
De Lotbinière understood the need for urgency without my mentioning it. He would make time to see us at eleven fifteen a.m. the day after tomorrow, he said. I should bring Margaret’s brain scan with me. He would not mind at all giving us a frank second opinion, or our seeking another one afterward, although he too urged me not to waste time—a malignant brain tumor was a very serious matter.
“By the way,” he added, “whatever you decide to do, until I have reviewed the scan myself, don’t let her have a brain biopsy.”
I tend to make friends instantly; Margaret’s instinct was more cautious. Once she had made a friend, he or she remained one for life, but she had a certain skepticism when it came to my sudden enthusiasms for somebody new. Although Margaret sometimes looked imperious to strangers, she was in fact rather shy, very English in the way she did not open up immediately to people she had just met—it took a while before her robust sense of humor and friendliness shone through. Ordinarily, she might not have been swept away by my conviction that Dr. de Lotbinière was the right man for her to see, and sensibly she put very little faith in the fact that he had been to the same boarding school as me—the bond of “the old school tie” carried no weight for her—but she had not liked the neurosurgeon we had seen in Poughkeepsie, and in any case preferred making a trip down to Mount Kisco and back for a consultation to having a hole drilled in her head. After all, who wouldn’t?
I dealt with the delicate task of letting the neurosurgeon in Poughkeepsie know that we were going to seek a second opinion and that Margaret would therefore not be coming for a biopsy on Thursday morning—fortunately I was able to leave a message, rather than having to argue about the merits of a brain biopsy with him.
The next day might have been idyllic, had it not been for Margaret’s diagnosis. I was, atypically, at loose ends, having called Mary Higgins Clark, whose editor I had been for over fifty books, early that morning to explain that I could not attend the lunch celebrating the publication of her latest novel, As Time Goes By, the first time I had missed one in forty years. Margaret thought I should have gone anyway, but it would have meant my being away for the whole day, and I was uncomfortable with the idea. The thought had crossed my mind—and surely hers—that there was no knowing how many more days like this we would have together. It was beautiful spring weather. We rode together, walked a couple of miles, and in the afternoon Margaret drove to Rhinebeck for a manicure, as she did every Wednesday, followed by an early dinner in the Tavern of the Beekman Arms, which we always enjoyed.
It would not have been in keeping with Margaret’s character to display any sign of nerves. The British war poster of 1939 and 1940 might have been written with her in mind, “Keep Calm and Carry On,” words that summed up a whole outlook on life. Whatever might be going on in Margaret’s mind, she would not want to display fear, although I could not help noticing that the fingers of her right hand were trembling ever so slightly, so that her knife rattled against the edge of her plate.
It wasn’t something she could control, I do not even think she was aware of it. It was not her mind that was making her fingers tremble, I know now that it was simply the tumor pressing on the left side of her brain, sending messages from the left mid parietal lobe down through the spiderweb of nerves to the fingers of her right hand. She couldn’t have stopped them if she tried. It was as if the cancer had a life of its own, which of course it did. It had moved from her right cheek to her lungs, and perhaps to her pancreas in the form of microscopic dots seeking a home, nesting there for years without doing any harm until they gained enough strength or vitality or life force to migrate through the bloodstream, past the blood-brain barrier that is supposed to protect the brain from almost every threat but metastatic cancer, to nestle in a place where the cancer could grow unimpeded without causing pain (the brain feels none) or, for some time, symptoms. Metastatic melanoma is, as oncologists often describe it, “a ticking time bomb” in the body. It bides its time, then years after you may have been told that the dermatological surgeon “got it all,” it explodes where you least expected it, far from the original site on the skin, inside the brain, for example. It can wait ten or eleven years or more, during which time you think you’re safe, having no symptoms, but given time a few stray cells are enough to kill you.
We tried not to talk about Margaret’s illness at dinner, although it took a conscious effort. As we were to discover, the tumor would soon become the proverbial “elephant in the room,” too big to ignore, more difficult still to pretend it isn’t there. Cancer not only takes over the body, it takes over your whole life if you let it. Margaret understood that, she had learned from my own brush with cancer the importance of trying to cling to one’s normal interests and routine for as long as possible. It was not a question of ignoring the disease or pretending it wasn’t happening, she was far too realistic for that, but she understood that the disease was the enemy, you had to prevent it from taking over your life to the exclusion of everything else for as long as you could.
When I had been recovering from cancer surgery at home twenty-two years ago and was still wearing a dressing gown to conceal the catheter and the bag attached to my leg, she made sure to invite for dinner friends from the city who would talk about politics, book publishing gossip, history, anything except what she called “cancer talk,” and now that she herself was faced with a far more serious and threatening problem than mine had been she was determined not to let the cancer become our only subject of conversation.
This was wisdom rather than escapism; we had learned it the hard way. With considerable effort we ate our crab cakes and talked about horses, movies, television, anything but what we both had on our mind.
The Cancer Treatment and Wellness Center at Northern Westchester Hospital in Mount Kisco, New York, is a separate two-story red-brick building with an entrance more like that of a hotel than a hospital. I had vaguely assumed that “Mount Kisco” was a geographical feature from the Old Testament like Mount Sinai, but in fact it was merely a poor transliteration of an Indian word for mud, a mistake made in about 1700. Mount Kisco today is a prosperous commercial center in Westchester surrounded by horse farms and big estates, something of a bridge linking expensive country homes to more modest suburban ones.
The two women at the admissions desk of the Cancer Treatment and Wellness Center showed exemplary patience as I filled out the forms—they smiled and made eye contact, and remembered our names, a very different experience from those who dealt with patients elsewhere from behind a glass window that they slammed shut as soon as they could. Here, the tone seemed friendly and informal, very unlike a hospital. I noticed that they each had their own pronunciation of Dr. de Lotbinière’s name, not surprisingly, and tended to refer to him for simplicity’s sake as “Dr. D.”
Once we were ushered inside, the center had a strangely soothing and cheerful look to it. There were big overstuffed armchairs and sofas, each with its own brightly patterned pillow, set around a large table with the latest magazines spread neatly on it, not the untidy piles of ancient, dog-eared copies of Reader’s Digest like those in most hospital waiting rooms. The colors were warm pastels, chosen no do
ubt to have a calming effect on patients and their family. There was a large aquarium full of brightly colored tropical fish and a long table with an urn of citrus-flavored water, hot water for tea and coffee, even a plate of cookies. In the background there was soothing music, rows of well-tended plants and flowers, the lighting was subdued, everything had clearly been selected with considerable care to reduce anxiety and create a sense of well-being. Here, there were no long rows of nervous or distressed patients sitting on uncomfortable hard plastic chairs against bright white walls waiting for their name to be called out—in fact there were only a few people here, seated comfortably in the big armchairs and looking about as relaxed as anyone can be in a cancer treatment center.
None of this tasteful décor seemed likely to altogether calm Margaret’s anxiety, but the surroundings held it to a sustainable level, there was nothing visible to alarm her, the background seemed hardly medical at all. The music was low and classical, and I was not surprised to read on the bulletin board that a harpist played here at certain times of the day. I recognized that all this had been carefully thought out, and as well that all the cookies and plants in the world could not alter the reality of what was concealed behind the polished wooden doors, but I could not help reflecting that there was a real and important statement being made here—there is no reason to treat those who have cancer as if they are army recruits in institutionalized settings that are only one step above a prison. Recognizing their need to be treated with care, dignity, and respect is the first step in dealing with their illness, even small touches can make the experience less distressing.
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