Passing

by Michael Korda

  I devoured as much as I could on the subject, keeping in mind that reading cancer sites on the internet was not going to turn me into an oncologist overnight—at best it might help me to ask more sensible questions after Margaret’s next MRI. I did not think it would do Margaret any good to share with her the experiences of those who had brain radiation necrosis, there was simply no point in adding to her anxiety, and no reason to jump to the conclusion that the steroids would not solve the problem so long as there was still some chance they might. As for me, I struggled with alarm and despondency as I read about what lay in store for Margaret.

  Everybody who lives with a cancer patient sooner or later has to confront the problem of how much to tell him or her, and, more difficult, how much the patient wants to know. Margaret, I knew from long experience, did not want to know the details, or read about what had happened to other people with the same problem. She wanted simple answers from Alain rather than long explanations from me. “What will happen to me next?” was basically what she wanted to know.

  In the meantime, we faced Thanksgiving, of all holidays perhaps the most difficult to deal with for two people—it’s hard enough to cook a turkey with all the trimmings for two people even if both of them are in good health, and nothing replaces the Norman Rockwell image of a large, abundant family gathering. Ours was bleak, and was made unexpectedly grimmer by the news that my former wife Casey had suffered a brain aneurysm on November 24 alone in her New York City apartment, and was not expected to regain consciousness. Her resentment over the breakup of our marriage had not cooled down a bit over several decades, and I regretted that we had never made peace. Too late now, of course. Of our closest friends, one was in hospital having a section of her bowel removed, another was in the hospital with pneumonia, a third had been hospitalized after a seizure and was now being treated for hydrocephaly. General de Gaulle, I reflected, was certainly right when he wrote, “Old age is a shipwreck.”

  As it turned out when the day finally arrived for Margaret’s next MRI—postponed at the last moment when we were already there because the machine broke down, so we waited for a whole day beside the tropical fish for something that wasn’t going to happen, feeling as trapped as they were—the subject of swelling in the brain hardly came up. I might have saved myself the time, trouble, and angst of reading up about it on the internet.

  One always knows that when a doctor begins a sentence with “Unfortunately,” something bad is coming, and that was indeed the case. Tactfully, gently, Alain broke the bad news to us. The MRI scan “shows further increase in the size of the two lesions such that we are now dealing with recurrent tumors as opposed to radiation necrosis,” as he wrote the next day. In other words, both the original tumor that had been resected in April and the smaller ones that had been discovered before Gamma Knife radiation in May had returned and were growing rapidly. This was not just going back to square one, it was worse. There were now two tumors instead of one.

  Alain was firm about what needed to be done—“surgical intervention” as soon as possible to “debulk” the two tumors, followed by a course of focal fractionated radiation. Would that mean entering the skull in two different places? I asked. Yes, he said. Margaret was shaking her head, I saw that it was very doubtful she would agree to this. Would the process be the same? Going somewhere for rehabilitation—I was sure Margaret would not go back to Burke again—then physical therapy, speech therapy, and so on, all over again? Alain said the process would be much the same, and Burke wasn’t the only place, of course. Margaret interjected for the first time, what if she had the radiation without the surgery? That would be better than doing nothing, he said, but it was not what he would recommend; removing the tumors was the first and most important step. What would the side effects of the radiation be? There might be fatigue—he paused for a moment—and significant hair loss.

  I could see from the expression on Margaret’s face that the sooner I got her home, the better. The first brain surgery had bought her less than seven months, she said quietly, most of them miserable. How many months would all this bring her? That was impossible to answer, Alain replied, a lot would depend on her having a PET/CT scan of the chest, pelvis, and abdomen “to determine the extent [of] her systemic disease.”

  This was something that Margaret had firmly ruled out. She did not want to see an oncologist specialized in the treatment of the melanomas, it was a can of worms she did not want to open—if she was “riddled with cancer,” as she put it, she didn’t want to know. We had too many friends who had gone down that road and ended up in the hospital having treatments that were as bad as the disease itself, suffering dreadful side effects without altering the outcome. I knew who was on her mind: Peter Forbath, a swashbuckling Time foreign correspondent in the days when that was still a glamorous profession, a friend of us both—nobody had been more supportive when I was recovering from cancer surgery—whose cancer diagnosis and treatment led to just the kind of long and destructive illness that Margaret feared. I had known others who went that route over the years, including the Hungarian nuclear physicist Leo Szilard, to whom I brought the final page proofs for his corrections of The Voice of the Dolphins as he underwent cobalt therapy of his own devising for bladder cancer at Memorial Sloan Kettering Hospital, and Cornelius Ryan, author of The Longest Day, to whom I brought the proofs of A Bridge Too Far as he lay dying of metastatic prostate cancer. Both of them were robust and courageous, and it had been terrible to see them as their cancer—and the treatment—destroyed them day by day.

  Margaret felt the same way, in fact even more strongly, about Peter Forbath’s death—much as she trusted Alain, the likelihood of her going to New Haven to see Dr. Kluger was approaching zero. Later I would ask myself whether I should have pressed her harder to go, and Alain asked himself the same question, but the reality is that you cannot push people beyond the level of their comfort zone, and Margaret more than most people was resistant to being pushed. She was not suicidal, she did not want to die, she was prepared for a battle, but not for a long and losing siege of what is sometimes called, both by those who experience it and those who give it, “desperation oncology.” Had she known what lay ahead in the next few months she might have chosen differently, but I doubt it.

  “I can’t go through a second brain surgery,” Margaret said firmly once we were home. “And I don’t want to go and see Dr. whatever-her-name-is.”

  “Harriet Kluger. Alain thinks you should.”

  “I know. But I remember what it was like at Sloan Kettering, I don’t want to end up like that.”

  I sighed silently at the memory. At some point when I was doctor-shopping to decide where I would go and what treatment I would have for my prostate cancer, we got lost and walked through the radiation department looking for the doctor whose specialty was radioactive seed implementation, and who, like so many specialists, once we finally found him, was a true believer—surgery was no good, hormone therapy wasn’t the answer, the only sure thing was radiation, everything else was a total waste of time. While searching for his office we walked down long corridors full of patients lying on gurneys or sitting slumped in wheelchairs, eyes vacant, tethered with wires and tubes to monitors and IV bags and catheter bags, bald heads marked in various colors to indicate the precise point of focus for the radiation they were waiting for. It was a sight that was admittedly unsettling, like opening a door and seeing something you were not meant to see, but for Margaret it must have represented everything she feared: helplessness, being treated like an object, misery. At the back of her mind she feared that Dr. Kluger’s immunotherapy program would be something like that (a fear that as we were soon to discover was not entirely groundless), she did not want to be “a guinea pig,” as she described it, in clinical trials of new cancer treatments.

  “You think I’m wrong?” she asked.

  “I think I might feel the same way you do about repeating the brain surgery. I’m not sure I could go through that a second time
either. But if I were in your shoes, yes, I would go and at least hear what Dr. Kluger had to say.”

  “But you’re not in my shoes. I’ll think about it after I’ve had the radiation,” she said. “I suspect that’s going to be bad enough, without going to New Haven as well. And I’m not going to put myself through another brain surgery, much as I like Alain. I just can’t. You’ll tell him?”

  I called Alain the next day to let him know that Margaret agreed to have the radiation, but couldn’t go through a second brain surgery, and also didn’t want to see Dr. Kluger yet, although she might do so after the radiation treatments were completed. He did not seem surprised. He would speak to Dr. Choi and get the plan for the radiation started as soon as possible.

  Later that day I emailed Alain to thank him for “breaking this bad news as gently as possible today,” and asked him what would happen if Margaret did nothing, and how long it would be before the symptoms become terminally threatening. He replied promptly, frankly and thoughtfully. “Breaking bad news is never easy, this despite the fact that I have had to do this periodically throughout my career as a neurosurgeon . . . To answer your question, if nothing is done Margaret will have but a few months left, how many is impossible to say. As the larger of the two tumors expands her speech will become more impaired as well as the coordination of her right hand. Eventually her balance will be affected to the point that independent walking will become impossible. The terminal phase occurs when patients slip into a coma and eventually stop breathing.”

  Well, I told myself, now you know.

  Had there still been any question of whether or not Margaret would go to New Haven for immunotherapy, it was resolved once and for all by a front-page story in the New York Times on December 3 headlined “Immune System, Unleashed by Cancer Therapies, Can Attack Organs.”

  There was never any chance of hiding this from Margaret even had I wished to, because the New York Times was placed in the tack room every morning next to her coffee. She still glanced at the front page, so she could hardly miss the headline. Dr. Kluger was the central figure in the story, which, while it offered a certain degree of hope for the treatments she was testing, noted “a risk of side effects that were severe, requiring hospitalization or were life-threatening 54 percent of the time.” Dr. Kluger admitted, “It’s at least that high, at least.” The story went on to describe in harrowing detail the side effects and “devastating results,” prompting another immunologist to remark, “I’m not sure you can get rid of the side effects—it’s really what you want.” You had to poison the body to destroy the cancer, in short.

  The Times story pretty much killed off any chance that Margaret might change her mind about going to see Dr. Kluger. To be fair, some of Dr. Kluger’s patients had their life extended even with stage IV melanoma, but one of them “spent 24 days in hospital, where trouble mounted, first his pancreas failed, then his bowels inflamed and his kidneys became dysfunctional”; another went into “diabetic ketoacidosis . . . when her pancreas shut down.” Dr. Kluger took this setback philosophically. “Her pancreas isn’t coming back,” she said briskly. “She has her life.”

  Alain sent me an email the next day to say that after reading the Times story any enthusiasm that Margaret might have for “an immunotherapy may disappear.” I agreed: “I have to say that the article makes it very doubtful that Margaret would want to risk something that has a 50%+ chance of making her very much sicker than she already is. Margaret’s overriding desire is to be left in peace for as long as possible. Despite the limitations that her symptoms produce, she still drives and rides, and looks after her animals, cats and horses. She wouldn’t want to enter a program that meant that she was going to be ‘a patient’ for the rest of her life, or going back and forth to emergency rooms, or dealing with side-effects and diseases almost as bad as what she already has, and perhaps worse.”

  Alain’s reply was a model of courtesy and good sense. “Of course I understand the dilemma Margaret is facing. In the end we all want to have a quality to our remaining days, given that each and every one of us will sooner or later face the inevitability of our own mortality. To spend those precious few months dealing with the complications of treatment is not appealing at all. I do not think that Gamma Knife radiosurgery is out of the question for the smaller of the two tumors, but for the larger one fractionated radiation therapy makes more sense, given the size of the tumor. My suggestion is that this be discussed with Dr. Choi when Margaret sees her.”

  “I want Tamzin to have all my jewelry,” Margaret said out of the blue a few days after the Times story.

  A couple of weeks ago I would have told her not to be silly, or that there was plenty of time left to think about that kind of thing, but I merely replied, “Of course.” Margaret had never wanted to be a mother, and in the years when that had been possible she made sure it didn’t happen. Her second husband Burt had always wanted children, and so did his family, who expected Margaret to have them. It had not been the only issue that undermined the marriage, but it was a major one. She had made her feelings on the subject clear to Burt before they married, so they cannot have come to him as a surprise, he may have supposed that Margaret would change her mind once they were married, but Margaret never changed her mind about the things that mattered to her, and this one mattered to her a lot. It was not so much that she disliked children, she simply did not want to have one herself.

  That did not mean that Margaret was totally without maternal feelings. She felt for Megan, who had worked part-time in the barn and ridden Margaret’s horses for twelve years, a motherly concern, and felt the same and more so about her goddaughter Tamzin Blinkhorn, who had lived with us on and off for over thirty years, long enough for Margaret to come to feel that Tamzin was her daughter, particularly since Tamzin is English and a good horsewoman in her own right. Tamzin went on to have a successful career in commercial real estate over here, and when she finally decided to return to the UK for good in 2002 it felt to Margaret like losing a daughter. Like any parent, she had muddled feelings, pleasure when Tamzin married and had a daughter of her own, alongside the feeling of being abandoned after Tamzin returned to her roots three thousand miles away. Tamzin’s mother and Margaret had been close friends since the age of three, and there was perhaps some unconscious transatlantic rivalry between them for the possession of Tamzin, but if so the competition between them was very English—everybody involved was polite, soft-voiced, it all took place without any visible emotion, indeed without anybody admitting, or perhaps even realizing, that it was going on.

  I was glad that Margaret had decided to leave her jewelry to Tamzin, not that jewelry had ever mattered that much to her. Except for her engagement ring, a present from me, none of what Margaret owned was particularly valuable. She loved turquoise, jade, lapis lazuli beads, and interesting silver pieces from Santa Fe or Taxco, preferring visual impact to value. Given a choice between a piece of jewelry or a new horse, she would unhesitatingly choose the horse. Still, all of it, even the costume jewelry, meant something to her, she knew where she had bought each piece and when, or who had given it to her. I asked if she wanted to see Tamzin, but she replied firmly, “Not yet.”

  Few things are harder than telling someone that they’re dying, unless it’s doing the dying oneself. Not many people are good at breaking the ultimate bad news. Most doctors don’t like to, perhaps because it’s admitting to failure—it’s one thing to pronounce someone dead, quite another to tell them that it’s about to happen. The only people who are good at it are hospice nurses—it’s often part of their job because nobody in the family has faced up to it yet; and Roman Catholic priests—after all you don’t get the last rites until you’re dying, being anointed with the holy oil is a sure sign. Rehearsing what you’re going to say to the person who is dying doesn’t help much, at any rate it didn’t help me. When the moment comes you have to find the right words, though in fact that part is easy. “You’re dying” will probably do it.

/>   When you tell someone they’re dying is more of a problem. If you delay too long, until communication has ceased, it may be too late, and by that time unnecessary. On the other hand, telling someone too soon is cruel. “Where there’s life, there’s hope,” is a platitude that goes back to the time of Cicero and further, but we still want to believe it even when it is no longer true. We hope for a miracle, we hope for a delay, at the very least we hope for a “good death,” whatever that is. Margaret was not naïve, she knew from the bad news Alain had given us about the MRI on December 7—“Pearl Harbor day, of course,” she had commented with trademark irony—that she was “terminal,” but terminal is not the same thing as dying, terminal is a process, not an end. Very few of us can imagine our own death. You can imagine what kind of ceremony you want, or how you want to be dressed when you are the corpse in the coffin, or how grief-stricken your loved ones will be (or you hope they will be), but nobody can imagine what it will be like to die. Margaret understood that things were going badly for her, but at the same time she was getting on with her life. She was about to start the radiation treatment, she made an appointment to see her dentist in New York for a routine checkup and cleaning, she was still getting a manicure once a week, riding two horses a day, walking a mile or two depending on the weather, carrying on, for how long of course nobody could say. The only person I knew whom I could ask about it was Thom Schwartz, a nurse who lived up the road. He said, “You’ll know when it’s time.”