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Novelet: ADVANCES IN MODERN CHEMOTHERAPY by Michael Alexander
While the title of this story might lead you to think it's a reprint from the Journal of Oncology, fear not: it is indeed a work of fiction, and it marks the debut of an analytical chemist who lives in Oregon somewhere west of I-5. Watch for more from this writer ... and watch out too for those folks sitting around in the ward who appear to be doing nothing.
Today's hypodermic needles are a love.
When I was a kid, there was always a Petri dish of autoclaved needles on the doctor's desk, drops of condensation hanging on the inner lid. They were fat and sturdy, built for many uses, dull as nails and painful as repentance as they popped the skin. Modern, single-use needles are thin and so sharp they go in with no resistance. When you are getting a lot of pokes this is a real advantage. Less scarring, the veins last longer.
Sitting in the recliner, watching the drip, drip, drip from the bag over my head down the line running into my right arm, listening to the kwee-kabup, kwee-kabup of the infusion pump next to me hooked to my left arm, I could read a magazine, sip coffee, and look around at the other patients in the treatment center. After a while you get to know the people on similar dosing schedules to yours. Alf, the nice old codger getting fluorouracil, irinotecan, and leucovorin for his colon cancer. Mary, carboplatin and paclitaxel for recurrent post-mastectomy breast cancer. Me, leuprolide, zolendronic acid, docetaxel, prednisone, and RGX-364 for metastatic prostate cancer.
After a decent year with testosterone suppression therapy, my prostate-specific antigen levels had begun to climb again and I was moved on to sterner stuff. My oncologist suggested a Phase III clinical trial testing a new compound as adjuvant therapy and I figured what the hell, so as the docetaxel solution dripped in one side, the RGX-364 was pumped in the other. The alphanumeric designation might sound sexy, but it's just an identifier the pharmaceutical company uses, in this case Rhone-Guiamme Experimental Compound No. 364. I assumed that meant the previous 363 hadn't panned out. Every three weeks, now on Treatment Number 39.
Side effects. The leuprolide turns off testosterone production to inhibit the cancer cells needing it to grow; it also turns you off below the waist, if you get my drift. You may now leave the monkey house. It also causes loss of muscle and bone mass. The latter will eventually lead to osteoporosis, so you take lots of extra calcium and vitamin D and get monthly infusions of zolendronic acid to minimize the bone loss and prevent your spine from collapsing. Assuming you live long enough. This compound has the interesting ability to produce what is known as “bone flare,” which in its finest form gives you a high fever while producing the sensation that every muscle and bone in your body has been worked over with a brick. It goes away after a while. Ibuprofen works fairly well for the discomfort. The docetaxel, like most anticancer drugs, has a differential toxicity for rapidly dividing cells. This means you try to balance killing most of the neoplasms while sparing as many normal cells as possible. Since your body has other rapidly dividing cells besides the cancer, you end up losing your hair and maybe puking and running for the bathroom. Compazine or ondansetron can help with the nausea. Docetaxel also can cause peripheral neuropathy, making your fingers and toes numb. I had been spared the worst of that particular problem, although I'm very careful walking.
The RGX was an investigational drug targeting specific receptors on the wild cell surfaces in an attempt to produce specific apoptosis. A laudable goal, but, as usual, the compound wasn't entirely specific, capable of producing an interesting set of, as they say in clinical trials, “adverse events.” “Among reported adverse events” (I'm quoting from the investigator's brochure here) “are fatigue, fever, and fluid retention. There are reports of blood discrasias and liver enzyme changes, in some cases requiring discontinuation of the drug. Neurological changes have been reported, including drowsiness, slowing of normal mental function, and in rare cases a schizophrenic state including loss of affect, mild paranoia, disturbances of visual fields, and aural hallucinations. These latter manifestations have been controlled by use of relaxants and neuroleptic medications (see Appendix 3a); severe cases may require antipsychotic medications and cessation of RGX-364 therapy.” And so on.
Really, don't get cancer.
Alf was lying back, eyes closed, a trace of a cannabinoid smile on his face. Mary was reading a National Geographic. National Geographic is the official magazine of cancer treatment centers.
I was enjoying the tail end of my nausea-free time, so I let my head ease back onto the pillow and closed my eyes. I had already read all of the National Geographics. Three times. Know all I want to know about rock hyraxes. I let the different noises wash over me: the television hawking cheap jewelry, people chatting with each other, the noises of a hospital, distant public address announcements. It all settled into a soft, distant murmur in my head. Not unpleasant. My mind seemed to drift away somewhere; I was existing, taking in vague stimuli, an experimental carrot.
hi larry
I cracked one eyelid and looked around. Nobody. I closed my eye and relaxed again to the murmuring.
larry can you hear me
I looked again. Nobody. The nurses were all in the back room. The TV was hawking tanzanite earrings, $49.95 the pair.
Maybe I was developing that RGX schizophrenia. Wouldn't that be a kick? Something to bounce around with the other patients when we compared all the ways our bodies and souls could find to go wonky. Like the time I had an allergic reaction to the cremophor vehicle for the taxane and my face swelled up and I couldn't breathe.
Yeah, I can hear you. What part of me is talking to the other part of me, here?
its mary
I snuggled around in the chair; my ass was falling asleep.
Okay, mary. I have to be here for another two hours, so I might as well have some fun. Now, are you the Virgin Mary, perhaps? I went to Catholic school, so I know all about you. Will I be seeing a tunnel of light in a bit? Baby Jesus? Or are you Sister Mary? Shall we do some flashcards?
next to you
I thought about calling over a nurse. I lifted my head and opened my eyes, turned to see which nurse was around, and saw Mary staring at me.
no dont loo—
And the voice stopped. Mary smiled, nodded and resumed reading her National Geographic.
I lay back once more and stared at the ceiling. Then I looked over at the TV. More tanzanite. Ugliest jewelry I've ever seen, and people appeared to be buying it. Mary was still reading the magazine. I started to speak, thought the better of it, and relaxed.
Mary was done about an hour before me. After getting unhooked, she came over and patted my arm. “Always nice to see you, Larry.” She glanced at her watch. “I have to run, but we can talk again next time."
"Uh, Mary...."
"You just relax.” She straightened up, wincing a bit. “See you next time. Assuming, as always.” She picked up her cane and I watched her walk slowly out of the room.
Aural hallucinations.
* * * *
I took the hospital jitney home; don't entirely trust myself driving immediately after a treatment, even if the side effects can be delayed from hours to days. I was beginning to feel a bit nauseated, but not terribly so. Meaning that two years ago I would have been running for the bathroom as fast as I could move, but now knew that I wasn't even close to actually heaving.
One of the things about a chronic disease is that you become closely attuned to your internal signals. After the initial wave of hypochondria, where every tiny twitch sends you into agonizing uncertainty, you settle down and tell yourself that as long as you don't see blood in your urine or spittle or stool, things are probably okay. Considering. In my case blood in the stool would just indicate hemorrhoid problems, and you probably didn't want to know that. But the heightened perception is still there, and you know almost immediately if that ache is just from yesterday's gardening or from wild cells finding a new home in
your bones.
I decided to try a dry sherry on the rocks. Alcohol is quickly absorbed and a mild drunk on an empty stomach can make any nausea less annoying for me. Putting a couple of ice cubes from the refrigerator in a short glass, I poured a generous dram or three and swirled it, watching the waves of refraction as the melting ice mixed into the liquor. I tried marijuana initially, but it didn't work for me, although Alf swears by it. All I got was an unpleasant disorientation and enhanced nausea from the smell of the smoke. Me, the Sixties Child, unable to toke. But sherry is an old friend. I know the disorientation of an alcohol buzz and can work with it. I took a Compazine capsule from the bottle over the sink and swallowed it. Sipping slowly but deliberately, I got half the glass down with no trouble. After freshening the drink I walked over to my stereo, put the A side from Brubeck's Time Out on the turntable, and lowered the needle. I'm old-fashioned.
I returned to my chair and took another gulp to the staccato piano opening of “Blue Rondo à la Turk.” I was finishing the drink as “Strange Meadow Lark” wound up, then closed my eyes and let my head lie back as “Take Five” began, waiting for that Peter Desmond sax riff. Desmond died of lung cancer. You begin to take note of these things, after a while. Still no real nausea. As I said, it can take a while to set in. The Compazine would help.
Brubeck relaxes me. The jazz and the buzz were melding to make me feel pretty damned good, all things considered. Trust me, it's always “considered.” The docetaxel was getting into my cells, disrupting the tubulin and short-circuiting their division. The RGX-364 was attaching to bits of protein standing out from the cell walls, telling them to kill themselves. Hopefully. I rubbed my bald head and let my mind go blank, nodding along with the music.
I must have dozed off for a couple of minutes. When consciousness returned I could hear the scritchy static from the record player needle rubbing the inner circle of the platter, a bit like the ocean sound you get from holding a shell to your ear. I just sat, eyes still closed, enjoying the nothing. And after a while, the nothing began to sound like something, like a group of people murmuring down the hall, like a theater lobby at intermission, like relatives talking to the doctor when they think you can't hear. Then I heard my name, the way you hear your name spoken in a crowded room and nothing else makes sense. It went away, then I heard it again.
"Okay, who's bugging me?” I asked the room, the alcohol. “Hippocampus? Inferior gyrate sulcus? Temporal lobe? The ghost of last night's chicken paprikash?” I always had a special dish the night before a big treatment, and I make a mean paprikash.
—ear me? i think you—
"Howdy again, me. Haven't we met before?” I giggled.
...ust relax listen and...
I giggled again, enjoying the drunk. “Larry in recliner, I.V. on the tree; d-r-i-p-i-n-g,” I chanted softly.
...issed a p...
I thought about another drink, decided against it. Not too much alcohol on an empty stomach. “Well, Brain, this is fun, but I really do feel like a nap. If I should die before I wake, let me know, eh?"
—ood idea go to sleep lar—
Psychosis. I found the quilt on the floor next to the couch by touch, pulled it over me and went to sleep. I had sad dreams.
I decided not to tell my oncologist about the voices. I figured it might get me kicked off the clinical trial and I didn't want that. Not yet, anyway.
"How are you feeling today?” he asked.
"Still on the bright side of the dirt."
He nodded. “Any problems with your daily routine?"
"No.” He didn't ask if I was having any problems at work; I had gone on “disability leave” two months before, a nice euphemism for “going home to die."
"Any pain?"
"Just the usual. The ibuprofen works fine when I need it, so far.” Every treatment day they gave you a form to fill out indicating where you had pain, a drawing of a naked man, front and back. I had put a check on his ass three times before anyone got it.
"Good. Any problems with urinating? Bowel movements okay?"
"Fine for both.” When you get sick you not only lose your health, you lose the illusion of privacy as well. But they always asked about bowel movements; must be Freudian. Sometimes I felt like saying, “Yeah, Doc, the damned things just got up and moved to Majorca.” But I didn't. “Just the fatigue."
"That's normal."
I always said I had fatigue. It's like a seven-year-old going to confession and saying he disobeyed his parents. If you offered something there was less likelihood of further probing. It was also true. A flight of stairs was my limit.
"Your PSA is still elevated,” he added. As if I didn't know. Not only elevated, but climbing fast. I knew the treatments weren't working much any longer. But what the hell, they got me out of the house.
He made notes on my chart. “Okay. Just remember to keep up the calcium and vitamin D. I'll see you next month.” Say five Our Fathers and five Hail Marys.
I stood up. “As always. Assuming, of course."
* * * *
I was the only patient in the treatment room, except for Ed in the corner, and he didn't talk to anyone, except to say he'd like to make everyone else on Earth and God Himself feel the way he felt. Nice guy. Grow up, Ed.
"Where's everyone?” I asked the nurse as she felt for a vein. It was getting harder all the time. I would drink lots of water before leaving for the hospital, they would put on a heating pad, but I was just running out of usable plumbing. I didn't really want a shunt implanted, though. I remembered back to my grad student days and how we would make the ear vein in a rabbit stand up by swabbing the skin with toluene. Grad student days; Christ, that was fast.
"Mary will be in a little late today; she's getting a CAT scan. Alf...” she let her hand rest on my arm a bit longer than necessary, “moved to hospice this week."
"Damn."
"Yeah. He told me he was pissed that he probably wouldn't have time to finish his book."
I smiled. “I didn't know Alf was a writer."
"Alfred Rees McCutcheon? He's a well-known art historian, I guess; that's what Mary said. Something like fifteen, twenty books, she told me. Alf said he was working on something about Olmec art. I think that's what he said. Whatever an Olmec is."
"Damn.” Here I had been sitting next to a guy who had actually accomplished something in life and it never once occurred to me to ask what he had done. We had chatted the inconsequential natter of standing in line at the checkout, wet weather, football, politics, drug cocktails. That this ancient, shrunken manikin had been—still was!—working at his profession, racing the hourglass like Ulysses Grant, well....
Suddenly, I felt very fatigued.
Mary came in about an hour later. I was staring at some soap opera on the television. It was in Spanish. I had realized that with soap operas language was optional, and that the women were uniformly gorgeous and foot-stomping fiery. “Hi, Larry,” she said.
I wiggled my fingers at her. “Hi, Mary. How are you feeling? Did you hear about Alf?"
She sat down in the recliner next to me. “Yes, he told me. Didn't he mention it to you?"
"No, not that I remember.” I reached up and tapped my head with a finger. “Unless chemobrain is setting in again."
Like fibromyalgia, chemobrain is a suite of symptoms in search of a mechanism. Memory and associational difficulties. Nobody knows if it's a side effect of therapy, the cancer itself, depression, or what have you. Like a cancer of the mind, it's as if your personality is being taken over by an invader as surely as your body is. Or maybe just an annoying relative moving in.
A nurse came over to put in a line and do a quick blood draw on Mary; stat creatinine level before starting the I.V. Mary waited for her to leave, then said, “He told me Thursday before last, I think. He knew it would be his last treatment and that he was checking himself into hospice. He was trying to be upbeat, but he was still annoyed, and a little sad."
"Yeah. I just found out
he was—is, sorry—a famous historian?"
"Famous isn't correct, but well-respected is. I've been helping him with some research he can't do online. When I can."
"Send him my best."
"Oh, you already did."
"Um.” I paused. “When?"
"Thursday before last? Thursday evening. Your last treatment day, anyhow.” You sounded a bit tipsy, but quite sincere.
"I was...how did you know that?"
You said so.
I was looking straight at Mary and suddenly realized her lips weren't moving as she spoke. She smiled, and it was a beautiful thing in her sunken face.
Welcome to the Last Days Club.
* * * *
Hmph.
Either I was experiencing something impossible, or it was time to start on those antipsychotic drugs. Least hypothesis suggested the latter. “Are you reading my mind?"
No, no. I guess you might say I'm listening to it.
"There's a difference?"
The nurse looked up from her station. I grinned, made a quick circle with my forefinger against the side of my head. The medical team had figured me out by this time. She made a laughing face and returned to her keyboard. Just try talking without moving anything in your throat, Mary said.
"Jerry Mahoney to your Paul Winchell?” There is an advantage to being of a certain age. Jokes that pass over the heads of younger people can still get a laugh. “'Eliminate the larynx,'” I replied. That got a look. “Bester. Ever read The Demolished Man?"
No. Any good?
"Yes. The Stars My Destination is better, though. ‘My name is Gully Foyle / And Terra is my nation / Deep space is my dwelling place / The stars my destination.’”
I don't understand.
"The story of a man who should have died and didn't."
Ah. Do you think you shouldn't die?
I considered for a moment. “I don't think what I think really matters. It's what a small patch of DNA decided to do a few years ago that does."
Mary looked at me. Do you like poetry?
I shrugged. “Yeah, but it doesn't like me. Lousy memory."
FSF, July-August 2010 Page 5
