Recessional: A Novel (15 page)

“And you fully recovered?” She nodded. Then to protect himself he called for Nurse Varney to join the conversation so that she could testify later that he had not practiced medicine: “Ms. Oliphant tells me that thirteen years ago she had a radical mastectomy of her right breast. Now they tell her, and tests confirm it, she has a cancerous lump in her left breast. And she’s asking us what she should do.”

“Are you satisfied the tests are accurate?” Nora asked and Ms. Oliphant said: “Yes, I’m satisfied there’s something in there.”

“What do your doctors recommend?”

“That’s the problem. I get a different answer from each doctor I see. I’ve had six of them, and they refuse to give me any clear answers. Each one has his own theory, but there’s no consensus.”

“Six doctors?” Nora asked.

“Yes, six. Dr. Farquhar told me: ‘If you had a major cancer thirteen years ago, and now you have a lump in your other breast, it has to be taken seriously. Go immediately to Dr. Swain, he’ll tell you how to proceed.’ ”

“And did you go?”

“Yes. And he told me: ‘We have two options. Another radical like before, or there’s this new theory—it’s a lot more than just a theory, it works. A lumpectomy. We avoid massive surgery. Go in with a very small probe, excise the cancerous lump, and move on from there. But first we must be sure of what the situation is.’ So he sent me to a radiologist who provided an X ray of the lump. It looked malignant, but to be sure they all wanted me to go to surgery and have a tiny biopsy, a probe, and it proved positive. I had the cancer, just like before but smaller. The doctors agreed that although I had a cancer,
we’d detected it in time. A lumpectomy was practical, but a mastectomy might be safer—more certain to get all of the cancer. To make that decision I had to consult another doctor, a surgeon who specialized in these matters, and he said: ‘Fifty-fifty,’ and he outlined everything I already knew, but when I asked him what I could do, he refused to say. Told me only I could choose among the alternatives.”

“Where does it stand now?” Zorn asked gently, and she said: “They all agree that there are several options among which to choose. Total job as before or a much simpler lumpectomy. Then follow-up radiation or chemotherapy. I’ll lose my hair with chemo, but that’s one of the options. After that, a concentrated treatment with the new wonder drug Tamoxifen, which they say performs wonders in neutralizing breast-cancer remnants. It sounds promising but they tell me there are also negative aspects. I’m confused.”

When both Zorn and Nora said that it sounded as if she’d done her homework, she grimaced and said: “Too well. Because no one would advise me what was best, I doubled back to the two men who had saved my life thirteen years ago. I called each on the phone and what do you think? My surgeon who did the great job on my right breast said: ‘Recent advances have convinced me that we cut too much. Nowadays I’m doing lumpectomies followed by lots of radiation to kill off the stragglers.’ And my radiologist said: ‘Laura, I no longer do that heavy radiation bit. What do I recommend? Full mastectomy, followed by chemotherapy.’ ”

She spread her hands beseechingly to the two medical professionals and asked: “So what does a woman do?” and Zorn said: “To help women just like you, hundreds of them left adrift in American medicine with no radar or old-fashioned ship’s pilot, a new specialty has appeared on the scene. The oncologist.”

“What in the world does an oncologist do?”

“He’s the referee. Studies all the reports on your case, listens to the conflicting opinions, weighs the evidence and gives you his judgment as to what’s best.”

“Where do I find one?”

“I’ll ask Dr. Farquhar to make a referral. There must be several in the area,” and when, as the manager of the Palms and not as a doctor, Andy consulted with his house medical adviser, Farquhar was able to recommend three trustworthy and knowledgeable oncologists.

When Andy asked: “Which one would you use if it were your wife?” the answer came loud and clear: “Dr. Sam Bailey. Practices here in Tampa, none better.”

When the time came for Laura Oliphant, seventy-six years old, to consult with the new man, she insisted that Dr. Zorn accompany her. Dr. Bailey, a man in his mid-forties, was not pleased with the prospect of counseling a patient when another doctor was present, but Zorn explained that he was there simply as director of the Palms and thus a kind of custodian of the woman.

“No husband?” Bailey asked, and when Laura said: “No,” he asked: “No trusted lawyer? No grandchildren? Well, you really are alone. Stay with us, Zorn.”

And then began one of the travesties of American medicine, a forgivable one that does little harm and some good. For a fee of four hundred and fifty dollars, Dr. Bailey simply told Ms. Oliphant what she already knew, but he did it in such a thorough, skillfully organized manner that she could understand each step in this intricate and frustrating battle with breast cancer. Even Zorn was amazed at the complexity and the routine guesswork facing any woman with the affliction, no matter how intelligent she might be.

Dr. Bailey sat in a straight-backed chair with no desk in front of him, in an office that resembled the living room of a genteel, middle-class suburban family. Ms. Oliphant was given a comfortable chair with armrests and Zorn was allowed to bring in a chair from the waiting room. The room was subtly lighted, hardly enough for reading, and decorated with three Winslow Homer prints of marine-scapes. His consultation consisted of a thorough lecture on breast cancer in American females.

“It is one of the disgraces of American medicine,” he began, “that research in this field has been left primarily to men, and they’ve treated the subject almost with nonchalance. Very little real work has been done, in the opinion of many, with the result that how you are treated, Ms. Oliphant, or women like you, depends largely on where you live when you consult your surgeon. In the conservative Mississippi River Valley and to the west it’s radical mastectomy and cutting out every lymph node—what you had some years ago. In the more sophisticated Northeast it’s now mostly lumpectomies. In the South, except for Florida and its geriatric specialists, it can be heavy surgery on the principle that if the patient isn’t well cut up she’s not getting
her money’s worth. Same way with radiation, very heavy in the West, not so heavy down here. Some favor chemotherapy as the follow-up, especially in cases of recurrence. And with Tamoxifen, it depends on which doctor you go to among the six on the same street.”

He apologized for this confusion, pointing out that much of medicine was influenced by the region in which the doctor had been reared and educated, and said: “But the variety of recommended treatments for breast cancer excels all other diseases.” He coughed, took a drink of water and asked: “So which of these seemingly endless variables is best? Let me explain the immutable fact, the one that overrides all else. If a young woman is diagnosed as having breast cancer and refuses to do anything about it, rejects her doctor’s advice, regardless of which part of the nation he practices in, she dies at a young age. She dies. In her stubbornness she dies. I will admit no debate on that salient point because I help to bury them, year after year.

“The same rule governs your case. If you refuse to take any steps, you will die six, eight, ten years prematurely. You have the option to do nothing, but you must be aware of how you’re endangering yourself.”

Allowing this mournful truth to sink in, he changed his tone of voice to a much brighter one: “So what are the avenues of escape?” and in a brilliant summary of current knowledge he reviewed the pluses and minuses of each of the acceptable procedures, making the evidence so forthright and unequivocal that any attentive listener could have understood: “It seems to have been proved a hundred times over that tracking down cancer cells that may have escaped into the lymph nodes and destroying them there, either by surgery, chemotherapy or radiation, saves lives. The terrible word in cancer therapy is metastasizing. If the cells break loose and are left free to attack other organs in the body, and they have time to take root there and multiply, all hope is lost. That’s when you hear the awful words: ‘They cut him open, looked around and sewed him right up again. Three months to live.’ ”

He smiled at Ms. Oliphant and said reassuringly: “I used the pronoun
he
because that sentence is used most often about men. They allow a cancer of the prostate to spread its cells to the liver and the spleen and the lower stomach, and by the time we get to the mess, nothing can be done. ‘Sew him back up.’ ”

He told her that metastasizing in women’s breast cases was less virulent or immediately deadly because the fugitive cells did not find so easily and rapidly an organ like the liver or the lower bowel in which to multiply at some horrendous rate: “With you, it’s slower but in the long run just as deadly. So what can we do to track down and destroy those vagrant cells that become such killers? Well, in the old days, like thirteen years ago, we cut out not only the breast cancer but also the places to which the wandering cell might have fled. Tough on the patient, as you know, but also very tough on those merciless cells.”

And he proceeded with case histories in the newer treatments. He said that lumpectomies, if followed by rigorous radiation or chemotherapy, were producing good results, but also had some drawbacks. He was not overly enthusiastic about Tamoxifen: “Because there haven’t been enough studies of possible side effects. That it slows down the migration and even the growth of cancer cells there can be no doubt, but at what cost we really don’t know.”

When it was apparent that he was concluding his lecture, Ms. Oliphant said: “You make it so clear that even I can understand it. Don’t you agree, Dr. Zorn?” When he nodded, she said to the two doctors: “So what course am I to take? I want to live as long as possible, because there is so much left to be done.”

Dr. Bailey then gave her the most dismaying news: “It is not in my capacity or knowledge to tell you specifically what to do.”

“Damn it, who can?” she almost screamed.

“No one. We’re in a dark alley of human experience where the rules of procedure are not yet known, so I cannot prescribe.”

“Who can?”

“Only you, relying on such counsel as your dearest friends and your doctors can give.”

“That’s why I came to you, Dr. Bailey.”

“And I can give you these guidelines to help you decide. If you do nothing, as I said at the beginning, you are doomed. If you take any one of the defensive steps I’ve outlined, your chances are markedly improved. And if you elect all three, I can tell you without hesitation that you will enjoy a ninety-seven percent chance of survival till something else finishes you off. If you’re sensible, your chances are extremely good.”

“You mentioned ‘defensive steps’ but you didn’t specify them.”

“Mastectomy or lumpectomy. Radiation or chemotherapy. Tamoxifen.”

“And doing only two?”

“The odds in your favor diminish.” When he saw her blanch he quickly added: “But not catastrophically. Look at your case. Years ago you had only two choices, yet you lived a good life for many years.”

“Are you married, Dr. Bailey?”

“I am.”

“If this were your wife consulting you, what would you advise?”

He reflected, then said: “I’m constantly asked that question, Ms. Oliphant. It’s sensible and inevitable. And I know exactly what I’d do, I’d listen carefully to everything I’ve said, and then I’d consult the three best doctors I knew, and maybe my lawyer and accountant, and one night at four in the morning I’d sit bolt upright in bed and shout: ‘Rachel, this is what we’re going to do, if you’re brave enough to go the route.’ And I would pray that she’d say she was ready.”

“And what would that route be?” she asked and he had to confess: “At this stage in my life, and with the imperfect knowledge we have, I honestly don’t know.”

When he led her from his office, he said: “Now you know everything I know. You also have a friend in Dr. Zorn, who seems eminently sensible. And you trust Dr. Farquhar. Make up your mind, say in about six days, and I shall pray that you have the courage and the good sense to adhere to whatever plan you decide upon.”

When Zorn trailed behind, Bailey told him: “We all need counsel. Don’t hesitate to help her because of some legality.”

But when he caught up with Laura, she looked at him with dumb despair, tried to speak and ended in a shriek: “Damn it, damn it! I consult the wisest men in Tampa and they can tell me nothing. Dear God! Why do you all desert us, leaving us to figure everything out for ourselves?”

Throwing his arm about her shoulders to calm her, Zorn took her to his car and drove her back to the only refuge she had left, her circle of friends at the Palms. But when they reached the fortress gate and could see the handsome center dedicated to health and rehabilitation, he thought not of her confusion but of his own: How strange that because of fear of litigation medicine has fallen into this state when notable experts like Dr. Bailey are afraid to give simple recommendations as to what a patient ought to do. We shy from the great
tasks and occupy ourselves with the petty. Wrong, wrong, but how can we correct it?

Later in the spring when Dr. Zorn had cause to believe that he had the Palms on a road to ultimate solvency, he launched a campaign that was to prove frustratingly futile. As he wandered through the three segments of his realm, he stopped to chat with residents, eager for them to know that he was watching out for their interests. He was increasingly greeted as “Dr. Andy” or referred to as “Our Dr. Andy” to whom questions of deep concern could be addressed.

He did his best to provide solutions to general problems or to help when the appeal was from an individual who needed help in his or her private concerns. Thus he lengthened the hours in which books could be taken from the library and arranged new starting hours for the films that were shown twice a week. He also helped a widow solve a bewildering problem with her taxes and found extra quarters when some couple was visited by three grandchildren instead of two. In this way he helped bind the residents into a closer-knit group while at the same time helping himself understand the complexities of a retirement center.