The Cancer Chronicles (28 page)

For all that work Russian thistle continued to spring up by the dozens. When Nancy wasn’t working or caring for her
horses and
when I wasn’t writing, we would walk every square foot of the land pulling up the weeds by their roots. Every weekend we filled big plastic garbage bags with hundreds of them and I hauled them to the dump. The hope was to grab every one before it set seed—to break the longstanding cycle. In the spring dead skeletons of Russian thistle would tumble in from afar, but we hoped to reach an equilibrium, something we could control. It was a relief when winter came and everything stopped growing.

Come spring we anxiously surveyed the land. It seemed clean at first, then patch by patch the evil little stars reappeared and the battle resumed. I began to notice that the seedlings hid from me beneath junipers, crouched almost invisible next to fence posts and rocks. And when I did spot them, just an inch or two high, some of them were already producing seeds—stealthily reproducing before I could stop them. They seemed to be adapting to me, evolving before my eyes.

There is an old thought experiment in physics involving
Maxwell’s demon, an imaginary little creature who tries to overcome the universe’s
inevitable march to disorder by catching wandering molecules and nimbly returning them to their proper location. Replacing each fallen grain in a slumping sand castle. Pulling every weed in a pasture. Repairing every
mutation in a cell’s DNA. With effort entropy can be forestalled—life itself consists of vessels of order swimming against the entropic tide. With our tools and intelligence we can strike small victories and hold off death for a while. But it is the tide that will eventually prevail. Try as he might, Maxwell’s demon will ultimately be defeated. In the end, the
Echthroi always win.

The next spring at the ranch, I’m told, the salsola was as bad as ever. I wasn’t there to see it. During that year our
marriage ended, seventeen years after it had begun. For a long time our lives had been diverging. The cancer had brought us closer but now it was gone. Brushing so near death makes a person think about how she wants to spend what is left of life. Nancy had her reasons for deciding it was not with me.

Around that time I received an e-mail from my youngest brother, Joe. He was on the road between his home in Dallas and Albuquerque, driving one of his daughters back to college. Somewhere in the expanse of eastern New Mexico he was chewing on a snack when suddenly he heard a loud crack and a searing pain ripped through his
jaw. He continued on to Albuquerque and lay awake all night before flying home to see his doctor.

Although he hadn’t talked much about it, Joe had been having trouble with his mouth for years. It had begun when a white area appeared on the gums of his lower left jaw. A biopsy found abnormal cells that were described as
precancerous. Nothing to worry about—just to keep an eye on as you might a suspicious mole. The problem didn’t arise again until three years later when he felt a soreness. It was also in his lower left jaw. During the next few months, a dentist, an internist, and an oral surgeon each concluded that the best course was to wait and see. Which is what he did until the pain got worse and he was found to have an abscess where a wisdom tooth had been extracted. There was also bone resorption in the area and a couple of dying teeth. All of this was on the left side of his mouth. The skeletal erosion was shored up with bone grafts, the two teeth were extracted, and work began on placing artificial implants. Meanwhile the pain in his jaw continued and was soon accompanied by a ringing in his ears and a sore throat. An otolaryngologist prescribed an antibiotic mouthwash. He had another bone graft and then, not long after, came the incident on the highway.

The next day in Dallas Joe was given a
CT scan and told that he had dislocated his jaw—that all the dental work had caused him to chew in a way that had twisted the bone from its socket. It seemed like a plausible explanation. The doctor prescribed muscle relaxants and, as Joe put it, soft, squishy foods. The white area first noticed three years before was still there and had grown larger. A stabbing pain in his ear led to another CT scan and, for the first time, an MRI. An MRI, I later learned, may be more likely to see abnormalities in soft tissue. And there it was. Inside his mouth and beneath the skin, a tumor—about an inch long—was eating into my brother’s jawbone. A biopsy identified it as squamous cell carcinoma, the same cancer
Percivall Pott found in the
chimney sweeps and that
Katsusaburo Yamagiwa induced by applying
coal tar to
rabbits’ ears. A
PET scan showed that it hadn’t spread anywhere else in his body. Holding on to that fact, Joe sent my siblings and me an e-mail with the subject line: “Good News!” That is the kind of man he was.

There was so much more information about this
cancer than there had been for Nancy’s carcinoma. Squamous cells form the outer layers of the epidermis, the envelope of flesh that is exposed to the world. Beneath them are the
basal cells. As skin cells die and slough off, it is the basal cells that divide and produce replacements. These push upward to form the outer skin.
Carcinomas of the basal cells are the ones that are usually harmless. Years ago I’d had one removed from the side of my nose. Carcinoma in the squamous region is more aggressive, but it still has a relatively high
survival rate, especially if caught early on. What was occupying
Joe’s body is referred to specifically as squamous cell cancer of the head and neck, and the
National Cancer Institute
said that about 52,000 people would be diagnosed with it that year. Why he was one of them was another mystery. Other than being male and over the age of fifty, he had none of the risk factors. He drank alcohol sparingly and he had never smoked. He did not chew betel nuts, which is offered as an explanation for the high rate of the cancer in Southeast Asia. He was tested and found clear of
HPV, another possible factor.

Surgery lasted eight hours and was mostly a success. The tumor was now 2.5 inches long—more than twice the size measured a few weeks earlier in the MRI—and was found
to be wrapped around a nerve. That accounted for the racking pain. The mass was successfully extracted along with the damaged part of his jaw. While that was happening a piece of bone was removed from his hip to fill the gap. In the end it couldn’t be used. That much of the surgery was a waste. The arteries in the transplant site had collapsed so that there wasn’t enough blood flow to support a graft. Later on there would have to be another operation. But for now the important thing was that the cancerous tissue was apparently gone. Of thirty-one lymph nodes that had been removed, only one was found to have been affected. Maybe it had done its job and kept the malignant cells from moving farther. Their next stop is usually the
lungs.

With a tracheotomy to help him breathe and a feeding tube temporarily threaded through his nose, Joe recovered for nine days in the
hospital and then went home. Next would come six weeks of chemo (
cisplatin and
Erbitux, a
monoclonal antibody) and radiation. He would also be given a medication meant to protect his saliva glands from burns, and a feeding tube would be installed in his stomach. He was taking this all with a humbling equanimity even when, just before
treatment began, he noticed a swelling. A new tumor was growing, this one in his upper left jaw. Another was found near his Adam’s apple.

“I always thought that hearing the words ‘you have
cancer’ were the worst you could hear,” he told us, “but I was wrong. ‘We found more tumors’ is much worse.…I think I now realize just what a vile, evil sickness cancer is. The doctors keep chasing it around the body.”

I thought again of
Solzhenitsyn’s
Cancer Ward,
where one of the patients is speaking in awed resignation about his own malignancy: “
A
melanoblastoma is such a swine you only have to touch it with a knife and it produces secondaries. You
see, it wants to live too, in its way.” The
recurrences of
Joe’s cancer were happening in spots that had been disturbed by the surgery, and the doctors thought the new tumors might have somehow been seeded during the operation. But there were other possibilities. I found a paper from 1953 describing
a concept called
field cancerization—
multiple primaries springing up in the same location at about the same time. It was possible that malignant cells from the original tumor could spread to nearby locations. But studies suggested that, in cases like Joe’s, each tumor might have developed independently. That seemed like an incredible coincidence, but there were ways it might happen. Researchers had discovered that tissue lying between squamous cell tumors—tissue that otherwise appeared normal—had
genetic abnormalities, including
mutations to the
tumor suppressor gene
p53
. The mouth and throat are steadily exposed to
carcinogens. A cell damaged by a mutagen would give birth to progeny all with the same defect. One of those might sustain another hit and give rise to a family of doubly mutated cells. In time, as the cells kept dividing, there would be
a field of
precancerous cells, all with multiple mutations and each awaiting the final push. Another possibility is that the cancer field was created early on during development, when a mutated mother cell gave rise to progeny that were all dispatched to form the lining of the mouth and throat. From the very beginning these cells would share the same abnormalities—a head start in becoming cancerous. However the field came to exist it would be lying there primed—“
a ticking time bomb” one paper called it—for multiple cancers. Yet it still seemed strange that so many cells could acquire that final precipitous mutation—all at about the same time—especially in someone who wasn’t smoking or drinking or chewing betel nuts.

After the initial shock, Joe accepted the news as another setback. It just meant expanding the target of the radiation and altering the chemo. He believed deeply in God and his doctors, and his wife and daughters kept him looking ahead. “I have a virtual army of people praying for my health and recovery—from all cultures, all denominations,” he wrote on a webpage his family maintained to keep people apprised of the news. “I have no doubt I will get rid of this cancer and will be back to normal—whatever it takes to do it. I am so blessed that I know in the depths of my soul that I will defeat this.” It would be good to believe in God. After two weeks of treatment his patience was rewarded. “Good news! End of week two and one of the tumors is GONE! Just a hole where it used to be. The others should soon follow.”

His treatment was as rough as it gets. Twice he returned to the hospital with
nausea and dehydration—the results of an infection. But he passed the halfway point—he told us he saw the light at the end of the tunnel—and then began the recovery from the cure. He felt better than he had in months and was happy how quickly he was able to work again from home. And then he got pneumonia, and at the hospital the doctors noticed a mass near his esophagus. It might just be mucous, they assured him. Of course it was a new tumor. As he prepared for six more weeks of radiation and chemo, another tumor appeared in his jaw. The doctors said that one too could be
treated. “Great news!” Joe wrote again. “Longer time in treatment, but it can be beat!”

It had been January when he heard that scary cracking sound while he was eating. By mid-October he had finished the second round of treatment. During that time he exhausted his sick leave. His boss tried to get him another extension, but soon Joe was unemployed. You can fire someone because they have cancer. Joe said he understood. He was sure he would get his job back once he was well. More than a month passed before he felt a new soreness, this time around his collarbone. “Buckle your seatbelt,” he said. On Thanksgiving Day he wrote from the hospital:

“I have so much to be thankful for this year.…I had surgery yesterday, to help my breathing (by removing dead cells that were left over from radiation) and to
biopsy the clavicle growth. Good news on both fronts. I am back to normal breathing! And the tumor close to the clavicle can be treated with radiation! I’m waiting to go home now.” There was no such thing to him as completely bad news.

But then came more tumors, too many now to radiate. A body can stand only so much. “We can shrink them as much as we can with straight chemo,” Joe reported, “but this will not kill them. I don’t know if I have 6 months or 6 years.” That was November 30. He didn’t even have six weeks.

He spent Christmas at home with his family. The chemo now was doing as much harm as the cancer, so the doctors had stopped all of his medications except for those to control pain. If he regained his strength, they said, treatment could always resume. We tried to believe that might really happen. He was lethargic and having convulsions, but just after Christmas he woke up clearheaded and feeling better than he had for days. He smiled at his wife and took her arm, looked in her eyes and said, “When?” Then he fell asleep. It was like in a movie, she later said. He reawoke and his daughters came into the room. They were all laughing together and he was telling them he loved them. He was Joe again. And before they knew it he was gone.

At his memorial service, the minister talked about the mystery of death, the love that cancer can never take away, the power of God to unbind and set free. He told how
Joe had sent him an e-mail the morning before surgery. He said he felt like Commander Adama on the science-fiction series
Battlestar Galactica.
He was going in to remove the invader.

In my collection of old scientific instruments is a device called a
spinthariscope, a name that comes from the Greek word for spark. It looks like a brass eyepiece from an old-fashioned microscope, and on the side is engraved “W. Crookes 1903.” That is the year
William Crookes, the inventor,
unveiled it at a gala held by the
Royal Society. I doubt Crookes made this one—there are a number of
spinthariscopes with the same engraving still floating around on the market. Maybe it was issued as part of some commemorative event. Inside the brass tube a piece of
radium is mounted next to a screen of
zinc sulfide—the phosphorescent chemical that was mixed to make the glowing paint that poisoned the
Radium Girls. As the radium decays it shoots out
alpha particles and they are registered as tiny flashes of light. Each flash is from the disintegration of the nucleus of a single radium atom, and you can watch the show through a lens on the other end of the instrument. The effect is mesmerizing. Crookes compared it to “
a turbulent, luminous sea.” Sometimes when I cannot sleep I pick up the device from the bedstand and watch the random light bursts—these miniature
nuclear explosions. I think about the
randomness of the mutations that cause cancer, and about the fact that I am holding something radioactive so close to my eye. The alpha particles are safely contained inside the instrument, but if I scraped out a speck of radium and swallowed it, I might die. How can life be so robust and yet so delicate?