The Cancer Finishing School

1. False start

‘Make sure you write the end first,’ Alan, one of my cancer patients, suggests when I tell him I plan to write the story of my own illness.

We laugh a little too loudly at the notion. If only a fairytale ending could be tacked onto any story, real-life as well as make-believe, and make it come true.

‘That would take away the suspense,’ I say. ‘Every good story needs an element of suspense.’

We share wry smiles rather than nervous laughter this time, born of our separate experiences. A cancer story is nothing if not a suspense story. Or, more accurately, a mix of suspense and mystery. Over the past forty years I’ve accompanied hundreds of patients on at least part of the journey to their endings, whether follow­ing from a clinical distance or holding their hands, literally as well as metaphorically. Yes, I still hold my patients’ hands at times, hug them and occasionally even kiss them, if only on the cheek. Physical affection is an evidence-based natural therapy, with few side effects – although the wrong dose tends to end up before the Medical Board.

Sometimes their cancer journeys have been sad short stories, sometimes decade-long epics, but in recent years, with the advent of the so-called novel chemotherapy drugs, happy endings have become more common, at least by the medical definition of a cure as not so much happy-ever-after as not-unhappy-five-years-after treatment.

Whichever way they end, and whatever the five-year survival rate, one thing these different stories have in common, besides the obvious pain and suffering, is suspense. Paradoxically, the exact opposite of suspense, boredom, is also a common thread: waiting-room boredom, all night insomnia boredom, the boredom of lethargy, listlessness and depression. But even when they – we? Surely not – lie becalmed in the doldrums, an undercurrent of suspense laps at the frail craft of the mind. Most cancer stories are serial dramas, serial edge-of-the-seat cliffhangers, especially on the eve of Results Day, or of Staging Day.

‘What stage is it?’ my patients, thoroughly briefed now by Dr Google, often ask about their own illnesses. Lately they’ve been asking the same question of mine.

‘You mean what stage am I on?’ I sometimes joke. ‘The next one out of town?’

Jokes are another useful alternative therapy, if not yet subsidised by Medicare, and, like hugs and kisses, not always appropriate.

‘Not funny, Dr Pete,’ the usually playful Barbra, a Greek matri­arch who long ago decided to adopt me as an occasional, informal grandson, lectures me. ‘You need to take your cancer seriously.’

‘Must I? If I ignore it, it might go away.’

My foster yiayia remains unamused. ‘If you won’t think of yourself, think of me. I need you to see me out.’

‘I don’t think I can guarantee that, Barb. You’re indestructible.’

This, at least, at last, cracks a crooked smile across her face. Like the other matriarchs in my extended family of yiayiades, she takes a grandmotherly interest in my nourishment. She reaches into her bag for the usual afternoon tea offering. Today it’s sweet almond short­cakes, kourabiedes, thickly dusted with icing sugar. I bite into one immediately, with gusto, a small explosion of crumbs and powder, a bit of deliberately clumsy theatre that also amuses her.

As for longer term happy endings, and whether I see her out or she me, I don’t add that the best guess for most of us, cancer-staged or not, is a mystery destination somewhere between the short trip to the Dodge City graveyard and the long, if bouncy, slow coach to old age. My mouth is too full for that. cautionary tales5

2. It

When patients ask about their own illness, the unfunny facts must always come first. Has it, they need to know, spread? Is it growing? Shrinking? In remission?

It.

The growth.

The mass. The tumour.

The neoplasm, a typically obscure medical code. The ‘mitotic lesion’, even more so.

The ‘long illness’ that is the default code of obituary columns.

Jack Dancer. The big C. The carcinoma. The (coined here, just now) mystery-destination stage.

The malignancy.

This last blunt word, at least, pulls no euphemistic punches. What’s the opposite of a euphemism? The plain, no bullshit – if hard to speak at times, especially to ourselves – truth? Which is precisely why the most truthful of all such words, two simple syllables, taken from the Latin word for crab (itself a translation from the Greek of Hippocrates, carcinos, from which, more directly, carcinoma) is the hardest of all to speak.

3. Cancer

Once the word is spoken, and thereby admitted, its most troublesome mystery must also be confronted: why?

Less why it, first-up, than why me?

Our restless brains don’t cope well with a dangling ‘why?’. They’ve been programmed by six million years of evolution to find patterns, attach causes to effects, impose narrative arcs. Worry is the brain’s default search engine, anxiety its highest-octane fuel; like some hardwired chess program it must forensically trace every possible move, every pathway in the search-tree to find a solution.

And what bigger worry than death? Or cancer, its master appren­tice, which in the back of our minds, where euphemism hath no power, is still a synonym for death.

It’s worth remembering there were, and are, no natural deaths in hunter-gatherer societies, not even from old age. Something or someone was always to blame: gods, ghosts, sorcerers, evil eyes, hidden hands, plus, of course, any useful human scapegoat that came to hand. Nothing changed when we came in from the ice-age cold and began living in cities: read almost any god-haunted page in Homer, the Bible, the Aztec or Mayan codices, the Sanskrit epics.

There are exceptions, such as the second millennium bc Edwin Smith Papyrus, a collection of carefully forensic medical case studies, sometimes attributed to the earlier Egyptian thinker Imhotep. But the exception proves the rule; even the famed Diagnostic Handbook of the Babylonian sage Esagil-kin-apli, set down on cuneiform tablets many centuries later, while scrupulously observant of physical symptoms, was primarily intent on exorcis­ing their supernatural causes. His diagnoses also included any omens that a physician (read exorcist) might encounter en route to a house call in ancient Babylon. My favourite: if a piebald pig crosses your path your patient has dropsy. The pre-Enlightenment Europe of exorcisms, witch burnings and trials by ordeal wasn’t much different.

Are we, today? Magical thinking is always lying low, biding its time in each of us – even the most outwardly irreligious. I flipped from zealous Methodism into zealous atheism at age thirteen, almost overnight, and have believed ever since that irreverence is the Eleventh and most important Commandment. Well, love thy neighbour as thyself and irreverence. But there are no atheists in foxholes, as army chaplains have long understood, and I proved cautionary tales to be no exception when, twenty years ago, I prayed, overcome by dread and helplessness, for the life of my son.

Daniel was in the foxhole, not me: critically ill in an intensive care unit in London, bleeding into his chest cavity and not expected to survive the night. His dodgy lungs were inherited from me – mine had likewise beached me in intensive care for a month aged nineteen – but his haemorrhaging was far worse, complicated by a bleeding disorder inherited from his mother.

Why Daniel? Why this particular ‘It’? Because his parents were to blame? We might have innocently inherited the same problems from our parents, but guilt, however irrational, was inescapable. His future wife Mutale and her parents were at his side; the genetic culprits, Helen and I, were a twenty-four-hour flight away, powerless.

Of course I prayed, for the first and only time in my adult life. I did not and do not believe that prayer can affect the material world, at least outside the rubbery material inside our skulls. Later I told myself that my prayer was a version of Pascal’s tongue-in-cheek deathbed wager – with nothing to lose, and everything to gain, why not pray? – but that wasn’t in the least bit true. It was nothing more or less than its own urgent, deadly serious self, a prayer that was forced out of me, vomited out by the pressure of powerlessness, along with the tears that accompanied it.

Please, God, save him. Please.

Religion is the opiate of the people, Karl Marx famously wrote, but the rest of the quote is usually forgotten. Religion is also ‘the sigh of the oppressed creature’; the sigh of the powerless, in short. Something produced under pressure from within, not merely taken, like a narcotic. Labelling such primal urges as superstition doesn’t make them go away, just hibernate, waiting to sprout fresh shoots: they are a very thick and very ancient branch of the forensic search-tree. How could they not be? Oppressors and oppressed alike are powerless in the face of death, against which religion was once the 8

only palliative. Without finding answers, we are helpless. Without cause there can be no cure, whether it be prayer, penance, venge­ance, blood sacrifice, magic potions or that great fulcrum of so many ancient suspense narratives, magic weapons.

In short, if we can’t find a cause, we’ll invent one. We need to invent one; we can’t help ourselves. Daniel survived, as I had, decades before, due to the semi-magical weapons of the thoracic surgeons. Prayer had nothing to do with it. But even as I laughed the impulse off, my guilt persisted, dumbly, a kind of spell itself, a black magic that couldn’t be shaken free, especially in the small, dark hours.

Guilt often feels like that to me, a tune I can’t get out of my head, less an earworm than a conscience worm, and less a penance granting release than an extra punishment, endlessly repeated without getting anywhere.

4. Crime and Punishment

Clara, another eighty-something widow, looks distraught as she walks into my consulting room one hot summer afternoon. She sits, shifting uneasily in her chair, unable to meet my eye – always an alarm bell. When I ask what’s wrong she raises the hem of her skirt a few inches and stretches out two swollen ankles, keeping her face averted as if unable to bear the sight of them.

A hoarse whisper: ‘It happened so suddenly.’

I haven’t seen her so troubled since her husband Bert died ten years before, a month after they moved into a retirement village. I examine the offending body parts: pitting oedema, so-called because a thumb pressed into the skin leaves little pits that take time to refill.

‘What is it, Peter?’

Puzzled as much by her agitation as the swelling, I examine her more fully. No signs of heart failure or fluid retention elsewhere in the body.

‘It’s nothing serious,’ I reassure her. ‘I need to do some tests, but it’s probably just a combination of the heat and varicose veins – and gravity.’

She isn’t listening. ‘There’s a new man at the village,’ she interrupts. ‘A widower. Nice enough, but very flirtatious. The hand-kisser type. I would invite him in for coffee once a week, but he kept pestering me for, well, more.’

‘He won’t take no for an answer?’

She meets my eyes for the first time, beseechingly. ‘I loved my Bert very much, Peter. You know that. I had always been faithful to his memory.’

Had? My ears prick up. ‘Of course,’ I say, and wait to hear the real reason for her anguish.

Her eyes are all over the place again. A deep breath, ‘I, um, gave in to him the other night,’ she finally gets out, again in a whisper.

I take her hand. ‘From what I remember of Bert,’ I suggest, ‘he wouldn’t have wanted you to be a nun.’

This also goes unheard. ‘I’ll never do it again. I’m so disappointed in myself.’

Her eyes fill with tears as she stares down at the bloated ankles. ‘I woke up the next morning with . . . this.’

For a moment I’m not sure where this is going.

‘Could the swelling be, well, you know – his, um, discharge?’

I try to hide my astonishment. ‘His semen?’

A slight shudder answers the question. I need to convince her otherwise, but don’t trust my facial muscles. I try to frown them into submission. The last thing she needs is any sign of incredulity, or worse, amusement. My turn to avoid eye contact. Head bent over her ankles, I test their range of movement thoroughly, a clinically point­less exercise that at least buys me a little thinking time.

‘No evidence of seminal fluid,’ I finally pronounce, trying to sound technical. ‘Ejaculate is also not that voluminous.’ 

I don’t add the stray thought on the tip of my tongue: in my bathtub experience it floats, not sinks.

‘How can you be so sure? Can’t you get rid of it? Aspirate it, or something?’ A pause. ‘I don’t want it there. It keeps reminding me.’

Another stray, farcical thought: is she worried – surely not! – that her ankles might be pregnant? Absurd, but is an ectopic pregnancy in a foot any more unlikely than a sperm bank? I lead her into the other consulting room, help her up onto the examination bench, place a cushion under her feet for elevation, give her a magazine to read and ask Vicki to bring a cuppa.

Half a dozen patients later, I poke my head in to find the swelling has vanished, if only temporarily. She seems reassured, but as I help her down, she immediately finds another outlet for her anxiety.

‘I’ve been lying here worrying, Peter. This is all between us, of course.’

‘Of course,’ I lie, or at least fib, because the story is too good not to share in some more universalised, anonymously fictionalised parable of guilt.

‘If it’s not semen, could it be, um . . .’

I wait for the usual underlying It, the dreaded C-word, but once again she surprises me.

‘He’s rather too popular with the other ladies. You don’t think I could have, um, caught something?’

I assure her otherwise, but she is not convinced, and this explana­tion being a slightly less implausible displacement of her guilt, and more easily disproved, I decide to run with it. I take bloods, swabs, request a urine sample and make a booking to see her in a week’s time. It’s going to take a lot more persuasion, a lot of reinforcement and some useful take-home hard-copy evidence.

Confessing her sin at least seems to have helped; she is calmer as she leaves my big, brightly lit booth. I know she hasn’t been to Mass since Bert’s death. I raise the possibility; she declines.

I offer my own dubious absolution: ‘Bert would have wanted you to be happy, Clara.’

She offers in return a wan smile and a promise to ring earlier than our appointment if she is struggling, emotionally. Otherwise, another session in the confessional next week.

I sit there in a slightly dazed trance after she leaves. Of course, the jokes crowd into my head, boisterously, cruelly, if only for relief – Congratulations, it’s twins! – but her pain is real, and each time I make myself smirk I feel my own twinge of guilt, although not, I remind myself, as much as she does, and only briefly, mine being more of a business-class guilt-trip, if truth be told.