TRIUMPHANT | Joy Liu
Jeremy, when we first met, I had just completed a research fellowship and I was going to use my power to blast your cancer into oblivion. The night before your intake appointment, my interest in you blossomed as I read about your tumor’s genetic profile, which had outfoxed several rounds of chemo and radiation. You were only forty-nine years old when you were diagnosed—young for this kind of cancer, but still twenty years older than me.
I had plans for you. I was going to bring you back from the edge of Hospice and you were going to spread the good word of Dr. Tan around Boston. I hummed around my unopened cardboard boxes in the living room, stopped every now and then to sip more wine while waltzing to the applause of my future packed auditoriums of hopeful mentees and wannabes, while you nodded approvingly from the front row, a living testament to my mastery of renal cell carcinoma.
You showed up to your appointment half an hour late, and when I came into the room, the cigarette smog made my nostrils clench. Your girlfriend was with you then—she still came to your appointments then—and I introduced myself.
You said, So you’re Dr. Tan. They’re letting kids straight out of high school become doctors now, huh? (I had that same thought recently when I met my new primary care doctor, a resident at my hospital. They look younger and younger every year.)
Don’t be rude, Linda said. I think you would have done better if she stayed, but back then, no one knew that one day she would tell you that she couldn’t take it anymore and she was moving back in with her mom. When you realized she had even taken her favorite photo of you, the one of you two at Niagara Falls in the beaded silver frame, you bellowed and sobbed in my clinic and Melissa had to move you to a different room and call our crisis social worker. No one could have known.
I look young for my age, I said. But I’ve seen a lot. I examined you, putting my stethoscope over your thumping heart and dulled lungs, apologizing as my cold fingers kneaded into your belly and your back to see just how much you winced.
While I slathered on hand sanitizer, we talked. I said, I can tell you that you don’t have a lot of options left. We can repeat treatments you’ve been through already, but I’m not too optimistic.
You asked me the most important question, the one I dread: How much time do I have left?
Months, I said, the word hailing down from my mouth like a missive from the mountain. It doesn’t look good when it’s in the lungs and bone and chemo-resistant.
You were stoic, always were, and rolled your eyes at Linda when she gasped and tears gathered. You asked the follow up question: What should I do next?
I’m running a clinical trial for a new drug called belukimumab, I said. You should think about it, Jeremy. The current treatment options are okay but not great. You could help science. You could help other people like you.
I don’t care about science as much as myself, you said, but you called me a few days later and asked how to sign up. I told you that you’d have to be randomized to one of two options: belukimumab, or the current standard of care. You got mad. You said that I’d promised you something new; I said my hands were tied, that’s how science works. You grumbled something about a government conspiracy but consented.
We’re going to beat this, I told you. Let’s play to win.
I knew I picked the right doc, he said.
Melissa told me you and Linda showed up to your first infusion appointment with chocolates for the staff. You continued to call it your “wonder drug” over the next few months, as you had to call out sick again and again until management said, next time don’t come back, Linda harped on you to give up your cigs and harped on you when she left for the last time, and you bought oxycodone from your neighbor to slow down what was happening to your body, and what was happening to you.
I only saw you for a few minutes each time while Melissa got you set up. If you’re having a lot of symptoms, that’s a sign that the medication is probably working, I told you. The red acne that roared across your skin, the knives that stabbed your throat when you swallowed, the crippling back pain, the memory lapses and endless nights: onward and upward!
I didn’t realize how callous it sounded as I checked my watch, left you with the check-out sheet and moved on to the next appointment. I wasn’t sleeping well myself back then. I thought it would be more glamorous than the smell of plastic and sick and too much brightness, going home to another bowl of leftovers and a wilting orchid named Fred. That year, I was sensitive and lonely, and was pretty sure that I had made the wrong decision but it was too late now and I would stick it out and become a spinster as a result. I told my mom that I had someone in my life, casual, but I was hopeful. How’s Fred doing? my mom would ask, and I would tell her, we’re good.
I didn’t know that in a few extraordinary years, I would marry the man of my dreams, I would give birth to our daughter, and that less than ten years after that, he would leave me for another woman less accomplished but more nurturing than me. No one could have known.
When I first saw the images from your CAT scan, I was disappointed that you were the second person in the experimental group who had progressed. The applause from my auditoriums of admirers faded as I scrolled through the shades of gray and white, looking at your moth-eaten bones. Your lungs lit up like stars with the failure of belukimumab, like the glow-in-the-dark stickers in my daughter’s bedroom.
I brought you back to review the images. I think you had shaved and dressed up in a leather jacket. I showed you the new white nodules in your lungs. But these are smaller! I added. You slammed your fist down on the table, and I jumped in my seat.
What have I been wasting my time on if the drug isn’t working?
The results are equivocal.
What the hell does that mean?
Some of the lesions have gotten better, and some have gotten worse. It doesn’t mean it’s not working.
It was like trying to smooth down porcupine needles. When you raised your voice, I was afraid the other patients would hear. I don’t have time, doc. I’m not going to throw away what’s left on someone else’s rainbow.
It’s experimental. We don’t know yet. Please, give me some more time. If in a few months, it’s still not getting better, then we’ll talk.
You showed me the inflamed rash on your chest. You pointed at your back and gripped your belly. You said, this is not me. This is not what I want to become.
I get it, I said.
I don’t think you do, you said.
I looked you in the eye and said, I believe that it will work with all of my heart. Believe me, Jeremy. I just need you to hold on for a while longer, and I bet we’ll see this cancer shrunk down in another three months.
It was a shameless gamble. The air stopped moving as you weighed my clinical trial in your mind. You said, you really believe it will?
You looked down and exhaled tobacco-tinged breath. If there’s a chance I can beat this thing, I want to take it.
I touched the top of your rough, dry hand and smiled.
You said, I wish Linda were here.
I stalked you through the medical notes that built up in your online profile over the next three months. Hospitalization #1 was for dehydration, #2 was for fever, #3 was for back pain, and #4 was for low potassium.
I made a note of that last one. Would I have to flag it as a potential side effect of belukimumab? That was going to make approval that much harder. I slogged through the other dozens of participants at our hospital, and held conference calls with my collaborators at other hospitals. I met with a few of them at a bar during a national meeting in New Orleans. They, too, were holding out hope, but not enthusiastic. We’re going to get marginal returns on this. You can’t put all your eggs in one basket, they told me. It’s time to start thinking about what you want to work on next.
It was at that bar that I met my future ex-husband, but back then, he was simply the charming researcher. We had worked at the same hospital for months, but as he told me later, he was too nervous to approach me, because he was sure that I was already taken. Three drinks later, the bar was closing down, and we were staying at the same hotel, so we went back to his room. We ordered room service the next morning. It was my first time ever ordering room service. I had a lot of firsts with him: first conference romance, first trip to Italy, first winery tasting, first child, first broken plate during a fight, first media interview for one of our trials, first divorce. But while we ate our parfaits and sipped coffee while skipping the early morning sessions, all I could think of was how disappointed you were going to be if my collaborators were right.
Each time you were hospitalized, I stopped in for a quick visit, and you said, Are we still winning?
I crossed my fingers and told you we had to wait to see the results of the next CAT scan. You responded by crossing your fingers, too.
During hospitalization #4, you said that you appreciated my sticking by your side. Your parents were dead and you had no siblings, no children, and since Linda left, there hadn’t really been anyone. You asked me if I would be your emergency contact.
I said I didn’t know if that was a good idea.
You said that you were scared. You didn’t know who would be there for you. I would remember the look in your eyes, your bruised arms sticking out of the blankets, and the bleached air of the hospital room as my lawyer drew up divorce papers with my husband’s lawyer and we sat across the table, staring at each other like we hadn’t loved each other for seven years before he decided he needed more out of life than what we had. Isn’t this all there is to life, just us, and how we take care of each other, I wanted to ask. I didn’t understand why I wasn’t enough. It took me a while to realize that it wasn’t about me.
In short, the second CAT scan was not what you and I needed. You didn’t get angry like the first time. You nodded, as if someone had already told you and I was repeating. This time, you had not bothered to shave and your breath was fetid, but for once, it didn’t smell like cigs. Linda would have been satisfied.
I talked about how I thought you had stuck it out with the experimental drug, but now you should be transitioned to traditional therapy. (Was saying that you hadn’t tolerated it well an affront to your manhood?) I started typing notes for myself and ordered the tests. We’ll get some blood tests and start chemo next week, I said. I’m thinking it’ll be three to four rounds depending on how you respond.
One round is all it takes, you said.
I get the joke now.
I didn’t know that just a couple of weeks before, you had purchased a gun and put it on your nightstand, and that you sometimes held it like a new baby before you went to bed. When I’m driving to work, when I’m sitting in a meeting with the Hospice director, when I’m kissing my daughter goodnight, I still wonder, if I had asked, would you have told me?
Melissa gave me the news on a bright, wintry morning when I was still changing out of my boots. I was caught with one shoe on and the other leg midair.
Jeremy, you broke my heart.
For a while, I wished that you had just taken the extra morphine I prescribed. I thought it would be more dignified for you to exit like some languid Ophelia as opposed to having your brains power washed from your bathroom tiles. Then, I thought you were an idiot, because you had other options, options we didn’t have time to talk about, that involved you getting your hair combed every morning and evening, eating whatever food you wanted, and getting visitors who wanted to talk to you about your life. How could you have refused that?
About six months after you killed yourself, after my broken, jagged memories of you had settled, you rose to the surface with a vengeance, as if you sensed that I was forgetting about you. I cried over old couples who held hands during their appointments. I cried over children who quit their jobs to move back in with their parents who were undergoing treatment at our hospital. I cried so much my boyfriend, the man who I would later see in a photo with a tanned brunette in Napa after our settlement, suggested I take another research year and work from home. He didn’t get it.
Belukimumab gave us a statistically significant, practically insignificant, improvement in mortality. On average, it extended life by two months. When I was doing data analysis, I had to count the number of patients who didn’t complete the trial. Triumph doesn’t come without sacrifice.
We published the data in a big-name journal. I got comments from readers across the country, across the world. They thought it was interesting, and showed promise. They praised me for the magnitude of the work given how young I was (straight out of high school). They asked me what I was going to work on next.
I think I’m going to do something on depression and suicide in cancer patients, I said.
Soft studies don’t publish well, they said.
There’s nothing soft about putting a gun to your head and pulling the trigger, I said.
I met lots of people who were close to doing what you did. They agreed to talk to me because they thought I was going to prescribe them lethal doses of morphine or teach them how to kill themselves.
Instead, I talked about you, Jeremy. They wanted to know all about you. And after I talked, they told me things that they hadn’t told anyone else, about the dark shapes that swam below the surface, about the gray dread that could not be named that was getting closer, the feeling of standing on a pinnacle without a bridge to anywhere.
We published a set of screening guidelines for suicide risk in cancer patients. We looked at attitudes and barriers towards enrolling in Hospice. I designed studies to look specifically at the psychology of patients enrolled in clinical trials and measured their outcomes. We looked at factors associated with better outcomes and coached our patients to take on the behaviors that would enable them to thrive, even if the cancer claimed their bodies.
I mentioned you in an acceptance speech for an award recently. I left a seat open for you in the front row, and I like to think that you showed up. I think you would have been bashful, but secretly pleased. I don’t think you’ve forgiven me yet, and that’s okay. When we first met twenty years ago, Jeremy, I believed that we were going to win. I think that we have.
Joy Liu is an internal medicine resident in Boston, MA. Her interests include speculative fiction, the history of medicine, and health advocacy. She has self-published one novel (so far), Watermark, available in the Amazon Kindle store. She maintains a technical medical blog called "The Friendly Intern," and recently retired a reflective blog called "Pathos and Pathology." She plans to write both facts and fiction in the future.