CHAPTER 1
Living in Prognosis
The Firing Squad of Statistics
After receiving my pathology report and full diagnosis, I found a set of prognostic charts in my burgeoning cancer library. Each listed the survival chances for a variety of subtypes of cancer. The left column specified tumor size (< 1 cm, 2–3 cm, 3–5 cm, > 5 cm), and the horizontal lined up the number of positive lymph nodes. Each box in the chart contained a number, such that the reader could correlate the characteristics of his cancer to the likelihood that he would be around in five, ten, fifteen, and twenty years. Ironically, no matter how hard I stared at it, the table could only mask the very thing I obsessively wanted it to disclose: Would I be in that percentage of people who had a recurrence just two years after treatment or in the 20 percent who would survive for the next twenty?
At my next appointment, I asked Dr. Slideshow the somewhat naive, somewhat urgent question, “What does it mean?” The doctor responded in a way that was both helpful and not helpful, depending on the moment that I recall it: “Exactly what it says.” Banal as a winter day or the color of the ceiling, survival statistics offer a smidgeon of information, but not much to cuddle with.
How could something be at once so transparent (you will live or die) and so pig-headedly confusing (will you live or die)? The prognostic skullduggery reminded me of a short story by Maurice Blanchot, a French philosopher whose life spanned nearly the entire twentieth century. World War II offers the backdrop for “The Instant of My Death,” in which a group of Nazi soldiers remove the French protagonist from his chateau and place him before a firing squad. At just this moment, a distraction in the bushes demands the attention of the German lieutenant. The soldiers disband and scatter, while the main character lives on within an impossible ambivalence. Blanchot writes: “There remained . . . the feeling of lightness that I would not know how to translate. . . . I imagine that this unanalyzable feeling changed what there remained for him of his existence. As if the death outside of him could only henceforth collide with the death in him. ‘I am alive. No, you are dead.’”1 In the instant of his death, or “The Instant of My Death,” two deaths implode, one inside, “I am alive,” and one outside, “No, you are dead.” In the meantime, the integration of the manifestly unnarratable event of one’s own death (no linguistic philosopher would accept the claim “I am dead”) preoccupies his (the soldier’s? Blanchot’s?) posthumous life.
The prognosis epitomizes the haunting character of death that transpired in this eponymous nonexecution.2 An attorney friend of mine, Mary Dunlap, who died in 2003, wrote a book-length manuscript while living with cancer, “Eureka! Everything I Know about Cancer I Learned from My Dog.” Ever the optimist, Mary found hope in her dismal prognosis for pancreatic cancer: a 5 percent survival chance wasn’t nothing. In the last chapter of her book, she handwrites: “On Monday, Maureen [her partner] and I were confronted with the news—predictable to many, but surprising to us—that the cancer discovered in my pancreas has moved into my liver. Today I am an asymptomatic person with an almost invariably deadly cancer.”3
When Mary found that her cancer had spread (had, indeed, been spreading), her health status retroactively shifted. I am alive. No, you are. . . . In one swift motion, the cancer prognosis detonates time, which scatters like so many glass shards.
Having harbored cancer in one’s body all that time before diagnosis, when one thought one was quite well, thank you, mystifies both past and future. One young blogger, who identified herself only as “cancerbaby,” wrote as she was dying of ovarian cancer: “The vernacular drones constantly. And for those who speak it, the talk is loose, as it should be. Rendered mute, you can only listen to the din. It swirls around you, looping endlessly in patterns and figures you can’t quite recognize—a language you once studied, but cannot speak or master.”4 Many, many people I have spoken to who have gone through cancer diagnosis echo this sentiment.
Unable to specify with certainty the behavior of any one particular cancer, oncology relies instead on statistics. Cancer and prognosis form oncology’s double helix. Patients might receive prognoses at a doctor’s visit or look them up in books and charts. Others may not want to know how they line up before the firing squad of statistics. One rarely knows if treatment has ended for good or if a next round with the “palliative” rather than the “cure” box checked on the medical treatment forms will be needed. A prognosis seems like a fact, if only a scrap of flotsom frenziedly bobbing in the rapids of cancer treatment. But its stunning specificity (“34.7%”) shields the bloodlessly vague platitude: in five years, you, yourself, will be either dead or alive. The prognosis purees the I-alive-you-dead person with the fundamental unknownness of cancer and gloops it into the general form of the aggregate. The individual cookie cut from the dough is both prognostic subject and cancer object.5
Living in prognosis severs the idea of a timeline and all the usual ways we orient ourselves in time: age, generation, and stage in the assumed lifespan. If you are going to die at forty, shouldn’t you be able to get the senior discount at the movies when you’re thirty-five? Does the senior’s discount reward a long life, or proximity to death?
Sometimes comfort lies in data. Taking numbers at face value, prognosis offers mortality odds, odds that one can potentially beat. Other times, when data feel vacant, literature provides a different sort of clue about the mysteries of living outside of normal time. Data and narrative each have their place, though neither ever really assuages the stupefaction of living in prognosis.
VANQUISHED ODDS
At my first week-long cancer retreat, I gazed at the other seven participants. Lisa (all names changed), about my age, with a two-year-old daughter at home: breast cancer. Kai, from Montreal: leukemia. Sharon, from Ottawa, worked for Canada Health: breast cancer. Then there was Tina, a nurse: oral cancer. Alice, mother of a twelve-year-old, had ovarian cancer and was about to start her third course of treatment. Beth had received a high-dose bone marrow transplant a decade prior in Montreal and had been ill ever since. Kate, an English educator twenty-five years older than me, was diagnosed the same day as me but with metastatic disease.
I coped throughout the week by indulging in a compulsive, downright sick guessing game of “who’ll die first?” Unlike my father, who at weddings delights in predicting out loud how long a marriage will last, I told no one of my hunch—which, as it turned out, was right. It seemed as though the bearing out of my wretched little assessment made these women’s excruciating deaths more reasonable, if not fair. Rationalization offers one of the few explanatory tools we have to account for death.
Perhaps I can attribute, even justify, my own window of survival to the treatment, my vegetarian diet, my good constitution, the surgeon’s skill, or possibly even my kindly nature and goodwill. Many explanations and secret theories belie objective measurement. Some breast cancer survivors credited the Halsted radical mastectomy long after most surgeons abandoned the procedure in favor of less invasive surgeries. Who knows? Just because it was overall less likely to work than other treatments doesn’t mitigate the fact that it may have saved some who would have died with the alternative surgery.
We assume survival—until we don’t. You don’t really think about it until you are called into the position of survivorship (by age, illness, anxiety, prognosis), until you are asked in some way to inhabit the category, to live amid those who are not, in fact, surviving. I know the muted exhilaration of the survivor. Each morning that I wake up not dead or sick, I’m happy and miserable at the same time: Pleased to be waking up at all. Blissed out to have landed on the vitality side of that prognosis. Repentent about my good cheer as my mind wanders to the three people from my support group currently dying. It’s not quite that one’s own survivorship