Dr. Guru calls me at work with the pathology report.  “I just got it,” he stresses.

(So he did read my  blistering email after my first surgery. Then I complained about him not sharing the pathology results until two weeks after he himself received them.)

“Everything completely clear, just as we knew it would be. Margin a bit larger than 2 mm.”

“Good job then, “I say.

Dr. Guru asks if I have decided to fore go chemo and when I say yes, he tells me it would have been of  little or no benefit in my case.

“Why add all those toxins to your body?” .

“Why did you not say so right away? I ask. “You knew I was terrified.”

“I wanted you to make up your own mind,” he says. “Some people will agree to chemo for a one percent better chance of survival.”

This is nonsense. How can a patient, a lay person,  “make up her own mind?” Even someone like me, someone who has cruised the interned “ad nauseam” cannot really decide. A lay person will often misread statistics and project wishful thinking into her readings. This is natural. This is why a doctor will see another doctor when she is sick. A lawyer will not represent himself. You need a professional, someone with experience and perspective.  Preferably a professional with no skin in the game.

But I say nothing

Dr. Guru tells me I may start radiation “any time.” “Your choice of hospital is fine,” he assures me. “Alpha is excellent. Many of my patients go to him.”

(Suddenly, he no longer refers to Dr. Alpha as “that radiation oncologist.”

Dr. Guru sounds upbeat. And I am amused. Now that the icy patches between us have been salted and sanded, everything is on the up and up.

That night, I go to bed relaxed and content.  For the first time since I received my breast cancer diagnosis,  I do not wake up in the middle of the night. Not even briefly.

The sign “Magnolia Cancer Center” does not look as surreal as it has during my previous visits. After all, I do have breast cancer and this center is for me. Although I do not yet have the hollow eyes, the waxy complexion, the bloated body, or the shuffling gate of so many of the other cancer patients I see here. I suppose it is because I have yet to start my treatments.

A large black woman with a gap between her teeth greets me. Her look is that of kindness and concern, but not pity. I must have “new patient” written all over me. Eventually, I ,too, will be ground down by all the chemicals and look like the others: a shadow of former self.

The oncology department’s reception is as spacious as a hotel lobby, and lit by large windows. Someone has obviously dumped a serious amount of capital into this interior. (Although not enough money to allow the purchase of scanners to allow the doctors to email reports to patients.) Yet, the setting is remarkably different from Dr. Weary’s crowded, and a bit shabby, office.

The first person to check me is not Professor Oncology. It is a short, slightly round faced man in a white coat. I assume he is a student at first. Then I notice his  name tag.  He is already a doctor,  a  fellow in oncology, he explains. He seems kind, serious, and gentle. He weighs me in fully dressed and I wish I had kicked off my shoes to reduce my chart by a pound.

Professor Oncology looks Indian and seems too young to be a full Professor and Cancer specialist . Had I met her in a hospital corridor I would have taken her, too,  for a  medical student. Her black straight hair hangs down below her shoulders as does her drab navy skirt which goes inches below her knees and her white coat.  Her face is completely devoid of makeup. Her hands have a pianist’s sinewy, long fingers. Carefully, she feels about my neck, looking for signs of swollen nodes. She feels my breasts, and my armpits. She asks for permission for Dr. Fellow to examine me also.

Dr. Fellow stops with both hands around my neck and looks over at the Professor. He must think that he found something. I tense up, but she shakes her head. I immediately relax as does he.

The professor does not print out an adjuvant online graph like both Dr. Guru and Dr. Weary did. Instead, she  scribbles a few things on the back of a piece of paper. She tells me what I already know: stage 1, node negative, ER/PR + strongly so, HER/2 neg. grade 1 tumor. Like Dr. Weary, she is a bit baffled by my relatively high oncodx score.  It is 23. But she is still convinced that chemo would only improve my odds by 2%.  The professor, more than any of the others, stress the toxicity of chemo therapy: Leukemia, heart problems, bone marrow loss, risk for other infections.

Unlike, Dr. Weary, she does not agonize even a bit about skipping chemo. To my immense relief, she seems to have no doubts. She does not wring her hands, does not stand up only to abruptly sit down.

She draws up a five-year plan for hormone therapy: five years on Tamoxifen.  Or, she suggest,  we can do 21/2 years  and then switch to Arimidex, an aromatase inhibitor. I look aghast. “Oh well, Tamoxifen then,”  she shrugs. She does not ask what I have against Arimidex. She gives me an appointment for two months later when radiation will, supposedly, be over. She does not explain why I can not be on hormone blockers while on radiation. She does not bring up insufficient margins. I do not tell her about Dr. Alpha other than to mention that I will have radiation at a hospital closer to home.

Dr. Weary piles on the good news about his chemo regimen:

“You will not suffer for five months straight. Only for six week-ends. You may have your treatments on Fridays so you can recover over the week-end and be at work by Monday. Maybe by Tuesday.”

“Great.”

“We give you medication to control nausea. You will not feel so hot, but it is bearable. You will be able to function. “

One thing he does not mention is this statistic: a large percentage of women who receive chemo loose their memory, and not insignificant: many can never again experience orgasm. It seems to me that this would be as important to mention as the hair loss, more important since hair grows back. But Dr. Weary does not bring these subjects up. Perhaps he thinks:. Death is the ultimate loss of both joy and memory.

While I am processing the thought of having chemo and  I try not to fall apart before his eyes,  Dr. Weary brings up a new National Study.

“Thousands of women are in it,”  he says as if there were safety in numbers. “Women with oncodx score lower than 11 get hormones only. Everyone with a score between 12 and 24 gets assigned by a computer at random to receive chemo or hormone blocking medication only. Everyone 25 or higher gets chemo. Of course, once you agree, you have to accept what the computer chooses. The decision is not yours,” he says.

My score of 23 is uncomfortably close to those who MUST have chemo. I feel faint. I try to divert his attention from chemo to hormone therapy. Which one would it be? Tamoxifen?

Dr. Weary waves his hand dismissively. No, his hormone blocker of choice is Arimidex. “Much better stuff,”he says

We talk about the study at length. He seems to have all the time in the world, no concern with the “patient time management schedule.” But I am anxiously aware of the clock on the wall behind him.

I hear myself tell Dr. Weary that I feel I ought to participate in the study for the sake of my two daughters. But I am really uncomfortable with the randomness. The Russian roulette aspect of the computer choice. I am terrified of chemo. After a long silence I ask Dr. Weary point blank:

“Would you let your wife take part in the study?”

He stares at his desk for what seems to be an eternity. Finally, he looks up.

“I’d like to think that I would be brave enough to let her do that,” he says softly.

I decide to make it easier for him:

“What about your daughter.”

“Chemo,” he says without the slightest hesitation. He shuffles the papers in my file, reads my score over and over. “I am puzzled by the high oncodx score given the profile of the tumor characteristics in the pathology report,” he tells me.

Eighty percent of my cells are well differentiated, strongly ER and PR positive, not HER/2 positive (25% of women are.) I am stage 1, excellent general health. But something in my tumor put me at intermediate risk for distant recurrence.

Distant recurrence is doctor speak for Stage IV, about which Dr. Susan Love in her breast book writes: “Take care of your affairs in the time you have left.”

“I will support you in whatever you decide,” Dr. Weary says with a sigh. He wrings his hands, stands up, only to abruptly sit down again.

“I don’t know,” he says, almost as if talking to himself more than to me. “This breast cancer thing, you just never know. It has a way of sneaking up on you, of surprising you. I suppose I have over prescribed, but it is so hard to see someone come back. It is so hard.”

Dr. Weary looks tremendously sad as he speaks. And his sadness fills not only the room, but me as well. People have told me about him, how he will come and sit and talk to patients while they are getting their chemo. I think about M. who asked him to keep her alive at stage IV as long as possible so her daughters would be older when they lost her, more able to care for themselves. I can not even begin to imagine the emotional difficulties of Dr. Weary’s job. I also imagine that without chemo, he would not have much of a practice.

“I used to give everyone chemo,” he says. “It was probably overkill, but I did not know it then. My colleague over there,” he points at the wall, towards the office next door. “He has been in this game for 30 years and he gives chemo to everyone.”

I laugh nervously and manage to make some comment about how “I will be sure to avoid him.” We agree that I will also consult the oncologist at the University Medical Clinic.  He does not seem the least offended that I like to have a second opinion. “She is the chemo lady,” he tells me, then, noticing my startled expression, he corrects himself: “No, she is the hormone lady. Well, I don’t know. You will find out.”

“Get a second opinion, then, decide. Some of my patients have gone to her.”  Dr. Weary  seems quite insouciant.

Just as I am about to leave, he asks if I wanted to meet with a radiation oncologist. “Might as well,” he says. “Either you will start radiation right away or in January when chemo is over, so you consult with him now. I will check if he is free.” Dr. Weary picks up his phone and tells the person on the other line that he will be sending over this “very nice lady.”

Dr. Weary’s office is crowded and a bit shabby. His nurse weighs me, takes my blood pressure and draws several vials of blood. The work area is cramped and cluttered. Staff bumps into each other as they reach for needles, gauze, and other paraphernalia. I walk towards my meeting with Dr. Weary himself  through a narrow hallway which is lined with a long row of vinyl chairs. Each is equipped with a rod from which the dreaded chemo bottle will hang (or does chemo come in bags?) I shudder.

Dr. Weary runs late, but quickly pulls his chair up to the desk. He is fiftyish, speaks with a slight Southern drawl. He has kind brown eyes, and smiles easily, but looks a bit tired.

In front of him, on the desk, is a file and a brochure entitled “Shared Decision Making Chart.”  I notice that it has the same adjuvant statistical grahps as  Dr. Guru’s, except these bars are in full color. Dr. Weary’s assessment is different too:  My improved survival with chemo is not one in a hundred, but four in a hundred. I feel my hands start to tremble and get clammy.

“How can that be?” I ask. (I should be delighted that it is four in a hundred not forty, but I am focused on disaster. I am so petrified of the chemo that I have also completely lost sight of its purpose.)

“Well, Guru based his on first generation chemo, ” he says. Now we have a much more effective therapy. We give six rounds, not four, and we give it every three weeks.

“We give cytoxan/adriamyacin/5FOX in six cycles. Your beautiful hair, ” Dr. Weary looks up to glance at my head, “will be gone, of course. With Andriamycin the hair falls out after the first cycle, but it ALL comes back,” he assures me.

I want to joke that the hair is more Van Michael’s than my own, but I am too shocked at the thought of chemo, and I try hard not to get weepy.

I have been so prepared to skip the chemo poisons. But  the issue again looms before me, like some growling, nasty pit bulldog in my path.

The Breast Consultants at Vanderbilt University confirm the previous findings in my pathology report. And Dr. Guru assures me that “he would not do a re-excision on his own wife.”  That does it for me. I cancel the appointment  with the second surgeon, the one set by my sister-in-law.

After all, the second surgeon has not been inside my boob. Dr Guru has.  And I find Dr. Guru’s statement that he would “not redo the surgery on his own wife”  more compelling than anything he could have told me. His wife was my anesthesiologist: attractive, funny, smart, a bit sassy. I believe that Dr. Guru has every reason to want her around.

For the first time in weeks, months really, I begin to relax. I don’t have to delay further treatments. I will have radiation for sure, but I can deal with that. No worries.

I still feel tremendously weary and anxious at the mere thought of chemo therapy though.  But Dr. Guru rolls that stone off  my heart with a few words: “Not much benefit for someone like you,”  he says, and shares with me a chart that shows only a one percent benefit of chemo therapy in my case.

-Why did you not say so right away? I ask him. You know I have been petrified.

-Well, I wanted it to be your decision, he says. Some women will opt for chemo even for a one percent benefit.

In a jiffy, life looks simple and uncomplicated.  No speed bumps ahead.  No re-excision. No chemo therapy. Now that I have dodged that scary chemo bullet, I promise myself to be a good person. I will be more patient, kinder, less judgmental. From this day on forward, I will be a new me to show the whole world my gratitude. Always.

I have an appointment, arranged by my sister-in-law, with Dr. Weary a much respected oncologist whose specialty, it seems, is to keep cancer patients alive long after others would have tossed in the towel. The day after, I have an appointment with another oncologist, at the Medical School, arranged by Dr. Guru’s office. I might as well hear two opinions, have two physicians confirm in unison that all is A-OK.

I am on cloud nine.

Although no cancer cells may have been found in a patient’s lymph nodes during surgery, 20 percent of these “node negative” patients still have cancer cells somewhere outside the breast area. Not surprising perhaps, since once a tumor reaches  1 cm, you have one billion cancer cells, like this one below, in your body.

In the past, oncologists have tended to administer chemo therapy to all patients, not knowing which ones were among those 80 percent not at great risk.  They  know that once your breast cancer spreads to other organs, you become Humpty Dumpty. They cannot put you back together again.  At best, they can  keep you stable.

But now one company, the only one in the world, California based Genomic Health has a way to test cancer tumors to predict distant recurrence. Based on the examination of 21 different genes in a tumor, they come up with a “recurrence score.’  The scale goes from 1, lowest, to 100 ( highest probability that your cancer will spread in the next ten years.)

While I anxiously wait for my OncoDX test results, I pour over probabilities and statistics for my cohort. Given the size of my tumor, 1.5 cm, the mitotic activity report, the nuclear grade, etc, I am guessing my score will not be the lowest. Nineteen maybe?  Twenty? OncoDX score 30 or higher: you should have chemo. OncoDx scores under 18, no chemo.  If I have a score of 19 or 20 ,  would it be “safe” enough to skip it? I  keep telling myself it would be.

My score was 23.  Right smack in the  middle of  the intermediate danger zone. Borderline for chemo.

“Right in the middle of the gray area, “ Dr. Guru tells me on the phone. “Do you want me to fax it?” Well, yes,  but my office is big and faxes have a tendency to go astray. He promises that Joy will fax it right away. I worry as I stroll over to the fax room.

Am I  an idiot for trusting that he will do it “right away?” Maybe his “right away” is the same day, not within five minutes. I do not want anyone else to see my OncoDX  fax.  But as soon as I enter the room, the OncoDx test result rolls out of the fax machine. I make a regular copy and leave, clutching it to my chest. Back at my desk I study the $3800.00 piece of paper more carefully than I would a sales contract for a $500,000.00  IBM server.

I note that Dr. Guru’s office   received the score already two days earlier. Do they not have any idea of the anxiety level of a patient who is trying to figure out if she needs chemo?

My recurrence score of 23 means that in the next 10 years I have a 14 % risk of  metastatic cancer, of becoming Stage IV. I read the words “distant recurrence” over and over. I taste lead in my mouth. The taste of fear.

Does this mean chemo? I feel lightheaded. When will it start? How long will it take? Which toxins will they use?

At home, I pour over chemo books and surf the web to try to figure it out. It looks like my stage will require four rounds. I start to feel resigned to the reality of nausea, aches and vomit; to loosing my hair, my mind, my ability to have an orgasm –yes, that is a possible side effect, possibly even permanent– and to gaining  30 pounds without the pleasure of eating more.

But then I read in Dr. Susan Love’s book:  chemo reduces recurrence to one third, i.e only five percent in my case.  And, most importantly, she states “chemo less effective in post-menopausal women.”

If it is less effective, it must mean there is not much help, not even chemo, for post-menopausal women whose cells have spread. Should I been happy or have a heart attack?.

Dr. Guru’s game plan is simple enough, provided there are no complications revealed by further tests and procedures.

Lumpectomy followed by radiation, followed by five years on Tamoxifen. (I don’t argue with him about  Tamoxifen. I don’t bring up  Astra Zeneca’s conflict as a maker of both cancer drugs and potent carcinogens. )

Dr. Guru looks surprised.

“I thought you would react to having radiation,” he says. He does not mention chemo, but as if he could read my mind he adds:

“At this point I don’t know about chemo. We have to treat even the 80% we know will be OK, because we do not know which 20% are at risk for metastatic cancer.”

I ask Dr. Guru about the spot on my back (he is, after all, a melanoma surgeon.)

“Don’t laugh,” I say. But could this spot on my back be melanoma? My family says they have not seen it before. ” He looks and laughs. “No melanoma.”

Suddenly it feels good only to have breast cancer.

Joy his assistant, is young and plump with a brisk , but accessible, manner. Like Dr. Guru, she deals only with facts, no small talk: surgery tentatively on July 6th “if you don’t need the wire.” She does not explain what the wire is and I, too dazed, don’t ask.  My husband does not ask either. “July 11th if you do need a wire.”

Before surgery I need an MRI. Joy will set it up, but I may have to wait  two weeks for the MRI procedure.

Two weeks? Is this tumor never going to come out? Why is it taking so long? How complicated can it be?

It turns out most of the MRI technicians are males and not allowed to touch a woman’s breast.  I need to wait for a female technician to take care of my procedure. Are they making this up? Who is running the place? The Taliban? But, again, I manage to stifle a cry of protest. After all, why argue with an institution that controls scalpels while you are in twilight?