Something in Dr. R’s message does not add up. First I have an old pneumonia scar. Then it is radiation damage on the left lung lobe. But I had my right side radiated.  If anyone could solve this mystery, it would be my radiation oncologist, Dr. Alpha.

I call Dr. Alpha’s number, fully expecting to get his voice mail, but he picks up on the first ring.

No, he never took any x-rays of me, but I had a CAT scan before I started radiation. (How could I possibly have forgotten that?) He will look at it and call me back.

In less than an hour, Dr. Alpha is back on the phone. He has compared my  CAT scan from five months ago with the new one. The 8 mm granuloma on my lower left lobe does not worry him. It was there before I started radiation and has not changed at all.

“More worrisome,” Dr. Alpha tells me, “is the growth on the lymph node just below your heart.”

I try to steady my voice so it will not quiver. All my bluster and bravado from my days of radiation have  evaporated. I hear how meek and scared I sound. He must have heard it too.

“They never told me anything about a growth under my heart.”

“No, they wouldn’t. They try not to give you all the information. You want to come down and see?” offers Dr. Alpha. “I will show it to you and explain.”

I want to take him up on the offer and drive down and see for myself. But I also do not want to crash into his busy schedule. What do I know about x-ray images anyway? I did not even know you had lymph nodes under your heart. I will have to take Dr. Alpha on his word.

“You definitely need a PET scan,” Dr. Alpha says. “This needs to be fully investigated. I will schedule one for you.”

“But I have one scheduled for tomorrow at 1 PM. I guess I have to go ahead then?”

“Yes, you do. I will read it and get back to you as soon as it is done,” said Dr. Alpha.

I feel doomed. Dr. Alpha’s words – this definitely needs to be investigated – throb in my ears. “Investigated,” has a serious ring to it, like a grand jury inquiry or Senate investigation. And, yet, the idea that Dr. Alpha will get to read my PET scan calms me and reassures me. I know he will level with me no matter what the outcome.

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.

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?.