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.

My cell phone rings at 7.42 AM. I am already at work.

“Just left you a message at home,” my internist says. “Ignore that one. Just want to tell you the CAT scan was inconclusive. It is nothing to worry about,” he said.” But one should also not ignore it. You understand what I mean? The radiologist being hyper careful and all.”

My internist is setting up a PET scan. He had talked to my oncologist, Dr. Weary “who is on board.”

As soon as I get off the phone with my internist, his  office calls. They need my new insurance information, the PET scan has to be approved before my appointment on Tuesday at 1 PM. “Eat nothing for four hours prior!” I am told.

At home, I go straight to the phone to listen to the message Dr. R. left before he called my cell, the message he told me to ignore and erase.  Like I could.

“R. here. “ (How much training did he have to be able to deliver bad news in a non-threatening, authoritative fashion?) “Looking at the report of the CAT scan, talked to your oncologist and he is on board with what we’re doing.  My radiologist, being super hyper vigilant and obsessive wants us to follow up with a PET scan, don’t know if you ever had one. He spelled it out in a loud, firm voice: P-E-T scan, we want to make sure there is no metabolic activity. (Nicely put, Dr. R., much better than to say we’re checking to see if you have cancer cells that are growing out of control.) “I talked to Weary,” he continued, ” and we really think the little changes in your lung could be the result of radiation.”

Interesting. The “area of concern” is in my lower left lung. I had radiation in my right breast. Besides, aren’t the lungs in your back?

“Dr. Weary has looked at this and is not highly worried,” R. continued, “but agrees that if the radiologist wants this done then we should go ahead and do it. So we will follow up with a PET scan, P-E-T, very similar to the CAT scan but measures metabolic activity, don’t think you have had a PET scan before. It will show if there is any activity in the scarring area which would make it more likely to be a tumor. I hate to leave a voice mail, but I wanted to follow up since the CAT scan was done a few days ago. Jonathan will call and set a time.”

A PET Scan stands for Positron Emission Tomography and it is pretty much only used to check for “abnormal cell activity.” The reason they said that my CAT scan was “inconclusive” must have meant that by just looking they could not tell if my granuloma was benign or malignant.  They had checked the size: small is good but not absolute proof. They had looked at the edges and obviously could not tell for sure if they were smooth or spiculated (smooth is better.) They checked the density: calcified or not?(calcified is better.) They were clueless.  I still needed a PET scan.

I felt like throwing up as I listened to his message over and over again.

My new internist calls unexpectedly at 10.30 AM to give me feed back from my routine check up from three weeks ago. He is back from vacation and has just sorted through his pile of paperwork.

My blood count looks great. My cholesterol is 208, but only because I have 108 of good cholesterol, so nothing to give another thought. However, the routine x-ray showed a lesion – a granuloma he calls it - on the left lower lung lobe. It is only 8 mm.  Sounds insignificant to me because on the phone with the doctor I am unable to process that 8 mm is almost 1 cm which translates to almost half an inch. And I have no idea what a granuloma is although it sounds a bit more sinister than “lesion.”

“This is most likely,”  my doctor says — and his tone is authoritative and upbeat –  “a scar from old pneumonia.”  Since I had had pneumonia numerous times as a child, I eagerly grasp his straw.

Then my internist asks if I have had any other x-rays in the past year?

“No, I can not recall any chest x-rays.”

“Well,   then I will order a CAT scan, just because my radiologist is so obsessive compulsive.”

I do not blink. I am even cheerful because I know that, what ever is on my lung must come from my old pneumonia.  The word metastasis does not even enter my conscious,  I ask:

“What if it is not from pneumonia? What then?”

“Then you have to see a pulmonary specialist,” he says. “But it is too early for what ifs.”

He hangs up.

His abrupt tone and unwillingness to speculate makes me realize that the lesion could be breast cancer that has spread to the lung.

I look up granuloma on a pulmonary web site:   www.pulmonologychannel.com/spn/types

About 60% are of granulomas are benign,  most are the result of an inflammatory, immune system reaction. It could be pneumonia, tuberculosis, fungus. The other 40% of granulomas, or solitary pulmonary nodule as they are referred to (SPNs) are malignant, three-quarters of which are primary lung cancers, and one-quarter of which are metastases from other parts of the body.

First my blood trains. But  I feel fine, great in fact. I don’t cough. I am not tired.  I immediately push the unthinkable thought away. It has to be a scar from my childhood pneumonia.

Once more I have failed to pick up on this important clue: nurses, assistant, and post cards deliver good news. Doctors deal with the scary stuff.

A new vaccine against breast cancer has shown promising results during trials, according to the Karolinska Institute in Stockholm, Sweden. The results of the study was published in the journal Oncogene in May.

For breast cancer cells to proliferate they need to stimulate blood flow by forming of new veins to carry that blood.  But if you block the protein Delta-like ligand 4 (DLL4) you can create new – but useless – veins.  This slows down the tumor’s growth and may prevent breast cancer recurrence following surgery, according to Dr. Kristian Pietras who lead the study, since the tumor, despite new veins, does not receive the nourishment from an increased blood supply.

The animal experiments also showed that the vaccine had no serious side effects and that wounds still healed well.

After my farewell to the radiation oncology department, I take the elevator up to the lobby and meander through the hospital complex to meet with Dr. Weary, my oncologist. (My heart feels heavy because Dr. Alpha is no longer my guardian angel and in my purse I have reams of computer print outs about the side effects of Arimidex, Dr. Weary’s drug of choice.)

Dr. Weary is late. I study my computer print outs for more than an hour, sitting alone in the small exam room. I feel clammy and light headed as I read other women, my cancer sisters, enumerate the side effects of Arimidex:  joint pain, bone pain, loss of concentration and memory, dizziness and insomia, hot flashes, nausea, hair loss, aging skin, vaginal dryness, trigger finger, loose joints,  anxiety,  leg cramping and  fuzzy brain. One woman writes: I hobble out of bed like a 90-year old, I will quit taking this pill. I’d rather die than live like this.

I  am about to fall off my stool and faint when Dr. Weary finally appears. He looks, well, weary. He apologizes profusely about letting me wait so long. But in the middle of his “I- am- so- sorries,”  his cell phone rings. He sighs. At first he looks like he plans to ignore it then glances and the number and answers. It is clear to me, it is another physician calling. And it is clear to me it is about a serious matter. “Go ahead, don’t worry,” I tell Dr. Weary has he excuses himself and leaves to continue the call out of my ear shot.

When he returns, I waste no time. I hand him the two-inch thick ream of Arimidex complaints. And just so he won’t have to read all the pages, I verbally high light the awful side-effects. Dr. Weary sighs again. He reaches out and takes the pages out of my hand, but instead of reading them, he dumps them in his waste basket with a thud, sits down and stares me straight into the eye: “You read too much,”  he says calmly.  “The only women who will go on  the internet are those who have complaints. For every woman you have read about, there are a thousand with no complaints.”

Dr. Weary scribbles my dreaded Arimidex prescription on his pads, rips it off, and hands it to me. “Here, the pharmacy is across the hall. If you don’t feel good, call me and I will put you on something else.” His cell phone buzzes again. Our session is over. Normally I would feel dismissed, not validated, and mad as a hornet. But somehow Dr. Weary makes me realize that his primary concern are those patients of his who are in immediate danger. Right now, I don’t need him all that much. As far as he is concerned I am making mountains out of mole hills,  and loosing sight of the real reason for the medication in the first place: To stop the spread of cancer. And if, or when, I do need Dr. Weary, he will be there for me.

I leave a bit befuddled, but calmer. I will be eating Arimidex pills for five years. The University Medical Center oncologist suggested Tamoxifen for 2 1/2 years and Arimidex for another 2 1/2 years. According to the National Cancer Institute the benefit of tamoxifen as a treatment for breast cancer is firmly established and far outweigh the potential risks of blood clots, uterine cancer, and many of the same side effects as Arimidex. Over thirty years, Tamoxifen has shown effective on pre-menopausal and post-menopausal alike.

Arimidex, on the other hand, is a fairly new drug without the same track record. So why am I on Arimidex only? Dr. Weary never explained why.  On the other hand, Tamoxifen works by binding up estrogen in a woman’s breast so it cannot feed the caner. But Arimidex prevents estrogen to develop in post menopausal women.  Somehow Arimidex makes more sense in my un-scientific mind. I buy my first jar. It costs $35 because I have health insurance. The cost is $378.70 for 30 pills  if I did not have insurance. Time will tell how I will feel and how much good they will do. By the way AstraZeneca’s profits for the first quarter of 2010 were on the order of  $3.73 billion.

When do you buy a car without inquiring about cost? Probably never. Chances are you carefully research different brands of cars, repair records, gas mileage, safety records, dealer cost (so you know how low you can negotiate)  or you read used car ads for a good deal until your eyes bleed.

When it comes to your health, shopping for the best deal usually does not enter into your equation. If you are told that six weeks of radiation is mandatory following a lumpectomy, you just say: When do I start and where? You don’t say: how much would that be? Usually you pick the facility closest to you and one that is covered by insurance. You do not call around and ask how much others may charge. (They probably won’t even tell you.) Also, you’d like to think that  you chose a radiation oncologist on his skills and a facility based on its equipment, not on price. Most people go to the radiologist recommended by  their oncologist.

The reality is that even with good insurance, you will end up paying between 10-20 percent of the bills yourself. And here is the reality check: My bill for one month of radiation comes to $44,681.00.

This amount does not include the whole six weeks. It does not include the bill for radiation set up, initial consultation with the radiation oncologist nor does it include the cost of a CAT scan.

Of course the total amount of $44,681 is what people pay who don’t have insurance. I will pay a percentage of the adjusted rate negotiated by my insurance company.  If I did not have insurance, could I have asked for “an adjusted rate?’ Probably not. I would have been stuck paying the whole thing.

When your life is in the balance, the price becomes irrelevant. Yet when I write the checks, a few thousand dollars at a time, for my part of the bills, I cannot help but think of people who simply do not have it. I think of people who have to put it on a credit card and pile up high interest rates. I think of people who don’t even have the ability to put it on a credit card because they don’t have them or their available credit would  not cover their medical  bills. Combine this reality with the fact that a woman with breast cancer usually sees her income go down by an average 26 percent. In my case it already looks like my income for the year will be down by close to 40 percent. For one reason I work a lot fewer hours, and when I am at work I am distracted. And I have not even had to have chemo therapy, a major stumbling block in anyone’s work schedule.

“Dr. Weary, my oncologist, called me yesterday,” I tell Dr. Alpha, on my last day of radiation. “Please note that yesterday was Sunday.”

Dr. Alpha nods, waits to hear what I have to say.

I tell him how sad and disturbed Dr. Weary seemed when I nixed chemo. I admitted to Dr. Alpha that the idea of chemo scared me more than death itself. Dr. Alpha listens attentively. I suppose it is this precise trait that connects him with his patients. He does not seem annoyed. He does not seem distracted or bored. His face is alert, with an empathetic expression which makes you think he agrees with you and makes you talk more. But actually, as you reflect on it, you have no idea what he is thinking. Had his profession not been radiation oncology, I suspect he might have been perfectly suited for diplomacy. (Doctors of Osteopathy are trained to listen and to talk to patients from all walks of life, I found out.)

His listening skills, his neutrality, are such that I , at one point, feel emboldened. I blurt out that I think some oncologists have to give chemo just to have a viable practice. How could they make any money writing prescriptions for hormone pills?

Dr. Alpha does not look shocked. He nods.

“Yes,” he admits, that might be true for some oncologists, but not for Dr. Weary. He has a practice with all the patients he can possibly handle.”

I know Dr. Alpha is telling me the truth. Dr Weary is legendary in our city. Stories circulate about how personal and caring he is. He keeps people alive beyond everyone’s expectations. He often sits with his patients while they get their infusion. He called me on a Sunday. Maybe he should get a life I had thought. But learned that he has a young wife and four small children. He has plenty of life to live on a Sunday. Yet he called me because he is conscientious. I feel ashamed.

I inform Dr. Alpha that I missed an earlier appointment with him because I was out of town.

“Did you go somewhere nice?”

“I was be in San Francisco.”

“Business or pleasure?”

“Pleasure. Visiting my youngest daughter. When you get cancer,” I added, ”you start taking your pleasures seriously, “

Again, I immediately feel embarrassed. How incredibly superficial this must sound to a doctor who has a whole waiting room filled with seriously ill patients: The young woman with cancer in her collar bone, the lady with the meat loaf neck, the two young men with colon and prostate cancer. The teenage boy who has a shaved head and who comes in with a different adult every day. Hospital staff? Ward of the State? It does not seem like friends or family accompanying him. Dr. Alpha has patients rolled down to him on their hospital beds. They are kept in a hallway adjacent to the small waiting room. But I can hear groans and moans under heaps of sheets and blankets. Are these patients needing radiation for pain relief? Yet Dr. Alpha is poker faced. If he was tempted to slap me, he did not let on.

Uninterrupted I prattle on .

“And by the way, I hate AstraZeneca! They pat themselves on the back about their cancer drugs which nets them hundreds of millions in profits. At the same time they produce and sell numerous carcinogens. No wonder they don’t  explore pills for prevention or a cure.”

“I don’t like them much either,” Dr. Alpha says.

“During radiation I feel I am doing something about my cancer. Every day.  Now I just have to anxiously feel wait and see.”

He nods

“Yes, that is all normal,” he assures me. “This is how people feel.”

I wondered if this was normal for all radiation patients, or just his? Did life outside his aura of confidence and care seem cold and uncertain, scary? What about patients who had distracted, stress out radiation oncologists who were poor listeners? Was it Dr. Alpha that made radiation seem healing instead of destructive? Or was it, really, the idea that the machine killed cells in your body that you found comforting? Or both?

Aware of the ticking clock, his packed waiting room, of which he did not seem the least aware, I felt the need to get up and go. My six weeks of radiation therapy have come to an end. It has been remarkably easy. No pain. No nausea. No fatigue. But that is how it normally is with breast cancer. Radiation of other parts of your body is a totally different matter.

“Well, I guess I am ready to transfer my emotional dependence from you to Dr. Weary now,” I say.

I wanted to ask him to be my medical oncologist, the cushiest job he would ever have. How much effort would it be for him to call my local pharmacy to fill my hormone prescription and to do my blood work now and then? But I know it is time to bid Dr. Alpha adieu. Upstairs in the next building, I have my scheduled appointment with Dr. Weary and I am already running late.

Whatever it was that showed up on my friend Elise’s mammogram, it needed a biopsy. A different doctor might have said “Let’s wait and see. Come back in six months.” But not Dr. Guru, he claimed that a biopsy was “the medically prudent thing to do.” So Elise went ahead and had her biopsy “just in case.”

It was a lucky thing too. Elise’s voice was shaking a bit when she told me they found cancer.  This was the second time in twenty years she had received this dreaded diagnosis. You’d think one gets jaded, but that is not how it works. If anything you are far more scared the second time around. You cannot help but think: “What is wrong with me?”

Dr. Guru assured her “it ” was early and extremely unlikely to have spread. She was relieved thinking she could probably avoid the much feared chemo therapy. Elise had a mastectomy, what the heck, her other breast was already gone. Why not even out the front side and avoid radiation?

That evening in the hospital, Dr. Guru stopped by her bed to check on her, and to tell her that he found a cancer cell in her sentinel node. On top of that, it was a different kind of cancer than the one he found in the breast. Elise could tell how shocked the normally cool Dr. Guru was at this unexpected turn of events.

After a review of the pathology report on both cancers, Elise’s oncologist allowed her to skip chemo therapy and opt for hormone therapy only. She is doing fine – so far. That is the horrible thing with cancer: you look good, feel good, and whoops, a little cancer cell jumps up and rakes havoc with your life.

I am telling you this to let you know: always look into something that is “probably nothing.” Yes, a breast biopsy is not pleasant, but it is no worse than getting a crown at the dentist, and infinitely much less painful than a bee sting. Remember the words from Dr. Susan Love: breast cancer is not about statistics, it is about the individual.

When you hope for the best always plan for the worst. Medically, it is the prudent thing to do.

My friend Elise, who had breast cancer more than 30 years ago, sends me an email. Back when she had her first breast cancer bout, she was a law student with two young children. She had a mastectomy. No implants. No chemo therapy. No radiation. Now she has discovered something in the breast she has left.

Right away I pick up the phone to call her.

“ I went over to the Magnolia Cancer Center to get a diagnostic mammogram and to see Dr. Guru,” she says.  “He is not overly concerned but wants me to have a biopsy. Told me it would be the medically prudent thing to do.”

She pauses. I am looking for the right words because I can tell she is more worried than she lets on.

“I must admit I am a bit rattled,” says Elise. “Although Guru seems to think it is highly unlikely this is cancer.”

“So did he look you straight in the eye when he told you it is nothing,” I ask Elise. “Or did he avoid eye contact, shuffle the papers or glance at the cell phone as he spoke? Did he say it was “nothing ” or “probably nothing?”

Elise and I speculate over the phone, like two high school girl friends speculating about some boy. Did he really say he likes me? Do you think he will call? Except Elise and I are now two middle-aged women, not two loved-crazed teenagers. And our speculations are not about a boy one of us fancies. It is about the surgeon oncologist we both share. And we are not trying to read tea leaves about love, but about biopsy results before they are in.

We analyze Dr. Guru’s every gesture as he talked to Elise. Every nuance of his demeanor, of his tone of voice, of the words and how he weighed them. Finally, I conclude: Well, Elise, if that is what guru said and if that is the way he said it, then it is from God’s mouth to your ear. Of course you will be OK. He would never say it that way if he wasn’t sure, I tell her.

Elise sounds relieved. I am relived too. I believe what I just told her. But then again – even if I didn’t – I would have told her that  she would be all right. Just as I would have assured her if she had asked: Do you think he will call? Like any   real friend, I would have said: Of course, he will call you. And then if the call never came: “He didn’t call you? How strange. Maybe he lost your number? Maybe he dialed the wrong number, could he have read your 4 as a 9? You write your fours like nines some time. Maybe he is too shy?”

What is even more typical in my friend Elise’s situation, she would speculate with a friend rather than turn to an expert. Her husband is a doctor, he works with guru, and they are practically neighbors. The most logical step, perhaps, would have been to ask her husband to ask Guru if he really thought it was “nothing” or if he was more concerned than he let on. But no, Elise mulls all these scary details over with someone, me, who is probably the least qualified in the world, medically speaking, to give advice. But I will say what she wants to hear.

Every day now the same routine: leave work for the hospital. Park curbside by the entrance and walk through the sliding glass doors into the main lobby. Take the elevator one floor down into the basement, turn a corner and – voila – radiation oncology. Change into the insane asylum robe, wait a few minutes before being called to lie down on the plastic foam bag and get zapped. You cannot feel a thing. You can only hear a hum from the equipment.

After a week of radiation, my right breast is red, feels warm, and a bit tender. Despite all careful instructions: don’t wash with harsh soaps, use aloe creams, don’t wear a bra. Don’t expose to sun light. Not now. Not for the next two years.

-Look at my breast. Is this radiation damage? I ask the two techs who attend me at each session. They are G., short and stout and severely menopausal. Fans her sweat attacks away with my folder. (At one session I cannot resist giving G. a card that reads: those who say “no sweat” have never been through menopause. ) The other tech is J., also short and fairly heavy set. She has a luminous black complexion, is cheerful, and has a great smile. She is making plans to take her 10-year old daughter to Paris on her next vacation.

They both glance at my red breast and laugh at my wild imagination.

-Honey, you will not be able to notice anything for at least three weeks, if that. It is way too early.

But my breast only seems to be getting redder, and feels hotter each day. I compare my left breast with my right by feeling them with the back of my hand and looking in the mirror. Yes, my radiated breast is much warmer than my left breast. I call Dr. Alpha, who I normally see only once a week.

-Your techs think I am a hypochondriac, but my radiated breast is red and hot although I am told it will not happen for weeks.

The next day, Dr. Alpha examines me, the same way I examined myself: By feeling the two breast with the back of his hand and comparing the color of each breast. He nods in approval.

-You are right. Again! says Dr. Alpha. Good thing you noticed too. You have an infection. It is not unusual after two surgeries. But it would have been difficult to detect later as your treatments proceed. I will give you an anti-biotic. He scribbles on his pad.

-Wow, Cipro, the athlete’s drug. Thanks. Do you have special instructions? Taken with meals? With a bottle of wine?

-Half of bottle of wine. Dr. Alpha chuckles.