Editor's Note: Aggressive melanoma is the villain in Hard Lessons, a book under development by William Pence. In this excerpt the cancer is discovered as a small pimple, treated as a simple surgery and dismissed as a threat.
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Fifteen months after Molly's wedding we packed up for another. Our son, Billy, met a tall brown eyed fireball named Maria at a softball game in San Diego. Her team of young downtown lawyers lined up against accountants and office workers—dozens of twenty-somethings out for serious socialization and casual sport. From her position on third base, she heckled opposing batters and shouted "way-to-go's" to her teammates.
By day Maria defended Mexican drug mules and illegal's arrested by the DEA or the ATF. Her clients had little money, transparent alibis, and spoke "Spanglish," the border patois. The Federal Public Defenders job was thankless and low paying but she did pick up a stunning repertoire of profane Spanglish.
Maria was introduced as Billy's "girl friend" at Molly's wedding in Tiburon. The couple deflected questions about their future plans but by early 1998, Billy proposed and they announced plans for a July wedding at Lake Tahoe.
Two days before the wedding—a complex affair planned by Maria with less emphasis on dresses and flowers than on rafting, hiking and tram rides—I packed our new Mercedes SUV with suitcases, cameras, audio equipment and garment bags. Linda packed grapes, chips and diet cokes in our well-travelled Coleman. We set the snacks on the back seat for easy access; locked the house and headed north.
After driving in LA for thirty years we knew to slip through the freeway system in the brief interlude between the morning rush and the lunch time crunch. By nine am we had Palos Verdes in the rear view mirror. The cool beach weather turned hot as we passed the UCLA turnoff in West LA, eased into the carpool lane and stormed up the Mulholland pass toward Lake Tahoe, four hundred miles away.
The new CD we bought for the trip, Bob Dylan's "Out of Time" was paused and restarted a dozen times as we ruminated mental check lists, shared memories and bantered. We were out of the LA basin before Dylan got to the chorus of "Sick of Love."
Linda asked if I had confirmed a singer for the rehearsal dinner.
"Yep," I said. "He's going to sing every song with the name 'Maria' in the title."
I asked about dinner plans with Molly and Glen and learned they would be leaving San Francisco after lunch. Being with our San Francisco daughter, our San Diego son, their spouses, together in the woods of Lake Tahoe: it was just too perfect.
"Edwards turnoff, Mojave ahead. Want to drive a stretch?"
We had a routine for trips up Highway 395. I battled the dense traffic out of the LA basin and Linda took over when the traffic thinned of commuters. At our favorite pit stop in Mojave, a Chevron station with a clean restroom, we swapped seats and Linda drove through Red Rock canyon and past Lone Pine, where movie crews filmed dozens of classic westerns. In California you can have breakfast at the beach, lunch in the high desert and dinner at 6,000 feet in the Sierra Nevadas. I love the diversity of my native state.
There's a long stretch of straight highway north of Lone Pine where the Sierras are close to the highway and the slopes so steep they look like a backdrop. Traffic was light; Linda had the Mercedes on cruise control.
"Not a bad view," I said. The sun was vertical, patches of winter snow still white on the peaks. Linda agreed.
"When does Billy get his ten year chip," I asked.
Linda thought for a second and answered.
"We did the intervention on March 15, 1988. So I guess he took his ten year chip three months ago."
"Do you think he would be getting married if you hadn't wrestled him into treatment?"
"Hardest thing I ever did," she said.
"And this weekend is your payoff."
"You had a part in his recovery too."
I accepted her recognition for my part in his sobriety but Linda played the lead role. A recovering alcoholic herself, she knew where alcoholism can lead and could not tolerate the risk of losing her boy.
I followed her lead—perhaps for the first time in our marriage. When Patty, our first counselor at Coast View Hospital, told me to "go to ACA and Al-Anon meetings" I agreed. Addiction is a family disease and recovery requires that every member of the family change.
Linda returned the compliment. "I couldn't do it alone. You changed your relationship with the kids."
It was more than my relationship with my children. At ACA meetings with other Adult Children of Alcoholics I dumped my secret stories and repressed anger.
I was seven years old riding in the back seat of a 1951 green Pontiac. My father pulled to the curb and told me to "stay in the car. " He and my mother got out and walked into the open door of a bar. I recognized the neon script 'Pabst Blue Ribbon' in the window. They expected me to go to sleep but I had to pee and I didn't know when they would return. I was told to stay in the car, so I did and peed in the ashtray. I hated that they made me do that.
In Al-Anon meetings I met men and women like me; people with alcoholic parents, spouses and children. We listened to each other, we told our stories, we followed the "Big Book," and life got better. Judgments faded and love deepened. After about 200 meetings, even the stubborn ones, like me, changed.
Our commitment to the twelve step programs paid off. Billy stayed sober, finished college and built up a small business. He had good friends and would soon be a married to an energetic woman who adored him. We would have patted ourselves on the back except that we knew that recovery isn't a condition you can will onto another person. It was my son who did the heavy lifting.
In Bishop, just south of Mammoth Lakes, we stopped at Schat's bakery and picked out chocolate covered coconut macaroons the size of apples. I topped off the gas tank and pulled on a sweater before taking the wheel for the drive up the flank of the Sierras. I smelled the pines as we passed 5,000 feet of elevation. Dylan's gravel voice sang, "It's not dark yet, but it's gettin' there."
At the highest point on Highway 395 I read the marker out loud, "Deadman's Summit, 7,950 feet."
Linda paused the CD. "Do you have your toast written down?"
"I am ready for both the rehearsal dinner and the wedding reception."
"Did you bring plenty of Imitrex?" she said, referring to my new migraine medication.
"Got it covered. I'm not missing another rehearsal dinner."
Lake Topaz straddles the California-Nevada border and drains into a granite and limestone canyon with steep sides covered with pines and cedars. A million years of scrubbing created a river bed of pale gray boulders. The clear water, dark in the deep spots and white where it splashes, runs for miles beside the winding downhill road. I slowed the car and rolled down the windows, coasting on the empty road.
"Listen," I said. "This is too perfect a scene to ignore."
Dylan, on the subject of lost love, sang "I'd give anything to be with you."
Linda got a cell signal as we cleared the canyon, called Molly and told me, "They are in room 206, speed up. I want to see my girl."
The River Ranch Hotel is a white clapboard landmark on the Truckee River. A large patio overlooks the river and adjoins the pull-out dock for rafters. Linda had her seat belt off before I turned into the large parking lot and killed the engine. She headed straight to Molly's room leaving me to pull our luggage from the hatchback and check in. The clerk gave me my keys and a thick envelope as Glen greeted me with an energetic hug and grabbed one bag.
"Molly sent me down to help." Glen pointed at the envelop and added, "You'll love that—it's Maria's agenda for the weekend."
"I take it she has us all organized?"
"She has assigned groups with departure times for the rafting," he said with a chuckle.
"Linda and I are in 202," I said as I took a bag and headed up the wooden staircase.
We talked business as we toted the luggage to 202, locked the door and went to see Molly and Linda. Glen worked for a young pharmaceutical company that had a new drug for rheumatoid arthritis. The company's stock rose each time a patient went bungee jumping or picked up the violin after the drug relieved their arthritis. Molly's marriage looked solid; Glen referred to her as "my beautiful wife" at every opportunity; money appeared to be imminent. There is a unique satisfaction when a man with prospects adores your daughter.
When we got to room 206 Linda and Molly were engrossed. Dresses and shoes littered the bed. Molly looked like a teenager in jeans and a faded UC Santa Cruz sweatshirt. She pointed to a pair of shoes and asked Linda "Those I think, right?"
I walked towards Molly, "Hey, don't I get a vote?" I said.
"Dad!" she said with a smile and a bounce. She scooted around the bed and fast stepped into my arms. I squeezed her and kissed her cheek while Glen gave Linda an appropriate mother-in-law hug. Molly smelled clean and fresh. I held her shoulders and put a serious look on my face.
"How's the marriage working out?"
Glen and Molly both responded with a playful "Hey! Off limits" as I feigned innocence and said, "Who's hungry? Let's start this party."
After dinner I carried Linda's dresses up to our room. We unpacked and settled into bed to read. I opened up a Tom Clancy novel and drifted into a world of spies and weapon systems. Linda lay beside me, quiet but not sleeping.
"I need to tell you something about Molly," she said. Her tone was serious, different than the happy voice I had heard all day.
"Molly has a mole on her back that worries me."
"Why?" I had no idea what was fearful about a mole.
"It's not a normal mole-more like a large pimple but dark, irregular. It looked malevolent. It made my knees go cold."
"She should see a doctor." Problem solved. I wanted to get back to the Russian spies.
"She saw her dermatologist."
"What's he going to do?"
"He wants her to get a biopsy."
I set Clancy down. "Biopsy" sounded bad. I turned toward Linda.
"Should we be scared?" I asked.
Linda shook her head then said, "Maybe."
I put my arm under her shoulders and pulled her close.
"Can you set this worry aside until after your son's wedding?"
Linda turned away, rolling towards her edge of the bed.
"I'm not sure I can. You didn't see it. It could be melanoma skin cancer."
I didn't know enough about irregular pimples and moles to be scared. I knew a little about cancer: colon cancer ravaged my mother until the morphine put her to sleep forever. A chain smoking friend of mine went from chronic cough to death in six months. But those were organ cancers, the kind that make you cringe when you hear the diagnosis. The idea that a skin cancer could be lethal was not in my head. Nor was the notion that too much sunlight could kill.
I grew up believing that a sun tan was a good thing. I got burned red and peeled dead skin off of my ears and back each summer. Linda, who better understood the risks of sunburn to red headed children, dabbed zinc oxide on their noses and slathered SPF 45 lotion on their backs. Molly enjoyed Linda's loving application of the scented lotions on her shoulders, ears, neck and legs. She absorbed the lessons as well as the lotions: Cover up and use sun block. Billy, more restless and anxious to get into the pool or lake learned too. Linda kept both our kids sunburn free through their childhood even as we camped, water-skied, and played at the beach. I comforted myself with this truth: we loved our children and protected them.
I went back to the fictional world of Clancy where heroes have crystal clarity of risky situations. Surrounded by lesser men who fail to see the risk or the solution, the hero finds the path to safety. I fell asleep believing I had the capacity of a fictional hero to see all risks and solutions and, as it turned out, I was wrong.
The three day party was a smash. Forty people floated down the Truckee, splashing each other and playing "ram the raft." The singer showed up at the rehearsal dinner, sang every song with "Maria" in the lyrics, and even if he did take off his boots as he played his guitar, was a big hit. A white haired Catholic priest in a white robe stood in front of a stained glass window, brilliant with mountain sunlight, and pronounced them "man and wife." At the evening reception friends and family offered toasts while a video showed the newly weds as children. The morning after the service we took the cable car up to Squaw Peak and hiked to Granite Chief.
At 9,000 feet in thin cool air with the sun a white ball in dark blue space, Bill and Maria kissed for snapshots. Glen and Molly held hands and goofy walked down the trail for the video camera. She wore a sun hat and long sleeves, aware that even when it's cool, the high altitude sun burns.
We drove home happy for my son and anxious for my daughter.
Two weeks passed. The tiny cancer grew while Molly waited for the minor surgical procedure to slice off the pimple and send it to the lab. Molly and Linda talked every other day, wondering when and what the biopsy report would reveal. Another week passed.
Linda called me at work. Her tone was funereal.
"She finally got the biopsy. It's stage 2 melanoma."
"What does that mean?" "Stage 2" didn't sound especially good or bad.
"The cancer's beyond skin deep, they've got to do the surgery." Linda dropped her pitch on the word "surgery."
"Okay. Sounds reasonable," I said, my concern still two notches below Linda's.
"The biopsy report sat on his desk for a week," she continued, anger in her voice. He hasn't even arranged for the surgery."
Linda's step father was a beloved internist who rose to become chief of staff at Huntington Hospital in Pasadena. Her mother was a registered nurse. Linda was betrayed by a medical professional, one who did not have the same passion for prompt care that her family had practiced.
I didn't know if a week's delay in reading a report was important but I joined her rant. "That's bullshit," I said. "She needs a different dermatologist."
I ended the call with Linda and went back to work.
In 1998 I knew nothing about the growth rate of melanoma. Left on their own, unchecked by the immune system, cancer cells will reproduce, essentially doubling their number in a couple of days. Each day she waited for a biopsy appointment, each day her dermatologist delayed reading the report and each day it took to schedule her curative surgery, the melanoma cells were busy duplicating themselves and reinforcing their colony. The melanoma lesion on her skin extended tentacles deep into her back like a well digger looking for treasure. The lesion drilled down for nutrition and for the opportunity to launch cells into her blood stream to start new colonies. In that month after the wedding the tumor had time to drill deeper and deeper.
A week later we got another call from Molly. Her dermatologist referred her to a surgeon who immediately removed the pimple that was now called a melanoma lesion. He told her "we got it all" and relief spread as if a war was won. If fact, cancer surgeons report "we got it all" and "good margins" because they can't see the cells left behind: their crude scalpels don't cut to the cellular level. At their best they remove slices of tissue based on their experience, examine them microscopically for cancer cells, and trust the immune system to sweep up any cells that got away. The surgeons have no better tools; nothing is gained by telling patients about loose cancer cells in their system, looking for a place to roost.
Molly's immune system kept the loose melanoma cells from colonizing for nearly ten years. The war inside her body was invisible; no battle reports or score cards. The grim truth is that most cancers are detected long after the colonies start to form, after several thousand successful reproductions have created a defensible tumor and our feeble instruments see them only after some symptom such as pain or swelling causes a physician to "take a look."
I wish I had taken Molly that first evening, as soon as Linda told me about the suspicious "mole," even before Billy's wedding, to a specialist. Stanford University was only 5 hours away. I could have insisted that the tiny growth be removed at once, pleaded with doctors, shorted the gestation cycle of the cancer by three weeks--maybe halted one or two cycles of mutation. I wish that I had disrupted my son's wedding but I didn't. I assumed like everyone else that "after the wedding" would be soon enough. I went along with her dermatologist making an ignorant mistake.
The second mistake was to minimize the post-surgical risk. With wisdom that came years too late, I wish I said the following to Molly:
"Honey, you have cancerous melanoma cells in your body. Now, if you are lucky, your immune system will sweep them up every day and kill the little mutant bastards. But, and I don't want to alarm you, if your system lets a few mutant melanocytes settle into a colony, it's important to destroy the colony. Your husband has good health insurance. Use it. Get an oncologist and insist on an annual PET scan—that's a Positive Emission Tomography scan. It can detect tiny colonies and give you time to have them removed. Think of this as a guerilla war. The enemy is lurking in your body, trying to establish base camps. What we need is an annual assessment of any emerging camp sites. The insurance company will resist paying for a scan without a current diagnosis of cancer, illogical as this sounds. Here are two strong arguments. First, you did have Stage 2 melanoma and while the visible cancer is gone, some cells are left behind. Secondly, the cost of treating a mature cancer tumor is a hell of a lot more than a PET scan, so prevention will save them money. If that doesn't work, I'll pay for the scans and negotiate the best deal I can find. But we must get you scanned every year."
Bio: William Pence lives with his wife in Portland, Oregon and works as a management consultant for high tech companies.