A malignant hemorrhoid has a lot to teach about cancer, U.S. health care, and the need to slow down.
Last year I wrote an essay about being told I had cancer and the deep metaphysical questions this raised, such as, “Is God a nice guy?” and “Will my bird dog go to heaven, or do I flush the quail of paradise with seraphim, cherubim, and putti?” But after a while diagnosis wears off. It’s time for an intermission in the self-dramatization of “I Have a Life-Threatening Disease.”
I wasn’t able to play the role to its full tragical effect anyway. Fortunately, the kind of cancer I had was highly treatable. Unfortunately, it was highly ridiculous. It’s not every time you get diagnosed with cancer and it makes you laugh. I’d had a hemorrhoid operation. Two days later the colorectal surgeon called. “I’m sorry to tell you,” he said, “your hemorrhoid was malignant.”
“Malignant hemorrhoid?” I said. “There’s no such thing as a malignant hemorrhoid.”
“In almost every case you’d be right,” the surgeon said, and paused in a moment of sympathetic hesitation and of unintentional comic timing. “But ...”
I wanted to argue. “Malignant hemorrhoid” is Rush Limbaugh radio talk. “Malignant hemorrhoids” is a Dave Barry rock band. I wanted to argue, but I had to get treated.
Going from the metaphysical to the all-too-physical makes for gratitude to God. You have immediate access to the top specialist in the field when you pray. (Do polytheists have difficulties with this?) At least I had the good fortune to live part-time in Washington, D.C.—a city full of flaccid old guys like myself who spend their time blowing smoke out of you-know-where and being full of you-know-what and sitting on their duffs. Consequently, the town is full of medical expertise about the body part in question.
It turns out what I had was skin cancer, squamous cell carcinoma. Practically every melanin-deficient (let alone Irish) person who spends time in the sun gets this if he or she lives long enough. “I call it ‘adult acne’ when it turns up on the face or arms,” the oncologist said. But why it occasionally turns up where it turned up on me is something of a medical mystery. I mean, I was naked a lot in the 1960s but not that naked.
There’s a considerable loss of dignity involved in trading the awe-inspiring fear of death for the perspiration-inducing fear of treatment. There are hells on earth. Until a generation ago the cure for anal cancer was a colostomy. Doctors have gotten over that. Most of the time. Now, with God’s grace, the cure is radiation and chemotherapy.
Would I have to go to some purgatorial place for this? To Sloan-Kettering in New York, a city I detest? Or out to the Mayo Clinic, although I have a phobia about hospitals named after sandwich toppings? “No,” the oncologist said. “The treatment protocol is standardized and is successfully used everywhere.”
I named my local New Hampshire hospital (which doubles as a large animal veterinary clinic).
“Almost everywhere,” the oncologist said.
I asked about the Dartmouth-Hitchcock Medical Center, seventy miles from home but still on the planet New Hampshire. Dr. Marc Pipas at Dartmouth-Hitchcock’s Norris Cotton Cancer Center came strongly recommended. Dr. Pipas is an avid bird hunter and an advocate of reintroducing the prairie chicken to the Eastern seaboard. So he and I had something to talk about in addition to my behind. I’d need radiation therapy every day for six weeks. (Every day, that is, Monday through Friday—the Radiology Department has to play golf, too.) And I would undergo two four-day stints of around-the-clock chemotherapy, carrying a fanny pack of poisonous chemicals to be pumped into my body through a surgically implanted medi-port. (Dr. Pipas convinced the Infusions Department to install this on the left side of my chest so that it wouldn’t interfere with mounting a gun.)
In theory I could get my radiation treatments elsewhere, within easy commuting distance. But it’s worthwhile to find out what a doctor himself would do if he had your medical problem. And he probably thinks he does. Several doctor friends have told me you can’t get through medical school without being convinced that you have every disease in the textbooks including elephantitis, beriberi, and Guinea worm infestation. Dr. Pipas immediately said that, for anal cancer, he’d go to radiologist Dr. Bassem Zaki.
Dr. Zaki is a Coptic Christian who immigrated from Egypt in his late teens. He and I talked about Middle Eastern politics, which, as far as I’m concerned, is the second most interesting blood sport after upland-game shooting.
Dartmouth-Hitchcock Medical Center is a sparkling edifice, full of light and air and surprisingly good art for a non-profit institution. The architectural style is higgledy-piggledy 1980s modern—2 million square feet, every one of which is between you and where you have an appointment. Finding your way around is a trial run for Alzheimer’s but a small price to pay for the pleasant surroundings. Even the food in the cafeteria is good. Various scientific studies have shown that patients recover better and faster in cheerful environments. Duh.
The staff at DHMC is also cheerful, but not too cheerful. They don’t make you feel like a small child at the receiving end of an over-ambitious pre-school curriculum. Perhaps they know better because DHMC is a teaching hospital. The Dartmouth Medical School is the fourth-oldest in the nation, founded in 1797. DHMC is venerable as well as modern. But not too venerable. They don’t use leeches.
Being at a teaching hospital puts a patient in a comfortable equilibrium with the institution. People are expecting to learn something from you, not just do something to you. But let’s not push the idea of equality too far. There’s a current notion that you should “take charge of your disease.” No thanks, I’m busy. I’ve got cancer.
I’m willing to face having cancer. I’m not willing to face having cancer with homework. I promised Dr. Pipas and Dr. Zaki that I wouldn’t show up with sheaves of printouts from the Internet containing everything on Wikipedia about malignancies. They each laughed with detectable notes of relief. (Although I suspect my wife has made her way into the health blog ether. Fish oil pills, raw kelp, and other untoward substances have been showing up on the dinner plates since I was diagnosed.)
Dr. Pipas and Dr. Zaki combined had something like half a century of medical experience. God wants us to have faith in what we can’t see. Therefore He certainly wants us to have faith in what we can. I could see the diplomas on the doctor office walls.
“I’ve got cancer” is more than an excuse for rational ignorance about medicine. It’s an excuse for everything. From niece’s wedding to daughter’s piano recital to IRS audit, you’re off the hook. I tried the excuse on the Pope. I couldn’t go to mass because of the effect that germ-swapping, Vatican II “Sign of Peace” handshakes could have on my radiation-weakened immune system. I continued to employ cancer as an alibi until last week when an exasperated spouse finally shouted, “You’re curable! You can too put your dirty dishes in the sink!”
The radiation treatments weren’t bad—twenty minutes positioned on a machine in a humiliating posture. Most of me was exposed and the nurses were embarrassingly pretty. But it’s interesting, the connection that physical modesty has with physical vanity. Once past sixty you can reasonably abandon both. This was one of the life lessons with which having cancer abounds.
I hate life lessons. Consider all the I-hope-you’ve-learned-your-lesson experiences: skinned knees, high school romances, wrecked family cars, flunked college courses, horrible hang-overs, failed marriages. I tell my children, “Avoid life lessons. The more important the lesson, the more you should avoid it.”
The chemotherapy was worse than the radiation. The pump in the fanny pack of poisonous chemicals made a whining whirr every minute or so — not frequently enough to get used to and too frequently to let me sleep. A long plastic tube that attached the fanny pack to my medi-port allowed me to bury the pump and its noise in a mound of pillows. But then I’d forget that I was connected. As with all attempts to forget one’s troubles, I was courting disaster. I’d get up in the middle of the night to go to the bathroom and be yanked back to the mattress by the tubing. The fanny pack came with a bag of protective clothing and instructions for dealing with chemical spills. According to these instructions I was supposed to do, by myself, what the entire U.S. government had done during the national anthrax panic.
The cumulative effects of the treatments were unpleasant. The loss of my previously full, thick head of ungreyed hair met with no sympathy from my age cohort of males. I developed fatigue, mouth sores, and a rash around my loins as if I’d been dressed in nothing but hip boots and an Eisenhower jacket and turned on a spit in a tanning salon.
Suffering makes us question God. My question was, what evolutionary purpose does the itch serve? Indeed, an itch may be an argument for intelligent design. Maybe we itch not for biological purposes but to give us a moral lesson about surrendering to our strongest passions. I had the strongest passion to scratch certain parts of my body. If, however, I had scratched these parts of my body near a school or playground I would have been sent to jail.
Dr. Pipas, Dr. Zaki, and the Dartmouth-Hitchcock staff were attentive to my complaints and gave me generous doses of things to turn complaints into complaisance. But I was nagged by a concern about the quality of my medical care. Was it too good? I’m well-insured and passably affluent. I asked Jason Aldous, Dartmouth-Hitchcock’s Media Relations Manager, “What if I weren’t?”“We’re a charitable institution,” Aldous said. “No one will ever be refused care here. On the other hand, we have to keep the lights on. We do try to find any possible means of payment—government programs, private insurance, et cetera.”
The hospital has a whole department devoted to that. “In about 60 percent of cases,” Aldous said, “people who think they aren’t eligible for any assistance actually are.” Then there are the people who have income but no savings or assets. Discounts are provided and payment plans worked out. Failing all else, treatment is simply given free—$63 million worth in 2007.
I asked Aldous about who gets what treatment from which doctor. Do your means affect the hospital’s ways?
“The doctors,” he said, “don’t know how—or if—you’re paying.”
What Jason Aldous told me seemed true from what I could see of the hospital’s patients, a cross-section of Yankees, flinty and otherwise. The Norris Cotton Cancer Center alone treats more than five thousand people a year. And we were all amiable in the waiting rooms. Any time someone new came in and sat down he or she was tacitly invited to spend about three minutes telling everyone what was wrong. Then the conversation was expected to return to general topics. The general topic of choice during the summer of 2008 was how the Democrats would destroy the private health care system that was saving our lives. When medicine was socialized we’d have to sit in waiting rooms forever, if we lived. (The exception to the three-minute rule was for a child patient. Then there was unlimited interest and upbeat chat.)
In my case at least, the amiability had something to do with pain-killing drugs, of which I was on plenty. Opiates are a blessing—and a revelation. Now when I see people on skid rows nodding in doorways I am forced to question myself. Have they, maybe, chosen a reasonable response to their condition in life? Being addicted to drugs is doubtless a bad plan for the future, but having cancer also lets you off the hook about taking long-term views.
I’m sure that various holy martyrs and pious ascetics will disagree but I saw no point to adding suffering to my suffering. And I can’t say I had a sign from God that I should, at least not if God was speaking though my old friend Greg Grip.
Greg was batching it in a cottage on Lake Mascoma, fifteen minutes from Dartmouth-Hitchcock. He’s divorced and his college-age daughter was away at a summer job. “I’m not saying you can stay at the cottage while you get treated,” Greg said. “I’m saying I will be deeply offended if you don’t.”
Dr. Zaki arranged my radiation treatments, late on Monday afternoons and early on Friday mornings. My wife and children were spared self-pitiful weekday grousing. And I missed them, so I was on good behavior over weekends.
Greg is a splendid Weber grill cook. Charcoal fires produce carcinogens, but the chemotherapy had that covered. Dr. Pipas said I could have one measured Scotch each evening. But he failed to specify the measure. I think the pint is a fine old measure, although the liter is more up-to-date.
I couldn’t tolerate the sun, but Greg’s cottage is on the southwest shore of Mascoma. The patio was in shade all afternoon. I read a lot, mostly histories of World War II concerning the Russian front. Everyone on the Russian front in World War II was having it worse than I was.
Tony Snow, the former Bush administration press secretary, wrote an essay about dying from colon cancer. Tony said that the sense of mortality promoted “the ability to sit back and appreciate the wonder of every created thing.” Every created thing put on a wonderful show for me at Lake Mascoma. A family of mergansers with six ducklings was living under the dock. A pair of mallards had taken up residence in the shrubbery. Beavers swam up and down the lake. I don’t know why—Mascoma has a concrete dam. There were bird sightings—hawks, turkey vultures, kingfishers, a bald eagle, even an extremely wayward pelican. A hummingbird visited the patio every evening. Skinny-dipping sightings were also made at a nature reserve across the lake. Water skiers and jet ski riders took amusing falls. Not to engage in the pathetic fallacy, but the weather itself was kind and cool. Greg’s pointer, Weezy, slept on my bed each night, though this may have had less to do with doggie compassion than the fact that Greg won’t let her sleep on his. Weezy’s dulcet snoring drowned out the chemo fanny pack pump.
I’m doing fine now. Anal cancer can be invasive, but mine seems to have had a wimpy EU-style foreign policy. The cancer is gone, as far as can be told. I still have a colonoscopy to worry about and a CAT scan to dread and six-month check-ups to fret over. I’ll be okay. Or I won’t. Or I’ll go through it all again.
Last summer was not the worst summer of my life—loving family, kind friends, skilled and considerate care, a big warm dog in the bed. The worst summer of my life was forty years ago when I was young and healthy and didn’t have a care in the world. But there was this girl, and a novel that refused to write itself, and anomie, and angst, and weltschmerz ... Nothing brings us closer to God than age and illness. I only hope the Almighty doesn’t mind having nothing but sick old people around.
P.J. O’Rourke is a leading political satirist and the author of thirteen books, including Eat the Rich, Peace Kills, and his latest best-seller, On the Wealth of Nations. He has written for such diverse publications as The Weekly Standard, House & Garden, Automobile, The Atlantic Monthly, and Rolling Stone. He is the H.L. Mencken Research Fellow at the Cato Institute in Washington, DC, and a frequent panelist on National Public Radio’s “Wait, Wait ... Don’t Tell Me!”
