Passing

by Michael Korda

  This was as far from country living as you could get, unless you counted a weekend in the Hamptons as country life, which she did not. Meeting “the right people” and making the right connections was Burt’s concern, none of hers. Even so, the model—and the perfect hostess that she almost instantly became—must have been buried somewhere in the horsewoman and colonial adventurer, to appear so quickly. It was as if fashion sense and arranging sumptuous black-tie dinner parties full of celebrities had been bred into her, waiting to emerge, although that can hardly be the case, since Margaret grew up in the solid, unpretentious comfort of the farm manager’s house in Overbury, Worcestershire, near the village of Broadway, which has since become a tourist destination, but was then a pleasant country backwater. She had a remarkable ability for becoming what other people wanted her to be while remaining herself at the core. It was not a process, or something she studied, and certainly Burt was no Pygmalion; Margaret simply seemed to know how to take wing and fly effortlessly from one incarnation to the next. Beneath all that, however, she remained the girl who had started to ride at the age of three and was given her first pony at the age of four. Among her most treasured possessions was a photograph of herself on Snowy at about that age. At some point in the early 1970s she took up riding again, in Central Park in the mornings, and gave up accompanying Burt on his travels to every corner of the globe as his model for Holiday, Travel & Leisure, Ladies’ Home Journal, and ad campaigns for Foster Grant sunglasses, Canadian Club whiskey, airlines, and cruise ships. That was when I met her, trotting around the reservoir in Central Park.

  Although she may not have realized it—certainly Burt did not—she was looking for a return to her roots, to country living and horses. It was not surprising that she conflated recovery and riding; I did not think it would be long before she got back on one of her horses, even if she had to approach the mounting block with a cane.

  But first came the Gamma Knife radiation, which took place at Northern Westchester Hospital’s Cancer Treatment and Wellness Center, where we had first met Dr. Alain. These were more congenial surroundings than a huge hospital like Westchester Medical Center. Over the next few months we grew to like the nurses and to feel as much at home as you can in a place where you didn’t want to be. Behind the comfortable waiting room with its cookies, pillows, tropical fish, verdant greenery, music, and soothing colors, the real work of cancer treatment went on in a businesslike way.

  We arrived early in the morning, Margaret dressed as instructed in loose, light clothing. She was not wearing any jewelry, just her wedding ring and her watch, which I put in my pocket. She was fitted with a metal frame secured to her head with sharp pins, scary to look at, but not painful, a topical anesthetic prevented her from feeling anything more than a sharp prick, and she was given an intravenous sedative. Shortly afterward she was wheeled away for a preoperative MRI to determine the exact position of the target. In less than half an hour she was back, while Dr. Alain and his radiologist Dr. Julie Choi drew up a customized treatment plan, perhaps the most crucial part of the procedure, since it involved focusing multiple beams of radiation on one precise spot in the brain. While we waited, the data from the scan was transferred to a computer in order to establish “the optimal isodose plan and configuration” aimed at “the tumor resection bed in the left frontal region of the brain,” where the surgery had been performed three weeks ago.

  Although we did not yet know it, the scan also revealed two small metastases “localized to the contralateral hemisphere,” in other words the right side of the brain. This dramatically changed the odds, since the appearance of two new tumors in the opposite side of the brain, small as they might be, was an indication that Margaret’s troubles were not over, despite the successful resection of the large tumor. It seemed to me like a long wait before Margaret was taken to the treatment area, and the discovery of the two small metastases perhaps explains it. The treatment plan was more complex than anticipated, since there were now three separate targets instead of one. Fortunately, Margaret was sufficiently sedated that she didn’t notice the length of time.

  Behind the big doors marked with a radioactivity warning sign, Margaret “underwent the gamma knife stereotactic radiosurgical intervention in an uneventful fashion,” to quote from Dr. Alain’s postoperative report. Some people panic when the big, hemispherical metal collimator that directs each pinpoint beam of radiation from over two hundred different angles to focus precisely on the tumor is put in place, others when they are fed headfirst into the cylindrical opening in the machine. For anyone who suffers from claustrophobia this must be a terrifying experience, but Margaret didn’t have a problem with confined spaces, nor wide-open ones either. She had no phobias except for a country girl’s slight dislike of swimming in the ocean, perhaps natural to somebody born in Canterbury, Kent, and brought up in the Cotswolds—the sea seemed to her an alien place, not like the gentle rolling hills of rural England. She didn’t mind pools, but always said that the most difficult part of her modeling career was the amount of time she had to spend on beaches and cruise ships for Burt’s photo shoots pretending that she was enjoying it for his camera.

  When the doors opened and Margaret was brought out, she didn’t seem any the worse for wear. In fact, she was quite cheerful. Here, at least, was a major medical procedure that didn’t involve pain or rehabilitation, hardly worse, in her words, than going to the dentist, except for the overwhelming size of the equipment. The frame was removed from her head, the small pin sites were treated with Bacitracin ointment and her head was wrapped in a full dressing, following which we were both served a light breakfast, quite a good one, in fact. The Northern Westchester Hospital’s Cancer Treatment and Wellness Center goes out of its way in every detail to make the patient feel comfortable and at ease, it might serve as a model for cancer centers in many much larger hospitals. Everybody involved was friendly, cheerful, and positive, as if “wellness” were their chief business rather than “cancer.” Whoever thought of naming the place “Cancer Treatment and Wellness Center” had a stroke of genius—there was no hint here of the icy remoteness with which cancer patients are often treated by the staff in many other places, perhaps a natural adaptation by the staff to having to know—and give—so much bad news during the course of every day.

  This is not a phenomenon limited to the United States. In his brilliant book Do No Harm, about "Life, Death, and Brain Surgery," the English neurosurgeon Henry Marsh describes many instances of emotional distancing from the patient, not only among the overworked staff of nurses, physician assistants, and hospital administrators, but among the surgeons, including himself. (Marsh balanced this out by subsequently writing another book, Admissions, that includes his own experience as a patient.) To the cancer patient, particularly one who is going to be coming back again and again to the same place, the small niceties make a huge difference—there is probably no other time in life when the “human touch,” so often lacking, makes such a difference.

  Dr. Alain appeared, dapper and affable as ever, to assure us that the radiation had gone well, Margaret need not have any concerns, it had eliminated any cells remaining in the tumor bed and, he added, taken care of two small metastases, which should give her no further problems. Margaret did not seem concerned about the two small metastases, nor, I have to confess, was I. It sounded like “tidying up,” and I felt grateful they had been found and eliminated. In hindsight I should have been more alarmed, or more curious. No fault attaches to Dr. Alain for this. Faced with a serious medical problem, patients (and those who are close to them) tend to hear what they want to hear, and what Margaret and I both wanted to hear was that the surgery and the radiation had been a success, she could get on with her rehabilitation and her life.

  I do not think it had fully penetrated to either of us as yet that the key word about her brain tumor was metastatic, as opposed to primary. A primary brain tumor develops in the brain and remains there; a metastatic brain tumor has traveled to the
brain from elsewhere in the body. When Margaret had a melanoma removed from her cheek five years earlier, either the surgeon had not “got it all,” as surgeons are fond of announcing, or more likely Margaret had waited too long before having the spot on her cheek examined by a dermatologist. Either way, the cancer had already begun to metastasize—possibly in the form of the small asymptomatic nodules the radiologist noticed on both Margaret’s lungs—and cells from these places eventually traveled through the bloodstream, crossed the blood-brain barrier, and flourished in her brain, in much the same way that cells from metastasized prostate cancer tend to travel to the spine and the pelvis. Every cancer seeks its own hospitable spot to develop and grow, and most cancers have a default position in the human anatomy toward which they move once they metastasize. As early as 1840 a British surgeon, Samuel Cooper, had traced the course of a metastatic melanoma and noted that “the only chance for a cure depends upon the early removal of the disease,” and his prognosis has not significantly improved since then. Margaret’s “disease” had not been removed early enough.

  To understand why, it is necessary to take a small step backward. In 2007 my hairdresser, Paul Kelley, asked me if a dermatologist had ever looked at the “stuff” on the top of my scalp. What “stuff?” I asked. I had never felt anything there when I combed or brushed my hair, and since it is impossible to look at the top of one’s own head, I had never noticed anything. Paul said he was no expert, but if he were in my shoes he’d have it checked out by a dermatologist. Although I am whatever the reverse of a hypochondriac is, I made an appointment to see a friend and neighbor of ours, Dr. Vincent Beltrani Jr., a dermatologist. I was not worried, but after all, I told myself, Paul spent his day looking at the top of his clients’ heads, and he was no fool. If he saw something, then perhaps something was there.

  As it turned out, what Paul saw there while he was cutting my hair was a large malignant melanoma, for which I had surgery and a skin graft at Memorial Sloan Kettering in New York City. This proved to be an altogether bigger deal than I had anticipated, and once it was all over and the skin graft had healed I was left with a wide, shallow crater about three inches in diameter in my scalp, with a raised rim of scar tissue around it. I did not mind, I wore a hat as often as possible, and so long as I had enough hair I could brush it over the site of the surgery easily enough. Margaret was brave about it, as she had been about my prostate cancer years before, but I remember the look in her eyes when Vinnie Beltrani Jr. called late at night with the results of the biopsy—it was, briefly, one of terror.

  More important, she inevitably saw the result of the excision and the skin graft every day—at first it looked like a badly healed war wound—and it would not be difficult for her to imagine how something like that would look on her cheek, with the result that when she did notice an irregular brown patch on her right cheek she put it firmly out of her mind, and dealt with it by covering it up with Clinique Superbalanced makeup; a light touch, and it was gone. With fair skin and a long history of sun exposure, or as we would soon learn to call it, sun damage, Margaret had plenty of freckles and sun spots, what was one more, after all? She was not one to stick her head in the sand like an ostrich in danger, but at the same time she wasn’t an alarmist, and certainly not the kind of person who would run off to see a doctor every time she noticed a small change in her skin. Perhaps she also unconsciously associated a melanoma with what had been done to my scalp, and didn’t want anything like that done to her cheek. In any case, when I finally noticed the spot and suggested that she see Dr. Beltrani, she didn’t want to go, and kept putting it off—by that time she may have suspected that she might be getting news she didn’t want to hear.

  Eventually, I succeeded by a ruse de guerre. I asked Vinnie Jr., a keen car collector and motorcyclist, if he would mind stopping by unannounced the next Sunday to show me his latest car, and perhaps take the opportunity for a discreet look at the spot on Margaret’s right cheek. He agreed, and no sooner was he out of his vintage TVR and into the house than he glanced at her cheek over a glass of water and said, “Why don’t you come to my office tomorrow so I can take a closer look at that.” It was not a question, it was a command.

  Margaret had known Vinnie Jr. for years. She liked and trusted him—his father, also a distinguished dermatologist, lived down the road from us—and there was no way she would ignore Vinnie, so the next day we saw him. He immediately identified the spot as a lentigo maligna melanoma, and persuaded her to let him take a sample of it for biopsy. Vinnie Jr.’s notes describe the spot. “On the right cheek, there is an extremely prominent, irregularly-pigmented, ill-defined, 2 x 3 cm brown patch [which] she has been covering with makeup for many years.” He performed “a narrow 1.6 x .02 cm incision . . . through the central portion of the lesion.”

  Once that was done, and the wound was closed with three sutures, he sat Margaret down and discussed in great detail the meaning of his diagnosis, a serious heart-to-hearter. Faced with the reality—Vinnie did not have any doubt that the biopsy would confirm his diagnosis—she was shaken but calm, and heard him out. He carefully explained that “the biopsy will clarify if the lesion is in situ or there is an invasive component”—that is, how deeply it had penetrated from the surface of the skin, the epidermis, toward the subcutaneous tissue where the blood vessels and lymph vessels lie. (An in situ melanoma is on the surface of the skin; its opposite is described as “in transit,” which is to say there is a possibility of its traveling, that is, metastasis.) He discussed the possibilities of treatment with Aldara cream as opposed to surgery, making it clear that if the pathology report “reveals an invasive component, surgical solutions would be more appropriate.” He was an early enthusiast for Aldara, but he mentioned it this time with an uncharacteristic note of caution. Vinnie was a friend, his manner was gentle, caring, sympathetic, he was careful not to elevate Margaret’s level of anxiety, but he left her in no doubt that the melanoma was dangerous and that she would have to take it seriously. Delay, he made it clear, would not be a good idea.

  Three days later the dermapathology report confirmed Vinnie’s diagnosis. The results effectively ruled out treatment with Aldara cream; Margaret needed surgery, and the sooner, the better. The report succinctly summed up the bad news. “Sections show markedly sun-damaged skin with confluent growth of atypical melanocytes along the dermal-epidermal junction and extending above it into the granular cell layer . . .”

  This was the moment at which our lives became dominated by the melanoma. We had a sense of urgency, but no panic. For two weeks we busied ourselves with doctor-shopping, that most exhausting of activities, looking for a dermatological surgeon with whom Margaret would feel at ease, and if possible one who would excise the tumor and perform the cosmetic repair at the same time, rather than two separate surgeries. Naturally, almost everybody we knew turned out to have his or her own favorite skin surgeon, and also to have strong opinions about the choice between Mohs surgery, in which the patient waits while tissue is removed and examined one microscopically thin layer at a time until pathology indicates that no further cancer cells remain, or the more traumatic excision of the melanoma with adequate margins. But in the end we found a doctor with whom Margaret felt comfortable, and had the surgery performed on October 27, 2011.

  We congratulated ourselves on moving fast, but with hindsight it was not fast enough.

  Or perhaps it had already been too late?

  Five years later, Margaret experienced no side effects from the Gamma Knife radiation except for extreme fatigue—despite the fact that she applied herself to her rehabilitation with her usual determination. Thanks to Colleen Sinon, we managed to get Margaret’s physical, occupational, and speech therapy in sequence on the same days so we would not have to spend the whole day going back and forth. MidHudson had recently been expanded, renovated, and redecorated. Its rehabilitation therapy was contained in a new atrium, another striking, modern piece of architecture—everywhere one sees the signs that h
ospitals are being run like competitive businesses, for better or worse. Only a few years ago the center of this hospital had been a crumbling Victorian building; now it had become gleaming glass, with valet parking. The Physical Therapy Department is up-to-date and state-of-the-art, and Margaret had the great good fortune to meet, and almost immediately to bond with, Christopher Dayger, a slim, supremely fit, and engaging physical therapist who got her competitive juices going at once. Of course, Margaret was the ideal patient from a physical therapist’s point of view—she had been extremely fit before her brain surgery, she loved physical challenges, and she liked Christopher and wanted to earn his praise. She actually looked forward to physical therapy, particularly the balance machine, in which she did exercises on a rocking platform wearing a harness like that of a parachute in case she fell, while focusing her eyes on a moving target. Under Christopher’s guidance she was able to exchange her walker for a cane in a couple of weeks, another big step forward. Speech therapy, predictably, went more slowly, but she did her homework after every session, despite the continuing difficulty of using her right hand. It would be difficult to imagine a place or people more determined to see her succeed, and Margaret’s day became like that of an athlete in training. No sooner had she graduated to a cane than we took to walking every day, building up to almost three miles, half of it uphill. Somewhere deep in her mind Margaret equated fitness with survival.