In Danger

by Josepha Dietrich

  The main reasons for my getting breast cancer at 35 appeared to be genetic ones. There was talk – in literature, informal conversations between friends, and research involving women newly diagnosed with breast cancer – of stress being a contributing factor to the development of cancer. All I knew was that the only environmental factor that I could name as a possible contributor was stress. In caring for my mother and my son I experienced a lot of it. However, I didn’t blame stress for my cancer, but rather I believed I inherited the tendency towards cancer from my mother.

  Stress comes in two forms: from working hard or from a situation you have no control over. The latter was what allegedly could dupe you.

  Scientist Dr Elizabeth Blackburn won the Nobel Prize for Physiology and Medicine in 2009 for her research into telomeres, the protective caps on the ends of chromosomes. She worked with psychologists on telomeres, stress and meditation. It appeared that she had proven a mind–body connection. Her Australian voice with its US West Coast twang came to me over the radio in my kitchen. She said, In my lab, we’re finding that psychological stress actually ages cells, which can be seen when you measure the wearing down of the tips of the chromosomes, those telomeres.

  Dr Blackburn’s work helped us understand why breast cancer cells divide without normal control. Her work also had a lot to say about bad stress and good stress. She said:

  … there’s all sorts of good stress; I just came back from the gym and believe me I stressed my body and I’m incredibly happy. And so this is a stress where you rise to a challenge, you control it and that’s something that we’re evolved to do very well, you know, the zebra runs away from the lion and so forth. So we can do all the kind of acute reaction to stress and acute stress situations very, very well. But what happens is that in the long term if the stress situation is something that the individual sees always as a threat or continues to see threatening rather than challenging situations, doesn’t identify resources to cope, etc. etc. That’s the kind of stress that’s been long known to have clear clinical outcomes which are poor outcomes. So that’s been known from a number of studies for a number of years. But the part of the puzzle that we added in was that we said well let’s look at ageing of cells right at the heart of the cell’s decision to renew or not and that’s the decision that a cell makes based on many things. But one of them is whether it feels its genetic material is at risk, and if the telomere is run down the cell will stop operations and will not self-renew.

  So we looked and said, does the running down of telomeres with ageing have any relationship to stress? And we found in one case a causal direction that the chronic stress was, we think, causally related to the telomeres running down. In other words – the longer the number of years a person was under an objective stressor … the more years the person was under stress the worse was their shortening of their telomeres over and above what normally would happen just in the normal course of ageing. So that to us was very interesting, because it said somehow chronic stress is having effects on the brain, which we clearly know, which is having effects on physiology in all sorts of ways, and one end result of that is that the telomeres are running down and our cells are losing the ability to renew.

  The attention to detail of my obsessive tendencies re-focussed on a healthy diet and exercise, as the stress of caring for my mother was behind me but the stress of having cancer and a high-needs child was smack in front of me. I was doing everything possible on the conventional medical front, so I turned to my Self. What opportunities did I have to improve? The first thing that raised its sugary head was chocolate. Oh to swim in Willy Wonka’s chocolate stream. I loved the stuff. I cut back on my consumption.

  My breast surgeon recommended I read a well-researched book about new ways of eating to support your body, written by a clinical professor of psychiatry, Dr David Servan-Schreiber, who’d had two brain tumours. He kept cancer at bay for years longer than his prognosis. A friend of his had asked how he was treating his terrain: the body’s underlying health, separate to medical intervention. At the time he was working so hard at the hospital he had a lunch of chilli con carne, a bagel and a can of Coke. He reflected later how this was an explosive combination of white flour and sugar, together with animal fats loaded with omega-6s, hormones and environmental toxins. He had also reduced his exercise and dropped his interest in meditation. He had done nothing to look after himself – to support his body to reduce his chance of relapse.

  After reading his section on diet I had another light-bulb realisation. It was like the decision to stop re-touching door handles and to stop taking ecstasy. This time I immediately excluded all pastries and fried food, in addition to the hot chips I’d already eliminated, from my diet. Easy. I haven’t touched any since and never will again. I modified main meals to include more steamed greens like Brussels sprouts, and I took up green tea to replace my English tea with milk habit. (I converted back to English tea six years on as the taste was too good to miss.) With chocolate I reached for 70 per cent cocoa, which was higher in nutrients and therefore better for you, or I didn’t eat it at all.

  I no longer ‘did’ exercise as a by-product of my passion for rock climbing, where getting rip-roaring fit went with the challenge of solving a difficult crux (the tricky part of a climb). Instead I tripped through the local door of a gymnasium before the sun rose to attend get-fit classes and later became a road cyclist to remain fit. I wasn’t developing a skill to aid a lifestyle choice, but I was fit again.

  Pink bits: can a doctor–patient relationship help heal you?

  In a novel by Joy Williams called State of Grace, a character says, ‘There must be something beyond love. I want to get there.’ The sick man has got there: He’s at a point where what he wants most from people is not love but an appreciative critical grasp of his situation, what is known now in the literature of illness as ‘empathetic witnessing.’ The patient is always on the brink of revelation, and he needs an amanuensis.

  Anatole Broyard, ‘The Patient Examines the Doctor’

  One year on from my mastectomy and reconstruction I entered Dr Theile’s office to cross one last t. I was getting my areolas tattooed. It was the finale to a year-long process to reconstruct my breasts.

  What’s the dye made out of? I asked.

  Dr Theile was leaning over me on the surgical table, penning where he’d place the areolas on my breast mounds. I don’t know, he answered. His nurse was beside him, handing him instruments.

  Great!

  The nurse smiled down at me. I’d come across a little harsher than I meant.

  He continued, But the cosmetic tattooing done on women’s faces is a vegetable dye, so it wears off eventually in case they don’t like it.

  That’s a good idea. The white lights of the room and overhead lamp meant I could talk more easily with my eyes shut. Eyes open I was distracted by the room.

  Dr Theile had me sit up, lean slightly back and then lie down again. He squinted and leant back to see the best place to tattoo my areolas. He was an artist working on a composition. He went over to a long bench and mixed up colours. Do you want browner tones or pinker?

  You know, this may sound silly, but I haven’t even thought about what colour I’d get them, not once.

  He turned and assessed my skin tone. You’re more pink.

  I nodded. Yes, I agree, pink it is.

  The pink ink Dr Theile had worked up was very bright.

  I don’t want fluorescent areolas.

  He chuckled. It’s okay – they start out brighter than the end result. After six weeks they fade considerably to flesh tones.

  Good … where did you learn to tattoo? It had interested me ever since I found out that Dr Theile was doing it and not a cosmetic tattooist. I envisioned a white room with surgical students wearing pink aprons and mouth-to-mouth dolls with pierceable skin laid out on tables.

  I used to get a medical tattooist to do
it, but she became too busy and my patients had to wait too long to complete their reconstructions … Dr Theile frowned, genuinely distressed at the memory of women’s final results getting drawn out. So I started doing it again. Originally I learnt to do it in America. I went over there for further surgical training and they taught me how.

  I mumbled, impressed that he had training from highly qualified Americans au fait with cosmetic surgery. All good as far as I was concerned.

  Have you read Direct Red? I teased.

  Dr Theile’s back was to me as he put down an instrument. No, I’m very slack.

  I had lent the book to him the previous year, hoping he’d find that his early experiences of surgery resonated with the author’s – that he could enjoy his highly specific knowledge explored from another’s perspective. I figured there were few good surgeon-writers.

  His nurse reassured him, That’s a bit rough on yourself, isn’t it?

  You are busy with work, plus you have a family, so it’s okay. I softened the tease.

  I read Direct Red: A Surgeon’s Story several months after my mastectomy because my friend Sara had told me there was a mastectomy scene involving a very young woman. I psyched up for it. However, when I read the book’s opening line – I am about to faint. Methylene Blue. Acridine Orange. I have been holding someone’s neck open for seven hours – I was hooked.

  The author, Gabriel Weston, gave up a training position in ear, nose and throat surgery in London for a fixed surgical job with less status after meeting Thomas, another woman’s baby on a hospital ward. Thomas had inspired her to give herself more time with her own baby. Up until then she hadn’t felt an overwhelming need to include more home time. Scenes from the book have stayed in my mind, conjured by her eloquent, haunting words. For example, she assisted on an emergency procedure with a man who’d struggled furiously with the anaesthetist trying to sedate him for an operation on his aortic aneurysm: a swelling or at worst rupture at the aortic wall. The aorta runs out of the left ventricle of the heart and is the largest artery in the body. It goes down into the abdomen, where it heads off into smaller ventricles, common iliacs:

  Looking down, I peered into the trough of Mr Cooke’s emptied abdomen, and could see it filling with blood so fast that the outline of the gushing source was visible beneath the red meniscus. Like when you fill a paddling pool with a hose and it’s half full and you can see a knuckle shape on the surface just above where the hose is.

  The man’s situation resonated with the experience of my post-partum haemorrhage, where my internal iliac arteries were tied with dissolving stitches to stop massive blood loss and mortality. Before they’d wheeled me in at 2 a.m. to undergo an emergency operation to save my life and uterus, I had catching pain in my right shoulder, a sign of internal bleeding. I read words of surgeons’ and doctors’ medical work and thought of the patient’s side – my side. I’d had hands like the author’s inside me moving my bowel out of the way and stitching me back together again.

  Dr Theile knew my body as only a surgeon could. He also had interests outside of plastic surgery, like mountaineering, which had once left him with a broken leg. He liked to travel with his family and read, and I was sure there were other pursuits I had no idea about. He hadn’t read the book, but I left the copy with him all the same.

  As the American writer, literary critic and editor Anatole Broyard said, I was a patient wanting an amanuensis. This man as surgeon transformed my body. I wanted a two-way acknowledgement. Dr Theile was the best type of medical specialist: someone with a life that informed his humanity.

  A new normal: is how I look important?

  I saw my life branching out before me like the green fig tree in the story. From the tip of every branch, like a fat purple fig, a wonderful future beckoned and winked. One fig was a husband and a happy home and children, and another fig was a famous poet and another fig was a brilliant professor, and another fig was Ee Gee, the amazing editor, and another fig was Europe and Africa and South America, and another fig was Constantin and Socrates and Attila and a pack of other lovers with queer names and offbeat professions, and another fig was an Olympic lady crew champion, and beyond and above these figs were many more figs I couldn’t quite make out. I saw myself sitting in the crotch of this fig tree, starving to death, just because I couldn’t make up my mind which of the figs I would choose. I wanted each and every one of them, but choosing one meant losing all the rest, and, as I sat there, unable to decide, the figs began to wrinkle and go black, and, one by one, they plopped to the ground at my feet.

  Sylvia Plath, The Bell Jar

  A year on I remained cancer free.

  In the mirror my once pale chemo-face held more lines. There was a darker hue under my eyes than before. I was more tired than before. My hair was thicker, darker and greyer. The curls returned. My eyes had a clarity to them: there was no rose-coloured glass through which I looked out at life.

  When I turned from my face to my body only the chest area revealed my cancer story. The rim of my portacath’s ten-cent dimensions no longer thrust out of my skin, making me look vulnerable. In place of the portacath was a 2.5-centimetre red scar.

  I had perfect-sized boobs with a hatching of scars where my nipples and areolas used to live. These were the just-discernible remains of my nipple surgery. My pink-tattooed areolas set a target for the eye amid the scars on my chest.

  But this was all surface.

  On the inside there was so much more to see.

  There were significant changes due to menopause. The sudden drop in oestrogen meant my joints ached. My hands were the worst: my knuckles had swollen and stiffened, and had a rheumatoid-arthritis kind of throb.

  The dry riverbed patterning on the skin around my nails remained the same, though the tree rings on my nails from my chemotherapy cycles had disappeared. I maintained hand creaming but the skin was drier, rather like dead skin that needed to flake off. Over the rest of my body my skin had lost its moisture. My youthful beauty was fading, fast. My mirror held a mature woman’s face – a new beauty – wizened contessa.

  In the last visit with my oncologist I enquired about all the joint pain, especially in my right elbow, which hurt to the point of distraction. There was no concern regarding cancer secondaries in my bones because of my symptoms, but rather the pain was likely some slow-healing damage from picking up Celso. I needed a chiropractor to check me out, not an oncologist. Of course, with any pain or bodily discomfort my first thought turned to The Big C.

  To calm down and combat the joint pain, I found time and exercise the best panacea. The medicos said that the significant changes due to menopause would ease somewhere between one and five years.

  At the end of September a horrible taste, akin to chemo-mouth, returned for a week for no apparent reason. When I didn’t have metal mouth I drank and ate a lot of foods rich in anti-oxidants like blueberries, powdered flaxseed with yoghurt (cottage cheese was better to get the flaxseed absorbed but I didn’t like its mashed cat-poo taste) on muesli for breakfast, any foods with plenty of garlic, onion and turmeric, and green tea. Dr Servan-Schreiber made an empowering comment about the right foods when he said that there were three meals a day you could use to do something about cancer.

  I also returned to some bad food habits around sweet things, and had to rein myself in on cake and biscuit consumption, but desserts are so much more fun to bake, I’d argue.

  I got a nasty cold or flu repeatedly, which might’ve been the cause of my foul mouth. In my second year post-chemotherapy, though, I was proud of my body and what it had coped with. It was not so robust. My strength had slunk away from my hands and arm muscles. I had to hand tight lids to B to open. It used to be the opposite between us.

  I got intense night sweats so I was sleep deprived. Because of all of the above my memory was cruddy, really cruddy – to the point that I became seriously concerned about future learning
and retention of new information; I thought I was becoming cognitively dumber.

  In conversations with strangers or waiting in rooms I could instantly turn red and glisten with sweat. Normally someone doing this is stressed out about something or really embarrassed. But no, I was just heat surging like all the other women before me. People responded simply and really well when I told them I was menopausal and to ignore my sweating self.

  I went from a rangy size 8 to 10 to a curvy size 10 and had to exercise regularly to remain so. I didn’t notice my reconstructed breasts, apart from an obvious cleavage in low tops. Sometimes, and this seemed odd, I got phantom tingling where my nipples used to be. It reminded me they’d departed. Also the fronts of my breasts were colder to the touch, especially along the scar lines.

  Most of the time I loved my body. I was 37 and had experienced many invasive surgeries, from the horror that was Celso’s birth to surgery for cancer, and the gruelling regimen of chemotherapy plus daily drug taking to suppress my hormones from attempting to develop another cancer site. I was not perfect in body, but with the return to health and fitness my body felt perfect.

  Heightened experience: is life’s meaning found in connection with others?

  When you climb

  out a black well

  you are not the same

  you come to

  in the blue air

  with a long sore scar

  circling your chest

  like the shoreline

  of a deep new sea

  your hands are webbed

  inviting you

  to trust yourself

  in water stranger

  and wilder

  than you’ve ever known

  your heart has a kick

  your eyes have

  a different bite

  you have emerged

  from some dark wonder

  you can’t explain