Cancer

Fighting for treatment

These days, having cancer isn't enough to get you into the hospital -- you have to really be sick.

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Fighting for treatment

Could anything be worse than coming to see the doctor about a sore throat and finding out that what you have is not a sore throat at all but an aggressive, malignant tumor?

Yes.

What’s worse, far worse, is finding out that you have a malignant tumor and not being admitted to the hospital then and there because the doctor is unwilling to play the elaborate intake game — leaving you on your own to negotiate the Kafkaesque system to arrange diagnosis and treatment. Because even if you have a deadly cancer and great insurance coverage, the doctor must provide an airtight excuse to slip you in past the bean counters and case reviewers. Otherwise you can waste a couple of your last precious few months trying to force your way through a healthcare labyrinth that is blind and deaf to your suffering.

On a recent and relatively calm night in the emergency room, I picked up the chart of a 55-year-old woman complaining of a sore throat. According to the triage nurse’s notes, the patient had just finished a course of the antibiotic Biaxin, but her throat remained swollen, which suggested a viral infection or a resistant strep.

I entered the examining room to find a diminutive Asian woman — probably Cambodian, judging from her 14-letter, five-syllable last name — accompanied by a slender daughter and the girl’s boyfriend. I ran through a few perfunctory questions. The patient answered in broken English, with an occasional assist from the kids: Fever? Cough? Trouble breathing? No, no, no.

Smoker? No.

Open wide.

Most adults don’t open their mouths properly. They bunch their tongue up toward the palate, blocking the view of the tonsils, and this woman was no exception. Even before I reached for my tongue depressor, I noticed a bulge where the woman’s left tonsil should have been. My interest ticked up a notch: a possible peritonsillar abscess. Sometimes a strep infection can escape the antibiotic assault and grow into a pocket of pus in the lymph tissue behind the tonsil, creating a potential hazard to breathing.

The abscess can be drained easily enough with a sharp needle jab, as long as care is taken not to puncture the internal carotid artery, millimeters away. A tiny mistake can result in massive bleeding and a howlingly disastrous surgical emergency. This is the kind of fun procedure that ER doctors salivate over: a quick fix, an element of danger, topped off by the patient’s admiration and heartfelt gratitude.

But as I positioned my stick and coaxed her tongue away from the roof of the mouth for a better look, I saw, instead, an angry red mass the size of a golf ball hovering over her larynx. No abscess, a tumor: Nothing else occurred to me. As I pulled back, trying to compose my face, I brought my hands up to feel the sides of her neck. There it was again on the left, just inside and underneath her jaw.

I launched into a new string of questions. You don’t smoke? No, you told me that already. Fever? No, you answered that, too.

Have you had TB? The daughter and boyfriend looked at each other, then at the woman. She smiled, uncomprehending. Huh? TB? A quick huddle with the kids: didn’t think so. I kept probing along her neck from the center of the bulk to the margins. The ball felt firm as wood.

Do you do a lot of gardening? Work as a florist? No.

Damn. She’d just ruled out a diagnosis of sporotrichosis, a definite long shot but the last soothingly benign explanation. I leaned back, sadly regarding her deferential smile.

How long have you noted the swelling? Two weeks.

No more than that? Are you sure? No, just two weeks.

Bad answer: This monster was growing rapidly.

No trouble breathing in all that time? No, none.

I knew what I had to do next: call an ear, nose and throat specialist. I hesitated because, well, they can be trying. After taking an hour or so to respond to a page, they usually want to know just one thing: Is the air passageway obstructed? If not, send ‘em to the office in the morning. If yes, intubate and admit to ICU and they’ll see the patient the next day. The most common reason for an ER call is uncontrollable nosebleeding — a messy, unpleasant affair. So from the ENT doctor’s point of view, the ER calls with nothing but trouble.

Worse still, I had on my hands an uninsured patient who might need surgery. There’s no overemphasizing the callousness of modern medicine when it comes to patients with no money and no resources, and I feared I’d have to discharge this woman with little more than an empty promise that someone else would see her in a day or two.

Why empty? Because on-call doctors are pros at rigging the game against uninsured patients. Here’s how it works: Hospitals receiving Medicare and Medicaid are legally bound to treat all patients — insured or not — who turn up at the door. To fulfill this obligation, the hospital enters into an elaborate bargain with specialists. The facility grants them lucrative admitting and operating room privileges; in exchange, the physicians agree to be on call occasionally and treat patients who appear during that shift no matter what their financial circumstances.

On their call day, they have to take all comers, most of whom are uninsured or on Medicaid, which generally pays less than private insurance plans. If the patient needs surgery or immediate treatment, the doctors have to rush to the hospital. If the problem is manageable on an outpatient basis, the specialist is supposed to grant them at least one office visit. But patients discharged with just a name for follow-up often end up right back in the ER in a day or two, unable to make an appointment in anything less than weeks or months. Even fully insured patients can be given the runaround, but their chances of gaining a physician’s sympathy are better.

Young doctors just out of residency training happily grab lots of call days for a couple of years so they can establish a reputation with the physician community and build a valuable referral base. In time, the referrals for insured patients pile up, superseding their interest in hits from the ER. That’s when they get a little testy about what they see as our ‘dumping’ patients on them.

One of the first things I do upon starting a shift is scan the call list to see who’s on: the good, the bad or the ugly. The ENT doctor on call this particular night was an unknown entity. I recognized his name, but I had never called him before. He returned his page quickly — an unexpected but positive omen — and asked, as I knew he would, about her airway.

Please understand: I am willing to lie. It may be in a patient’s best interest for me to paint a bleaker picture simply to facilitate admission to the hospital or, at a minimum, to lure the on-call doctor in to make an evaluation. Although this woman was breathing comfortably, the easiest way to force the ENT doctor’s hand would have been to report that her trachea was in imminent danger of obstruction. The downside of presenting a false clinical picture is that when they come in they’ll think I was either lying or stupid — and they’ll remember it the next time I have to call. So I use this tactic sparingly.

Since this ENT guy had responded so promptly and sounded concerned, I decided to tell the truth. I said she was breathing fine but that the mass was huge and had erupted in a mere two weeks. He mulled it over for a moment. Then he asked me her name and performed the doctor’s version of racial profiling. “Southeast Asian?” he said. “High incidence of oropharyngeal carcinomas in that population.”

Uh, oh. No way out.

“So you want me to send her to your office tomorrow?”

This was a defeatist’s question. Fifteen years ago, during my training, it would have been unconscionable for me, or anyone, to toss a patient back into the street with a diagnosis, or even a suspicion, of cancer. But now compassion — the system’s not mine — competed fiercely with the bottom line.

Once again, the ENT surgeon paused and considered my question. “If her airway’s not obstructed … Well, let’s get as much of the pre-op studies done now as we can, though, and see what we’ve got. Is that OK?”

It was more than OK: He was obviously going to look after her very carefully. After running down a list of baseline labs to order, he gave specific instructions to get a CAT scan of her neck area.

I returned to the patient and her family and admitted that while I didn’t know what the mass was, it could be something bad. A specialist was already involved and might be in tonight, tomorrow at the latest. I couldn’t tell her anything more until after the scan. I spoke slowly and accompanied my speech with a lowered gaze, a lot of sighs and meaningful eye contact: The classic shorthand way to convey that it was bad-news-with-worse-coming.

They met me sigh for sigh, lowered gaze with lowered gaze. They understood. The woman again offered me that lovely smile.

An hour later, I found the ENT doctor and radiologist in the CAT scan suite, film hanging on the light-box. They were standing before the mosaic of black and gray images, silent in the way that only means careful calculating, weighing, studying: sarcoma or lymphoma? high grade or low? pushing up against normal structures or chewing them up?

“How bad?” I asked.

They turned to me, startled at the interruption. “Oh, hi,” the ENT guy said, shaking my hand and introducing himself. He pointed out what looked ominous on all the images: an unnaturally round black-gray sphere. If he had to guess, he’d put lymphoma at the top of the list, an undifferentiated sarcoma next, perhaps thyroid carcinoma third. Bad, worse, terrible. TB would have been nice, under the circumstances. He sighed deeply. “But it’s not TB.”

He’d give her maybe six months. He said it as if he knew for sure.

As we walked back to the ER, I asked about the surgical options. “I could take it out, but these bleed like stink,” he said. “It’s better to do a small needle-biopsy to get a tissue sample and then let chemo shrink it down. I’d really hate to operate on it. Her airway’s OK, right?” I told him again it was. “Yeah, you only go in after these if she’s going to obstruct.”

Meaning if it’s going to choke her before it kills her.

I didn’t accompany him into the room and didn’t ask afterward what he’d told them. I simply thanked him. It was reassuring to know that someone with cancer and no money could still get admitted to the hospital right away. He smiled and shrugged. “You know,” he said, “I think you were wrong about that airway. It is compromised. She’s retracting a little.” He shot me a significant look as he said this.

“What? No, she’s …” I paused. “Oh, yeah. That’s right. She was working a little hard to breathe, wasn’t she?”

The utilization reviewer would never allow the hospitalization otherwise. The ENT doctor would be counseled about a ‘bad’ admit and he’d have to watch himself a bit more carefully in the future. So, yes: She had respiratory distress.

A day later, back in the ER, I scanned the on-call roster at the start my shift. The same ENT guy was listed. I asked the secretary to put in a page. Again, he answered promptly. I was really beginning to like this guy.

Any news?

The needle biopsy had been performed that morning, he told me. Lymphoma, as he had guessed. Aggressive, invasive, ugly. Probably six months, like he’d thought. He was lining her up for chemo to shrink it so it wouldn’t compromise her airway. However long she lasted, and whether she died at home or at the hospital, we both knew it would be a nasty death.

“When it’s my turn,” he said, “just give me a six-pack and a fishing rod.”

J.B. Orenstein is a physician practicing pediatric emergency medicine in Fairfax, Va. His writings have appeared in the Washington Post, Annals of Emergency Medicine and Pediatrics.

Kate Hudson’s cancer horror show

The bubbly actress's horrific movie, "A Little Bit of Heaven," turns terminal illness into a twee joke

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Kate Hudson's cancer horror showKate Hudson in "A Little Bit of Heaven"

Ladies and gentlemen, we are gathered here today to mourn a sad loss. A luminous, unique presence who ably graced our lives and then was snuffed out far too early. A moment of silence, please, for Kate Hudson’s career.

It seems like only yesterday we were beguiled by the lively, bohemian Penny Lane in “Almost Famous.” But it’s been a painful decade since, as I know many of you gathered here can bear witness. Those of you who steadfastly supported Hudson over the years, who paid good money for “Bride Wars,” for “How to Lose a Guy in 10 Days,” for “Raising Helen,” “You Me & Dupree,” “Fool’s Gold,” “My Best Friend’s Girl,” “Alex and Emma,” “Le Divorce,” and “Something Borrowed” — you know what I’m talking about. You’re heroes for sticking around this long. That’s why it’s both tragic and necessary to come to the end of our journey now, to let her go off to a better place. The D-list. It’s called “A Little Bit of Heaven.”

The movie, which opens in theaters Friday and is available on demand on iTunes, tells the story of Marley, a free-spirited young New Orleans advertising executive. Marley has good friends — including a pregnant lady and a gay black man, because she’s awesome. She has an adorable dog and a penchant for casual sex and whimsical bike riding. But no sooner can her pals offer a champagne toast celebrating the “youngest and hottest vice president” in her company’s history than things start to go terribly wrong. Like millions of helpless white people every day, Marley begins having visions of a cool African-American as God. There is no known cure. Once Marley starts chatting with Whoopi Goldberg in that ethereal, cloud-heavy set, you know she’s in trouble. She’s got terminal Movie Cancer. Naturally, this is the perfect opportunity for her to get in touch with her feelings, have many scenes of hugging her crying costars, and start banging Gael García Bernal. It’s a little weird because he’s supposed to be her oncologist.

It’s not easy making entertainment out of cancer. Yet Showtime’s “The Big C” has mined the terrain to Golden Globe-winning effect. Llast year’s “50/50,” based on writer Will Reiser’s real experiences as a young person suddenly diagnosed with a potentially fatal diagnosis, became a critically acclaimed sleeper hit.  And when you’ve got a condition that will directly affect roughly 41 percent of us, there’s surely some dramatic and comedic resonance to be found in the subject matter. Speaking as someone who has had Stage 4 cancer and endured a clinical trial, and who believes firmly that anyone who’s been through all that ought to at the very least get to bang Gael García Bernal in the Big Easy, I am the ideal audience for this movie. Why, then, somewhere around the inevitable shopping spree montage, did I scrawl the words “WORSE THAN CANCER” in my notebook, and then underline them fiercely in the darkness?

Maybe it’s the way Bernal, as a doctor with seemingly zero ethical problem about sleeping with his terminally ill patient, says “schmuck” – because he’s supposed to be Jewish. Maybe it’s because Kathy Bates, as Marley’s mom, looks like she’s trying so hard with such unforgivable material. Maybe it’s because the biggest audience laugh of the whole movie came when Hudson said, with a straight face, “Come on, Doc. Level with me.” Maybe it’s because when Peter Dinklage, as a male escort, says the title of the movie, it turns out it’s his character’s nickname. Little Bit of Heaven. Oh, human suffering. Truly, this is what it looks like.

Mostly, brothers and sisters, I think we know why this movie causes a pain all the medical marijuana in the world can’t make a person forget. It’s Hudson. Hudson, whose character ostensibly goes through chemo, yet never loses a bouncy curl off her blond head. Who enters a trial but quits with a shrug about “quality of life.” Hudson, who, thanks in large part to director Nicole Kassell and first-time screenwriter Gren Wells, willingly put herself in a movie about cancer that seems to have been created by people who’ve only had cancer described to them. Hudson, who chose to place herself in the pantheon of life-affirming doomed sick girls like “Sweet November’s” Charlize Theron and “Autumn in New York’s” Winona Ryder and the mother of them all, “Love Story’s” Ali McGraw, and comes across as a shrill, affected parody of her hair-tossing Almay ad persona.

It’s an occupational hazard that any actress with marquee value will sometimes find herself in romantic schlock. Yet women like Renee Zellweger and Sandra Bullock have managed to balance their turkeys with riskier performances and a broader range of films. Hudson, in contrast, has remained frozen in time, forever doing variations on her young rebel with a heart of gold, Penny Lane. So let us remember Hudson today not as the husk of an actress she became, endlessly subjecting moviegoers to lazy dreck. Let us remember her as bright, fearless Penny. She’d want it that way. Let us move on, and spare ourselves the ordeal of further films in which a daffy blonde flashes a megawatt smile and recites terrible dialogue and dances adorably even though she’s, like, dying, you guys. For truly, life is much too short for such trials.

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Mary Elizabeth Williams

Mary Elizabeth Williams is a staff writer for Salon and the author of "Gimme Shelter: My Three Years Searching for the American Dream." Follow her on Twitter: @embeedub.

Lessons of a baby bucket list

Avery Lynn Canahuati accomplished a lot in her six months of life. Imagine what the rest of us can do in a lifetime

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Lessons of a baby bucket listAvery Lynn Canahuati (Credit: http://averycan.blogspot.com/)

What have you accomplished since November? What dreams have you fulfilled? In that time, Avery Lynn Canahuati threw out the first pitch at a baseball game, got a letter from the president and dressed up like a troll doll. She experienced deep love, and changed the lives of her family and friends. And that’s just what Canahuati got done in the first six months of her life. They were also the last.

Canahuati was born in Texas on Nov. 11. This past Good Friday, she was diagnosed with spinal muscular atrophy (SMA), a group of rare neuromuscular diseases that, in her case, were terminal. “We asked our doctors specifically if there is anything. Is there trial drugs, anything out of the country?” her mother, Linda, told CNN this week. So after “sitting around for two days crying and being devastated, since there is no cure and there is nothing we can do,” her father, Mike, decided to make the most of what was left of his daughter’s cruelly brief expected lifespan. Writing in Avery’s voice, he created a blog — and set a few goals.

“Imagine you’ve been diagnosed with an incurable genetic disease and you are told you will not only lose your ability to walk and move your arms, but you will die between now and the next 18 months. What would you do?” Avery’s blog reads. “This has become my reality. But before I die, there’s a few things I’d like to accomplish … this is my bucket list and my story.”

During an adventure riddled with so much good humor, so many images of smiling, laughing people that it’s damn near impossible to read about it without dissolving into a sobbing, balled-up wreck, Avery and her family went about achieving the feat of simply “celebrating life.” Avery’s objectives were as seemingly mundane as to “stay up past midnight” and “keep smiling even after surgery” — and as grand as raising a million dollars to fight SMA. Along with good-natured jokes about man-purses, hospital cribs that look like “Lockup: Texas Children’s” and insanely cute pictures of a smiling baby with a chick fuzz hairdo, are the harrowing realities of life with a fatal disease. There were tubes and operations and weight loss and reflux issues that affected her breathing and swallowing.

For all the items Avery got to cross off her list in just a few brief weeks — “eat ice cream,” “meet someone else with SMA” — there are many she didn’t. She didn’t, as she’d written she’d hoped to do, graduate college. Or get married. She didn’t play in a softball game or ride a Ferris wheel or attend a birthday party. She died suddenly on Monday afternoon, when, as her father wrote later, “one of her lungs collapsed and she went into cardiac arrest.” And one last time in Avery’s voice, he wrote that her final dream was “spreading awareness and helping to fund a cure for my friends.”

We live in a mortality-denying culture. Just this month, an Aflac WorkForces Report announced that “sixty-two percent of U.S. employees say it’s not likely they or a family member will be diagnosed with a serious illness.” Yet disease comes for many of us, and death comes for everybody. That’s not an abstract concept. It’s the truth. I didn’t always get it, either. But I certainly understand that much better now than I used to, after watching a few of my loved ones die over the past year while my best friend and I faced our own life-threatening cancers. And I’ve got to say, death really clarifies the hell out of one’s to-do list.

Avery’s goals were not her own, of course. They were the ones her parents set to maximize her remaining time. But it’s easy to see in her photos what a cheery, friendly baby she was, and the ways in which her sunny nature inspired others. It’s easy to see a mother and father who could have become embittered by a devastating twist of fate, who instead chose to fight fear with love, pain with compassion, who are trying to use their loss as a means of raising awareness and doing service for others. They did it in a matter of weeks. Think of what the rest of us could do with a few decades.

You shouldn’t have to wait for a diagnosis to consider the possibility that you are going to die. You are. Maybe even in the next six months. The question is: What will you do with the time you have left? Will you eat a cupcake, get a kiss? Avery did. Will you reach out and connect? Will you love and be loved? Will the ones you leave behind be able to call your life a “celebration” too? As Avery and her parents tell us, “You can live life dying or you can die living life.” Imagine you’re on the clock. Start acting like it. Go.

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Mary Elizabeth Williams

Mary Elizabeth Williams is a staff writer for Salon and the author of "Gimme Shelter: My Three Years Searching for the American Dream." Follow her on Twitter: @embeedub.

Words we had after he died

When we lost my husband to cancer, my family's world went upside down. We made sense of it the best we could

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Words we had after he died (Credit: Tinga via Shutterstock)

On the day my husband died, our daughter Allison started screaming my name from her bedroom, where she’d taken refuge. I burst open the door, imagining she had hurt herself, but she was just standing there in the center of the room. “Mom. Mom,” she said. “You are a widow now. A widow. I don’t want you to be a widow. You can’t be a widow.”  I had to agree: It just didn’t seem possible.

I tried to hold her, but she was hyperventilating a bit. “I’m ‘the girl whose dad died when she was 13′?” she choked out. “Oh my God. That’s who I am now.  When people ask me what my dad does, or how we get along, or anything, that’s how I will have to answer: ‘My dad died when I was 13.’”

Words. Labels for things, for people. We spend our whole lives making sense of them, I guess. Figuring out which one is the best, most accurate choice.

So many words become insider jargon in families: We are the only ones who know that “black toast intolerant” means “lactose intolerant”; that “minimisize it” means “minimize it,” which big pot is the “pasta pot.” These special languages that families create are another way they are individualized, that a family becomes a unique organism of its own.

Of course “widow” cannot apply to me. That word applies to little old ladies in fairy tales or someone who lives far, far down the street. My daughter cannot be identified forever by this one event.

But she is, and I am a widow, and in the months immediately afterward, we preferred life in the anonymity of Philadelphia over our small South Jersey town where even going to the convenience store means acquaintances’ pseudo-counseling, or others who steal quick looks at us, then look away, as if we are contagious.

We spent weekends in Philadelphia, and even though we live 15 minutes away, we slept on the floor of my brother’s one-bedroom, three-story walk-up, rather than in our own beds in our own four-bedroom, three-story home.

The kids learned that word, “walk-up,” and the phrase “wiz wit,” to get cheese sauce and onion on their cheesesteaks, and though they already knew what a contortionist is, and what break dancing is, and what a bong is, they get to see all of these things in Rittenhouse Square Park,  mere blocks from my brother’s place.

They learn these words because I could not sit my children down and say, here are words that changed your life: PICC line, ascites, carcinoid.

When Don was in and out of the hospital, and I learned more and more about his disease, its treatments, their side effects, I thought about language a lot, how I now knew all these words I had never even heard before. The gastroenterology team had to be updated about what the oncology team had said, and the interventional radiology people needed to know his newest albumen levels. There was a note in Don’s chart, “Ask the wife.”

“The wife”: my old label.

I would sit in the hospital and think about when we were first looking to buy a house, and how I was so proud when I could “speak real estate.” We would go out each evening with our real estate agent and look at six, seven houses a night.  I sat on the window seat of one home, nursed our baby Allison, and Don did a slow walk around the perimeter of the yard.  He came in and saw us there, and said, “Oh, so this is the one.”  And everything felt right and rich and I wanted to go to sleep right there, on the bare wood of the empty house that just that moment had become our home.

Once the house was ours I would wander around Home Depot and marvel at the language spoken there, how I felt like some mole who had just come up from underground to discover a whole other world going on above. The “wife” label, the “mother label,” the “homeowner label” all new; none felt generic, at least to me, they were points of pride and exactly where I wanted to be.

About two months after Don died, the kids and I were at a friend’s beach house and we watched the new version of “Freaky Friday.”  In it, a widow remarries, much to the teen daughter’s (initial) dismay.  When the movie was over, Hayley, 11 years old at the time, said, “Mom. You can get married again. In three years. Don’t get married again for three years.”

Allison stood up and just started yelling at Hayley. “She can’t get married again in three years. She can’t get married again ever. I’m not going to have a stepdad.”  Christopher, only 5 years old, said, “I would like a dad, Allison.”  Allison yelled at him, too, and soon I was saying, over and over, “We don’t have to talk about this right now.”  And none of us could understand what the other was saying.

When Allison was 5 or 6, the boy from across the street, a year older and therefore much wiser, took it upon himself to teach her how to properly pronounce “yellow.” She said “lell-o” and I hadn’t had the heart to correct her. The charm of her mispronunciation mattered more to me. I listened from the kitchen as he broke it into two syllables and made her repeat, again and again, “Yell-oh, yell-oh.” I wanted to rush in and stop him but knew that I couldn’t, that it was time, that it was natural and organic and even lovely that another child would teach her.

In other words, I couldn’t stop her learning, like I can’t stop this, can’t take away this label, this horrifying application of the word “widow,” of the phrase “my dad died when I was 13.”

Life went on and when I’d be out with the kids one or the other would say, when it seemed like all the other families had a mom and dad, “I hope people don’t think we’re divorced.”  Divorce implies decisions, and no choice had been made in the shape of our family.  The use of “we” was endearing to me, and only made my heart break more.  We would go places with my brother Steven and waitresses or ride attendants or whomever would assume that Steven was my husband/their father, make some kind of reference like, “You’ll have to ask your father” when a child asked for more Coke; none of us corrected these ignorant strangers.  The kids were simply more comfortable when we had that male figure with us, when we looked “normal” to the outside world.  They needed my brother as a placeholder for what was missing.

I have my label and the kids have their phrase, “my dad died when I was 13,” or 11, or 5. I fill out forms and I get irritated when the choices are “married” “single” or “divorced.”  But when “widow” is an option — even now, seven years later — I think of that first day and Allison’s horror at the term. The kids are now old enough that they have to sometimes fill out their own forms.  They tell me they sometimes write “deceased” and sometimes just cross the father’s info section out. I didn’t know when to take off the wedding ring or what to do with it when I did.  I don’t know when the transition happens between being a widow and being widow-ed.  The label is the label no matter the verb tense.

I have been dating someone for five years and I still choke on the word “boyfriend.” I could not even bring my tongue to the roof of my mouth for the word “love.” I asked my therapist why, when friends all around me profess love within the first two weeks of a new relationship. “What is wrong with me; why can’t I say it?” And she said, “Because you know what it means.”

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Kathleen Volk Miller is co-editor of Painted Bride Quarterly, co-director of the Drexel Publishing Group and an Associate Teaching Professor at Drexel University. She is a weekly blogger (Thursdays) for Philadelphia Magazine's Philly Post and is currently working on a collection of essays. Follow her @kvm1303.

Look at my scars

The remnants of my own illness have taught me that when it comes to difference, don't stare -- but don't turn away

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Look at my scars (Credit: Natalia Klenova via Shutterstock)

“Do I freak you out?” she had asked.

It was the kind of question adults rarely pose. But Abigail (a pseudonym, like some other names in this piece) is 8, and she doesn’t have any qualms about being direct. The person she was asking, my daughter Beatrice, likewise didn’t hesitate in her reply.

Abigail is new to our school this year. She is in every way a typical second-grader, except that she was born without a left hand. It’s a trait that makes her undeniably noticeable, and so, sometimes, people ask questions. Sometimes Abigail has questions of her own. Sometimes, when you’re different, you want to know.

When Bea told me what Abigail had inquired about a few weeks ago, I’d winced a little, wondering how my child had answered. Had she passed whatever test Abigail was giving? I know how frank Bea can be, how she walks behind me when we’re out in public, checking whether the shiny, taut expanse of bare skin on my scalp is visible. “Mom, your bald spot,” she’ll say when we’re in a restaurant, fussing with locks to try to hide the five-centimeter circle where, a year and a half ago, I had surgery to remove cancer.

I know that Abigail’s question haunts many of us who are physically different, in ways both small and large, either by birth or circumstance. It plagues my friend with accident scars on his legs, who’s already nervous about summertime and exposing his flesh at the beach this year. Maybe it’s a small yet indelible birthmark on the chin. Or it’s a big burn. Or a missing limb. Does this make you want to look, or want to look away? Do we make you uncomfortable? Do we freak you out?

“It’s a thing that has to get explained,” says Natalie, a New York executive who’s had three serious melanoma surgeries and lives with ongoing psoriasis lesions. “For me, the anticipation of that is hard. I think people want to distance themselves from someone who’s had a traumatic event. Somehow you wind up having to reassure them that you’re not contagious, that they’ll be OK.”

Though she tries to be “very open about my illness, because I want people to get it,” Natalie admits she has nevertheless “some really upset moments” of unasked for attention. “I once had someone literally cross the road to ask what was wrong with my legs,” she says. “I was feeling really proud of myself for being brave enough to wear the skirt. And this woman came along and destroyed it.” She adds, however, “I don’t feel sorry for myself, and I don’t wear this as a badge. I just want to be looked at as the successful, independent woman I am — but I understand that some people can’t do it.”

It’s true that some people can’t, and there’s loss in there. I used to have a friend who liked taking pictures of his buddies, including me – right up until my diagnosis and my relatively minor disfigurement. Then he never took another photograph of me again. I wonder if I freaked him out.

My friend Frank, a West Coast entrepreneur, understands. A few years ago, Frank had radical surgery for bladder cancer that left him with what he calls a “Guinness Book of World Records scar” that starts at his sternum, loops around, and ends at his pubic bone. He also has a partial hernia that leaves him, in his word, “lumpy” under a shirt.

“I get a lot of people staring. I’m used to it,” he says. “It usually doesn’t bother me. I’m just a little self-conscious when people are peeking out the corner of their eyes in the locker room.” And, he recalls, “one time my wife and I were at Caesar’s Palace lying out in the super-bright, crystal-clear Vegas sun, and this woman next to us asked, ‘What happened to your stomach?’ She was pretty horrified when I told her.”

He’s still sometimes horrified himself. “I look at myself every morning, and I think of all the horrible shit that I’ve been through because of this disease,” he tells me. But when he looks in the mirror, he also sees a mark of survival. “I’m working out and riding my bike to train, and if that doesn’t tell you how I’m doing, go ahead and ask me. I don’t think I look that bizarre. I think I look like a guy who’s had major abdominal surgery.”

As Frank knows, when you’ve been through something life-altering, the first person you have to get to accept your look is yourself. “The first time I saw myself afterward, I thought, That looks very interesting,” says Johan Otter. Johan is a master of understatement. Seven years ago, Johan was hiking with his daughter in Glacier National Park when he was mauled by a grizzly bear. His scalp was torn off; his eye was clawed. He had to wear a halo brace for 12 weeks and go through multiple grafts and surgeries to recover. And then, he says, he had to learn to “push through” his first time out in public again.

“You get used to it,” he says. Besides, he jokes, “I never have a bad hair day.” Otter admits he can still be somewhat surprising to strangers. “Once at Costco this woman said, ‘Oh my God, what happened to your head?’” he recalls. But though he admits, “I’m a vain person just like anybody else,” Otter says that “I’m always extremely proud of my scars. When you go through something like this, people see you with your true self. You learn that what matters is what’s inside.”

It’s not always easy in our perfection-driven culture — where a weight gain of five pounds can be treated as a life crisis and toothpaste brands wage war on dingy teeth and a “puffy face” means you’re no longer considered “pretty” – to believe that within battle scars and what others would call abnormalities, there is a raging, painful exquisiteness. It’s often hard to feel the sideways glances and puzzled stares. But it’s harder still to be overlooked entirely, to feel like the remnants of the trials we’ve endured are the things that make others unable to look at us. We want to be looked at not with pity, not with fear, not with morbid curiosity. Simply with clear and open eyes.

So when Bea told me her friend Abigail wanted to know if she was freaking her out, I hoped Bea had answered honestly. More than that, I hoped she answered kindly. I hoped she didn’t pretend she’d never noticed Abigail’s missing hand, or changed the subject altogether. “What did you say?” I asked her nervously. “I told her no,” she shrugged. “I said, ‘Why would I be freaked? I love you.’” And then I exhaled.

I know life for Abigail – and Natalie and Johan and Frank and everybody else wounded or scarred or born different — is more complicated than that. The things that make us stand out in the crowd define us in a million little ways. They can remind us of the most dramatic, heroic moments of our lives, and of every small indignity and cruelty that has happened since. But what Bea and Abigail got to in the span of one recess period was that life isn’t about seeing past each other’s imperfections. It’s about being unafraid to look at them directly. Because that’s where the love is — in the cracks and the sufferings and the challenges. Life isn’t flawless. But it can be very, very beautiful. That day at recess, Bea told me, she had kissed Abigail, right on the place where her arm stops at the wrist. And they played together until the bell rang, and it was time to go back to class.

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Mary Elizabeth Williams

Mary Elizabeth Williams is a staff writer for Salon and the author of "Gimme Shelter: My Three Years Searching for the American Dream." Follow her on Twitter: @embeedub.

Confronting cancer webcast

Full videos posted for Salon Core conversation on "coming out of the sickness closet" VIDEO

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Confronting cancer webcast

My oncologist says that whoever came up with the phrase “the gift of cancer” has the worst taste in gifts she’s ever heard of. But though it’s not exactly a set of car keys under the seat, cancer has, for the past year and a half, been the gift I’ve been given. And from an initial malignant diagnosis of melanoma through surgery through a Stage 4 rediagnosis through a last-ditch, Phase 1 clinical trial to a recovery that has stunned the research community, I’ve shared this adventure with the readers of Salon. And along the way, you’ve given so much in return. You’ve told me your own experiences with illness, with the healthcare system, with grief and frustration, and with the ways a shattering experience — either your own or that of someone you love — can turn life around. Sometimes even for the better. So it was a unique privilege to get to talk to a few of you recently for a Salon webcast, and answer your questions on life here in Cancer Town. For those of you who couldn’t make it live, videos of the full webcast are posted below.

The connections we find in unlikely circumstances are what get us through them. They’re a gift. Thank you for it.


Mary Elizabeth Williams

Mary Elizabeth Williams is a staff writer for Salon and the author of "Gimme Shelter: My Three Years Searching for the American Dream." Follow her on Twitter: @embeedub.

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