The Cancer Chronicles (5 page)

There are other risks in being female.
Hormone therapies, administered during menopause or pregnancy, have been associated with some cancers. And
obesity, especially in older women, can increase estrogen along with cancer risk. But none of this is straightforward. Strangely enough, excess body fat can actually
reduce the chances of premenopausal women getting breast cancer. And while
oral
contraceptives may slightly raise the odds for cancer of the breast, they appear to reduce the risk of getting
ovarian and
endometrial cancer. Nancy wasn’t using birth control pills and she was far from being
overweight, but she worried, just a little, about another factor: the wine we liked to have with dinner.
Alcohol might also tip the hormonal scales and has been associated for entirely different reasons with digestive
cancers. Snuffed out by alcohol, epithelial cells lining the esophagus must be replaced—more DNA to be duplicated, more chances for
error. There is evidence linking alcohol to
liver cancer, but more certain is
the risk from
hepatitis viruses or long-term
exposure to
aflatoxin, a poison produced by funguses that can invade peanuts, soybeans, and other foods.

You could live your life with a calculator.
Consuming two or three drinks a day might increase breast cancer risk by 20 percent. That is not as bad as it sounds. The chance that
a woman between the ages of forty and forty-nine will get the cancer is 1 in 69, or 1.4 percent. Alcohol consumption would raise that to 1.7 percent.
Even tallness is a risk factor. (Nancy was just five foot three.) An analysis of data from the
Million Women Study found that every four inches over five feet increased cancer risk by 16 percent. A clue to the mechanism may be found in
Ecuadoran villagers with a kind of
dwarfism called
Laron syndrome. Because of a mutation involving their growth hormone receptors, the tallest men are four and a half feet and the women are six inches shorter. Life is not easy for them. The children are prone to infections and adults frequently die from
alcoholism and fatal accidents. But they hardly ever get cancer or
diabetes, even though they are often obese.

When you’re healthy and cancer remains an abstraction, enumerating life’s hazards can be reassuring. Neither of us were smokers, in whom cancer risk is
measured not in small percentages but in
factors of ten to twenty. A twentyfold greater chance of getting
lung cancer—nothing sounded subtle about that. From all the public service announcements and scary warning labels, I assumed that a large proportion of smokers must die that way. It was surprising to learn that
the figure is more like 1 in 8. With a statistic like that, so many details are washed over. Surely the odds are far worse for a lifetime chain-smoker. In search of an answer I came across the
online
Memorial Sloan-Kettering
cancer prediction tool. I plugged in some numbers. A sixty-year-old man who had smoked a pack a day since he was fifteen and now plans to give up cigarettes will have a 5 percent chance of getting lung cancer in the next ten years—and a 7 percent chance if he doesn’t quit. I thought the odds would be so much worse. If the man is seventy and has smoked three packs a day, the risks are 14 percent and 18 percent. That still leaves heart attacks, strokes, chronic bronchitis, emphysema, and other cancers—a variety of ways to die. Smoking damages health and lowers longevity. But when you hear those stories about the uncle who smoked like a chimney every day of his life and never got lung cancer—that is the norm and not the exception.

Geography also plays into carcinogenesis, and there were dangers involved with living in
Santa Fe, New Mexico, a place we loved for its stark juxtapositions. The semiarid plains giving sudden rise to 12,000-foot peaks. The old Spanish families sharing the same dirt street with artists and college professors. And there was the cool, dry, high-altitude air. It was too dry at times, and some summers we would anxiously watch smoke plumes billowing from distant forests. Ashes would fall from the sky, and the sun would set blood orange like images from Revelation. In the night the mountains glowed and erupted in plumes of fire. One of the fires swept through parts of
Los Alamos. A study later concluded that the radiation spread by scorching the laboratory grounds posed
one-tenth the risk of the naturally occurring radionuclides released by the burning pines. Good news, I guess—except for knowing that every
forest fire may pose a measurable risk from nature’s own fallout.

Santa Fe is nearly a mile and a half in altitude, so there is that much less atmosphere cushioning skin and eyes from solar rays. Sweeping from red toward blue on the spectrum, the frequency of
light increases. The higher the frequency, the higher the energy, and by the time you get much beyond violet there is enough energy to break molecular bonds, to mutate DNA. Many times every summer a double rainbow would arch over Talaya, the conical peak at
Santa Fe’s eastern edge. I was almost sure I could see, barely visible at the underside of the arc, a shimmering band of deadly ultraviolet. Beneath that would be colors our eyes don’t know:
x-rays and
gamma rays. Sunlight is dangerous stuff. Yet there is
some evidence, weak and conflicting, that the
vitamin D it helps generate in the body lowers the odds for
colorectal
cancer—while raising the risk for cancer of the pancreas. At least
among male Finnish smokers.

The assaults came from above and from below. As in so many parts of the country, the granitic soils our neighborhood was built on contained tiny amounts of naturally occurring
uranium. Uranium-238 decays, shooting out alpha particles to become thorium-234 and eventually
radium and then radon, a radioactive gas that cannot be seen or smelled. Radon is considered a risk factor for
lung cancer, occupying
a distant second place behind cigarette smoking, and is being investigated for a lesser role in other cancers. It accumulates at a geological pace (the half-life of U-238 is more than 4 billion years, meaning that it would take that long for half a portion to decay). The gas itself lingers only a few days, breaking down into radioactive daughter particles and ultimately into minuscule traces of lead. But it is constantly being generated, and when I bought our house the inspector measured 5.4 picocuries per liter of air, a little above the
Environmental Protection Agency’s “action level” (4 picocuries per liter) at which a follow-up test was recommended and people were advised to consider radon mitigation with sealers, blowers, and vents. I began caulking floor cracks—
Pascal’s wager—which had the more tangible result of reducing the population of spiders and centipedes. I was soon diverted by other things. For someone who never smoked, 4 picocuries per liter poses a lifetime risk of dying from lung cancer of
about 7 in 1,000—less than 1 percent—and that assumes
constant exposure, as if you spent your life indoors like a shut-in or a kidnap victim.

We lived near no
industrial sites and
Los Alamos, the Atomic City, was twenty-five miles away, on the far side of the Rio Grande Valley. In the early 1990s,
an artist living there had reported what
appeared at first to be a high number of
brain tumors in his neighborhood.
State health officials investigated. During the previous five years there had been ten cases in the county instead of the six that would be expected from state and national averages. But the numbers were too small to be meaningful, and epidemiologists concluded that there was no way to distinguish the increase from what could have arisen through chance. There was nothing unusual or alarming, they said. If you stepped back and examined the world at large you would find similar bunchings in space and time, but you would have no reason to assume that they pointed to an underlying cause. Epidemiologists talk about the
Texas sharpshooter effect. Blast a barn door with a shotgun and then find the holes that are closest together. Draw a target around them and it looks like you hit a bull’s-eye. As soon as it peaked, the brain cancer rate fell and then zigzagged around normal. The Los Alamos investigators had also found a blip in thyroid cancer. But again the numbers were small—a total of 37 cases over twenty years in a population of 18,000—and in the following years they too declined. A public health assessment concluded that residents were receiving
no harmful exposures from chemical or radioactive contamination whether from the water, soil, plant life, or air.

In thinking about exposures, there was also the past to consider. Nancy had grown up in New York, on Long
Island, where in the early 1990s the suburbs began to reverberate with fears of a breast cancer
epidemic. When a friend or family member is struck out of the blue with a malignancy, the mind becomes magnetized, pulling in specks of data. There is that woman down the street who was also diagnosed with breast cancer. And the sister-in-law in the next town and the wife of the man at the office. The brain, built to seek patterns, insists on connections.
The Long Island
cancer cluster was born.

And so you start looking for a reason, a source, the spider crouched at the center of the web. Was it the Brookhaven National Laboratory, with its particle accelerators and research reactors? Or
the
pesticides and weed killers used in the old days when the island was mostly farmland—and, more recently, to maintain all of those flawless Long Island lawns? Or the
DDT that had been sprayed to control mosquitos? Was it the high density of
power lines in an area hungry for electricity?

The worry and fear—so reasonable, so understandable, so very human—lapsed sometimes into hysteria, which lapsed into paranoia. One activist ominously alluded to “
a type of population control,” as if Long Islanders were being exterminated, willfully or by neglect, by the wholesale damaging of their genes. The
politicians had to listen and Congress mandated a study. A decade later the
National
Cancer Institute issued its $30 million report. The incidence of breast cancer in Nassau and Suffolk Counties was slightly higher than for the United States as a whole. But the same was true for much of the urban Northeast—a clue that anything the cancers might have in common was very diffuse. The cluster was more like a sprawl.

No link was found between pollutants and breast cancer. If there were more cancer cases on Long Island, the study concluded, the causes were probably
socioeconomic. There may also have been a
genetic factor. Many Long Island women were from
Ashkenazi Jewish families, which show a propensity for breast cancer. But the likeliest culprit was the relatively affluent suburban lifestyle. Long Islanders were apt to eat richer diets, to be overweight, to bear fewer children, and to live longer—
the median age for diagnosis of breast cancer is sixty-one. Long Islanders were better educated than average and therefore more likely to get frequent mammograms, discovering tiny, slow-growing, possibly harmless neoplasms that are treated, just to be sure, and recorded in the statistics. A woman living in a shack in Appalachia might carry these “in situ” carcinomas to the grave, dying beforehand of something else.

These are not the kinds of reasons people want to hear—that their cancer might have been prevented had they chosen to forgo careers and, like the squirrels and foxes, be pregnant all of the time. That they might have enjoyed too many good meals and gained too
much weight. That their lump
mastectomy might have been
unnecessary. “Blaming the victim,” some activists complained, and one of them dismissed the report altogether: “We certainly believe
there is an environmental connection, and we don’t have to have proof to say what it is.”

Everyone has risk factors for almost every
cancer, and they take on significance only in retrospect. One day our neighbor
Vivian, happily working at home as a translator of scientific documents, “presented,” as they say on
grand rounds, with cancer of the ovaries. She died on an Easter Sunday, and the next thing we knew we were sitting at her memorial service. She was married to a mathematician. There was no mention of God. Around the same time,
Susan, a former girlfriend of mine and a colleague from the journalism world, also died of
ovarian cancer. Both she and Vivian were childless. But there was also Mrs.
Trujillo across the street, a mother well beyond middle age who died of the same thing. All of us acquire our own personal cancer clusters, and a mental file of anecdotal evidence as unreliable as it is impossible not to deep down believe.

When Nancy’s cancer came we didn’t know if it had started in her ovaries, her breasts, her uterus, her lungs. For the longest time (weeks—the clock was ticking so slowly) we didn’t know where it was growing, only that it was shedding cancerous cells into her body. She had been visiting a girlfriend in San Diego and was doing sit-ups in a local gym when she noticed a lump on the inside of her right groin. The words “swollen lymph node”—like what you might get from a sore throat—leapt to mind.

Cat scratch fever, we quickly decided, after seeking reassurance from the Web. Weeks earlier, startled by a sudden sound, one of our cats had clawed her leg, and an immune response from an infection could have led to
lymphatic swelling. That is what lymph nodes are for, to capture and neutralize immunological invaders. The human mind, ever hopeful, has a talent for absorbing aberrations.

The bump didn’t go away. Her doctor thought it might be a hernia
and recommended a consultation with a surgeon. But that didn’t happen right away. A phone call from out east brought news that Nancy’s father had suffered a hemorrhagic stroke—what a horrible year this was—and lay in intensive care at Stony Brook University Medical Center. The appointment with the surgeon was postponed and a flight to LaGuardia Airport was booked. Nancy called home that evening and told me about sitting at his bedside: his eyes, his smile, the grip of his hand, his obvious comprehension. He filled every cubic inch of her soul, except for a tiny space. The space got larger. In the days since her arrival, the lump had obstinately endured.

She didn’t have to leave the Stony Brook campus for a medical consultation. The next time she called she was walking back to her car from an appointment at a clinic, past familiar buildings (she had taken a degree in biology there). Her voice was wavering just enough that I knew she was probably crying, or trying not to. The doctor had palpated the lump. It was not soft and round as it would be from an infection. It was not cat scratch fever. It had the hard, irregularly shaped feel of a malignancy. The look on his face told her that she almost surely had cancer. He recommended a
needle
biopsy—the sucking out of cells to see if they are malignant. She decided to come home for the procedure.