Karma, punishment, coincidence? A GP faces his cancer diagnosis

This story is part of the March 9 edition of Good Weekend.See all 15 stories.

Cycling everywhere gives my dodgy knee a few more years of life but, in August 2018, it gives way, refusing even its basic weight-bearing duties, apparently for good. After a week on crutches, I book a scan, hoping the problem is just another tear of the medial meniscus, and not the end of my flesh-and-blood knee joint.

?MM, I scribble in medical shorthand on the request form, then hobble, still on crutches, around the corner to the photographic studio of my friendly neighbourhood radiologist, Shaun Fowler. Shaun has seen far too much of me over the years, at least from the inside out, through his various futuristic magic lanterns. After half an hour of noisily clanking MRI magic, he calls me into his office to inspect the damage.

“Bone on bone. Bone oedema. Yes, it needs replacing – but there might be another problem.”

“The graft screws from the ACL surgery?” I second-guess him, always the would-be distinction student at heart, back in a radiology tutorial, eager to impress.

He ignores me. “The bone marrow. Looks a bit odd. It might be multiple myeloma.”

Which is also known as MM, in case-note shorthand. I search his face for evidence of a complicated joke, a bad-taste play on words, or acronyms. Both are common usages, albeit with a small difference: one MM is cancer, the other isn’t.

“Look here,” he is saying, “on the T2 weighted images. And here.”

I look but don’t believe him for a moment. Whoever heard of myeloma, a cancer of the plasma cells, being diagnosed by looking at pictures of bone marrow – at least without a microscope, after a biopsy?

The scan of the author’s knee showing “odd” bone marrow. The dark area in the middle is the wreckage of a 30-year-old ACL reconstruction; the larger, paler spots indicate myeloma infiltration.Credit: Courtesy of Peter Goldsworth

“Admit it, Shaun. I put the notion into your head, right?”

Wrong. But if he isn’t joking, some kind of cosmic trickster clearly is.

I amuse myself as I head home by limping into the newsagent and buying a lottery ticket on the strength of this unlikely coincidence of M&Ms, then amuse myself further by wondering whether the gods of luck will only sprinkle their magic dust on my ticket if I do have the serious kind of MM. The $70 million Powerball jackpot would be a partial consolation, at least.

I find myself in a strange, elevated mood, excited in a complicated way that I find difficult to acknowledge, let alone understand. It feels as if I both have cancer, and don’t, simultaneously. No: as if I’ve had the experience of being diagnosed, the shock of being told, of being on the other end of the telling for once, the sharp end – but am standing aside, watching from an ironic distance, immunised against it by the beautiful joke of its diagnosis.

It’s as if I’m reading a first-person cancer narrative, suffering with the victim, me, by proxy, but still able to make notes in the margins, close the book and
walk away, unscathed, when it turns out to be a work of fiction.

And if it doesn’t? My first stray thought: cancer is a gift. I might be lucky to have it. What priceless material for a doctor-writer! Which is, if nothing else, an original variation of that most ancient of psychological defence mechanisms: denial.

And for which there will be no further need once I prove Shaun wrong. Falsify his hypothesis. All it needs is a simple blood test.

I drive straight to my surgery and wrap a tourniquet around my left arm. Having spent half the morning in radiology, I’m not about to join a queue in a blood collecting centre. I’m sitting there, probing for a vein, when my friend, James, the physiotherapist next door, glances through the window as he walks by. If he notices, he pretends not to. Using again, Peter? Your business, not mine.

After labelling the blood samples I summon the pathology courier and head home, still a little manic. My adventures so far will make a good story, and I am keen to tell it, but for the moment I need to stay mum. This won’t be easy, given my state of mind. It’s Wednesday. The protein lab (where my samples will be analysed) runs its tests in batches; the verdict will not be in until Friday. No need to panic anyone – meaning my wife Lisa and my children, Anna, Daniel and Alex – for no reason.

Three sleeps to Results Day, but I feel no particular sense of suspense. Either it is what it is, or it isn’t. It’s not yet a full-blown cancer suspense story. Either I get a clean bill of health, a priceless gift in itself, or I get a new wealth of experience, a journey, beyond imagining.

“You seem preoccupied,” Lisa says over dinner.

“Do I? Sorry, darling.”

“You’re eating very quickly. Automatically. Which rabbit hole is it tonight?”

“Busy day. Hard to slow down. How was yours?”

After we have cleaned up and she is marking essays, I sneak another look at the MRI images on their big wobble-board plastic sheets: black and white and only a little grey. I can see what Shaun is getting at, but it doesn’t gel with my natural optimism or new detachment.

“Cholesterol check,” I reassure Lisa in bed, when she notices the cute Minnie Mouse Band-Aid in the crook of my elbow. Reassured, she is soon innocently asleep.

I also sleep soundly, spoon-nestled against the glow of her body, as reliable a source of forgetfulness as if it were a warm-blooded tributary of the River Lethe.

I deserve my cancer. Not because I was born lucky, and can’t complain, but because of what I’ve done with my dumb luck since.

After she has left for work the next morning, I cash in my winning lottery ticket: $17.35, less a jackpot than a jack-thimble, but coincidentally the exact price of a ticket in the next draw. All of which adds an extra dash of irony. In short, my feelings are still all over the place. On one hand, I am enjoying being where I am, the victim of a small but increasingly shaggy cosmic joke; on the other, I can’t wait for Friday, when I will finally be free to share the joke with Lisa.

And if the decision of the protein lab goes against me, and the joke is on me? Not to worry. What are the Lotto odds of that? Either way, I can’t lose. Part of me will be disappointed if I haven’t got cancer, the part that half-hopes it is a gift, if only partly unwrapped, the hand of the giver still gripping the other end, ready to take it back.

---

The first answer my surprised mind coughs up after the results come through is that karma is to blame. No use complaining, I tell myself. I’ve led an undeservedly lucky life, and my luck has finally run out. Getting cancer is just some sort of overdue rebalancing of the cosmic equilibrium. Apart from that stint in intensive care in my late teens, my life has been blessed, beginning with the first luck any of us can have: the big birthright lottery, the biggest we will ever win (or lose). A big Lotto win doesn’t come close. Genetic luck, geographical luck, familial luck: I hit the jackpot in all of them, through no efforts or virtues of my own.

My handicaps were so light they might have been wings. We had no money, we mostly lived in houses that were little more than shacks, kitchened with a wood stove and kerosene Primus, and we never owned a television set – but we had a wealth of love and books and music. Which helps confirm my next overexcited thought: cancer might be good for me. Not in the priceless, raw material it has gifted me, but in the lessons it might teach. Lessons, perhaps, born of a necessary grounding, a long-overdue humbling.

From that stray, albeit conventional, thought, it’s a quick knight’s jump to a
completely weird idea: I deserve my cancer. Not because I was born lucky, and can’t complain, but because of what I’ve done with my dumb luck since. I mean, simply, I’ve got away with enough over the years to deserve some sort of punishment, even if its delivery is pure happenstance – and the penalty a tad severe.

What jumps into my head next shouldn’t ambush me – I had brooded about it in the past – but the connection, the retroactive coincidence, leaves me stunned: the case of one of my own myeloma patients, Hedley, an
elderly bloke, now years dead. I’d missed making the diagnosis for far too long.

Doctor misdiagnoses cancer in patient; 10 years later, doctor gets the same cancer.

It might not be the worst mistake I made in a lifetime of doctoring – there must be some I’m not aware of, and others I’ve managed to forget – but it was the most blindingly obvious in retrospect. Yes, all doctors make mistakes, and the stakes can be catastrophically high, but the important things to do in the aftermath – the only possible things to do – are to apologise and learn from the error. The second is the easier task, if only because the acid of guilt etches deep grooves in the brain.

“Thalamic learning” it was called during my days in medical school, when public humiliation of students who gave wrong answers on ward rounds was still routine. The upside: you never forgot your errors. For some time after this one, especially in the dog hours of night, when even at the best of times I tend to revisit my life’s mistakes, among which I hope medical mistakes are a small subcategory, I couldn’t understand how I had missed the obvious. The anaemia, idiot! The bone pain!

With children (from left) Anna, Alex and Daniel, in 2021, receiving an honorary degree of Doctor of Arts at the University of Adelaide.Credit: Courtesy of Peter Goldsworthy

The case damaged my sense of myself as a diagnostician. Whatever my faults as a doctor, however nerdy or impatient my bedside manner, especially when younger, I prided myself on being a near-faultless diagnostician.

Hedley, a stoic if frail bloke, got to 90, just, but how many more years might an earlier diagnosis have added?

I know perfectly well my bruised ego was a minor injury in the overall scheme of things, those things being his things, his serious disease, his pain – but as
I wait for Lisa I can’t get him out of my head. Doctor misdiagnoses cancer in patient; 10 years later, doctor gets the same cancer.

Yes, the human brain can no more leave a coincidence in peace than it can stop worrying at the bone of a dangling Why? But this is not just any amusing run-of-the-mill coincidence.

I think of my two current myeloma patients, diagnosed in a timely manner, and doing well in the care of Noemi Horvath, a specialist haematologist at the Royal Adelaide Hospital (RAH) and legendary super-specialist in the sub-
specialty of myeloma. I think of my close friend Deb, who died of the disease two years before, also diagnosed late although not through medical negligence.

But I keep coming back to Hedley. An eye for an eye, a cancer for a cancer?

---

Lisa parks her pushbike in the hall, hello-kisses me and runs straight upstairs for a shower before I can get a word in.

Not that I try hard; I’m still mentally drafting The Speech. I felt an urge – a need – to ring her when the results were phoned through earlier in the afternoon, but managed to restrain myself. Such news needs to be delivered face-to-face, as with my patients and their families. Thinking of which offered a coward’s way out: should I be the one doing this? Shouldn’t my cancer specialist be telling her, telling the two of us together?

But that would mean having to first confess that I have a cancer specialist. In fact, I’ve only had her for about five minutes, having rung and paged Noemi Horvath at the Royal Adelaide Hospital after the results came through. We’d never met, or even spoken by phone, but over the years I’d been regularly impressed by her succinct correspondence about our shared myeloma cases, one of whom she has kept alive for a decade, to my continuing astonishment, given his comorbidities. I also know a little of her by reputation: a no-time-for-fools authority in her field, with a long research track record and a dry sense of humour.

Stalking her online, I find she studied medicine at the University of Otago in New Zealand, a good school.

“It’s an incurable disease,” she tells me, succinctly, after I recite my protein numbers. “As you know.”

“Um, I suppose,” I mumble, meaning I don’t quite believe her, and the only incurable thing inside me is optimism.

“Of course, it can be incurable for many years,” she says, confirming my sense of elasticity in the word. “I can fit you in next Thursday. I’m always overbooked, so be prepared for a wait. You’ll need more tests, then we’ll book a bone marrow biopsy.”

Peter with his wife Lisa, who told him never to hide anything from her again.Credit: David Solm

None of this, especially the incurable disease part, gives me much material for my speech to Lisa as the shower splashes on upstairs. I haven’t even decided on a strategy, let alone a form of words.

My day, darling? Bit of a hiccup. Curious, in a way. But tell me about yours first.

Or get straight to the point?

You’d better sit down, Lisi. I have some very bad news.

Upstairs, the shower stops; downstairs, the clock is ticking. I mix two gin and tonics, Dutch courage for me as much as a shock absorber for her. It occurs to me that the G&Ts will look suspicious since we hardly ever drink them, but I carry them up anyway, unable to delay any longer.

She is wrapped in a towel, brushing her hair. She glances at the drinks. “How romantic,” she says, and smiles mischievously. “Something on your mind?”

If only it were as innocent as sexual desire. Instead, I blurt out the first words that come into my mouth, which not surprisingly happen to be another version of the good-news-first routine: “There are some excellent new treatments for multiple myeloma.”

She looks at me askance. Long accustomed to my habit of dropping random nerd-facts on her, her puzzlement clearly comes from somewhere else.

“Bit late for that now,” she says.

It takes me a moment to twig. She thinks I am talking about Deb, dead from myeloma two years before.

“Deb would have survived,” I say, still making it up on the run. “These days.”

Puzzlement gives way to suspicion. “Why are you telling me this?”

“She was diagnosed too late,” I say, then blunder on before I have second thoughts: “I’ve got it early. I’m lucky.”

Understanding arrives, slowly, in the form of tears in her eyes. I wrap her in my arms as my eyes fill too, for the first time in that long week.

“How long have you known?” she says.

“I sent off the blood on Tuesday.”

“You knew on Tuesday?”

“I knew it was a possibility. The knee scan, remember? Yes, I need a new joint, but Shaun thought the marrow looked suspicious.”

“And you didn’t tell me?”

“I didn’t tell myself. I didn’t believe him. I did the tests to prove him wrong.”

“You must have been so lonely,” she says, and we sit locked together, rocking slightly.

“It’s a good cancer to get,” I murmur in her ear. “If you have to get one.”

She draws her face back, looks into my eyes. “A good cancer? Deb lasted three years. You told me it was incurable.”

“Did I?” I’m surprised to hear this, but if I spoke the word I must have believed it true at the time. I offer some truths that are more consolatory: “It can go into remission. For a decade. Even longer. The treatments are better now.”

“You must promise,” she says, with a hint of steel behind the tears. “You must never, ever hide anything about it from me again. I need to know everything.”

“I promise. Now that it’s confirmed. I honestly didn’t believe I had it.” I keep talking as she pulls on her dressing gown, sits on the bed and reaches for her phone.

“Average life expectancy four years,” she announces, and her eyes brim with tears again.

I glance at the screen over her shoulder. “That’s the average over the last five years. It’s improving all the time. Probably five or six by now. There are new drugs every year.”

She interrupts. “What stage are you?”

It’s on the tip of my tongue, but this isn’t the time for a next-stage-out-of-town joke. “Maybe no stage. Stage zero. Maybe I’m just smouldering.”

“Smouldering?”

Are all doctors frustrated poets, tossing such adjectives around? Pernicious anaemias. Malignant cancers. Incompetent heart valves. Massive insults to kidneys, insulted hearts likewise. Deranged liver function tests. Compromised immune systems. In this company, “smouldering myeloma” sounds less like a
disease than a Hollywood sex kitten of the 1950s.

“Sometimes it smoulders forever,” I tell her. “I’ll need a bone marrow biopsy to find out.”

Another silence. She examines my face again: can she see through these assurances? Probably, because I’m still not quite telling the truth. I know from the protein levels that I am long past smouldering. My marrow is ablaze.

Lisa is already coming up with her own plans to help save my life. Less medical work, more meditation. Less impatient inner-city rally-driving, more slow cycling. Less animal fat, more blueberries. Less trash television, more music and poetry. More silent, sustained reading. She is a teacher, after all, of English literature.

And if worse comes to worst?

I know she worries about this; of course she worries about it.

“Remember that patient of mine?” I say. “The minister whose wife died?”

Ivor, a retired Uniting Church minister and former missionary in the South Pacific, attained sainthood in my eyes during the protracted ordeal of his wife’s bowel cancer. He was to die himself a few years later, but six weeks or so after her death, he bounced into my consulting room jauntily.

“How are you, Reverend?” I asked.

“Well,” he announced, breezily, “I’ve replaced her with a budgie.”

Momentarily speechless, all I could come up with was: “What did you call it?”

“Jeremiah,” he said.

Denial, or a self-administered dose of therapeutic humour?

I chuckle again now, remembering it. As does Lisa.

“You want me to replace you with a budgie?” she asks. “What shall I call the new you?”

“Ishmael?” I suggest, a slightly obscure joke, although not to us, silent, sustained readers of big, thick novels from way back.

This is an edited extract from Peter Goldsworthy’s The Cancer Finishing School (Viking; $37), out now.

To read more from Good Weekend magazine, visit our page at The Sydney Morning Herald, The Age and Brisbane Times.