She gripped the handlebars harder as the cobblestones sent vibrations through the bicycle tires that made her teeth chatter and the beads of sweat on her back trickle down like raindrops racing down the car window in a storm. She peddled faster until finally l’Arena came into view on the far end of the piazza. The anticipatory buzzing of the crowd steadily grew as she got closer and found a spot to lock her 30-year-old garage-sale-it-breaks-a-lot-but-was-such-a-good-deal-bicycle. She hurriedly flung her tote over her shoulder, flashed the security her library-printed concert ticket, and ran into l’Arena bathroom to change from her biking shorts and tank top to a two-piece linen set that she had sewed herself. She leaned closer to the bathroom mirror, sucking in her stomach to avoid the puddles of sink water, and painted her parted lips crimson. She pulled out a comb to attempt to control the remaining rebellious strands of hair, and satisfied, waltzed out of the bathroom and climbed the giant pink limestone steps to her assigned seat as Adriano Celentano’s orchestra tuned their instruments one last time. And then she sang Il ragazzo della via Gluck, Pregherò, and Impazzivo per te as loud as if she were a 20-year-old again, going through her first breakup. As she biked home at 2AM still levitating from excitement, the cobblestone vibrations became the bass accompaniment to her one-woman-concert.
But pancreatic cancer doesn’t discriminate.[1] It’s terrifying and humbling to know that no matter how healthy and fit you can be at age 83, that at the end of the day everyone’s cells divide. And a couple might keep dividing even when they are not supposed to.
Divide, divide, divide
Naturally, my 83-year-old nonna does not possess a cellphone. Or computer. On the first day of my ambulatory care rotation, I received a single text from my mother who got a WhatsApp message from her sister who received a call from my grandmother’s physician saying they had found a tumor in her pancreas.
Divide, divide, divide
I squinted to read the pixelated radiology reports that had traveled 5,931 miles to my mother and another 2,519 miles to me. Inoperable. I’m not sure how many other 1-word phrases hold the same gravity. “We did everything we could” is five words, “Will you marry me” is four words, “I got in!” is three words, and “I’m pregnant” is two words. Maybe defendants who stood before a judge and held their breath as the gavel struck wood would argue that “guilty” holds the same weight in a courtroom as “inoperable” does in a doctor’s office.
Divide, divide, divide
Who gets to deem a tumor inoperable? How do you know on what side of the five-year-survival rate my otherwise-healthy-zero-medications nonna will land? The UpToDate searches became a staple; CA 19-9 levels, vascular involvement, gene-profiling of tumor tissue. What about all the big academic centers in the United States that are redefining what is considered inoperable? I wished I had rotated on the Ranson service during my surgery rotation so that I could be more knowledgeable on the trials and treatments.
Divide, divide, divide
What role does a medical student play when she is the only person in medicine in her family? How does she respond when her mother sends her articles from Frontiers in Oncology about treatment? How does she navigate the underlying familial sentiment that bringing her to the United States would be more optimal for her care? “Nonna should be taking pancreatic enzyme replacements, right? She is losing too much weight and they haven’t prescribed anything, should I get the generic supplements from Amazon since the Italian pharmacies don’t have the medication in stock?” Universal healthcare is great except for when a patient with metastatic cancer needs to advocate for basic medications, wait one month for imaging and another two months for a biopsy. “What will the biopsy results tell us? Should I still be holding on to hope? What should I tell my sisters? When do I need to drop everything and book a plane ticket?”
Divide, divide, divide
A physician-in-training. A granddaughter. Can I be both objective and data-driven, and immersed and emotionally involved? Is it inauthentic to use PEARLS [2] statements when my mother shares updates on the phone? Is it inauthentic to give her displaced hope when she asks what the future will look like? I’m constantly code-switching to balance what she brings. If she is focused on the literature, then I focus on humanity. If she is caught up in circuitous emotions, then I focus on facts. Maybe being a physician makes me a better granddaughter. Maybe being a granddaughter makes me a better physician.
Divide, divide, divide
No matter my role, one thing is certain. If I had pancreatic cancer, I would want my daughter with me. And I would want her to forget about the diagnosis and the prognosis and the appointments and the treatment. I would score us tickets to Adriano Celentano’s concert, paint each other’s lips crimson, go to l’Arena (perhaps take a cab part-way this time) and sing and dance until my voice becomes a raspy whisper and my limbs meld into a blissful blur. Because I can’t keep those cells from dividing. But I can choose what to do with the rest.
Divide, divide, divide