Chapter 10

It was one o'clock on a cold, bright January afternoon when Ken wheeled his Mercedes into the parking lot of the Marshall Medical Plaza of Roseville office complex. Meghan sat next to him, dressed in blue jeans and a fuzzy cashmere sweater. A red scarf was wrapped around her neck and trailing down over the swell of her breasts. Her face was tired and worried, almost as tired and worried as Ken's.

Ken had a 1:15 appointment with Dr. Susan Berkenstein, the internal medicine specialist Dr. Adrial had set him up with ten weeks earlier, when his elevated liver enzymes had first been discovered. The appointment was at Dr. Berkenstein's request. She had called Ken personally to make it. She had told Ken that a "colleague" of hers would be there as well. She had also requested that Ken bring his wife. None of this suggested Dr. Berkenstein had good news to share.

The appointment, in fact, seemed particularly ominous in light of what had already been discovered these past eight weeks. The abnormal liver enzymes were not just a fluke or an atypical case of hepatitis. The elevated levels had been repeated on two subsequent lab draws, leading Berkenstein to schedule a CT exam. The CT showed a dark area over Ken's liver, something unidentifiable but definitely out of the ordinary. That led to an MRI being scheduled. This produced a picture detailed enough to show that the dark area was actually a mass of some sort, and it was not just on the liver, but on the pancreas as well. It was at this point that the C-word had first been spoken aloud, although it had been on everyone's mind since the CT.

"We need to do a needle biopsy," Dr. Berkenstein told him after reviewing the pictures and the radiological report from the MRI, "Just to make sure this isn't cancer we're dealing with here."

"Is there anything else it could be?" had been Ken's frightened reply.

"Oh sure," Berkenstein replied. "It could be that these are just benign tumors that are irritating your liver and your pancreas enough to account for the elevated lab values. Let's not start worrying about cancer just yet."

Easy for Dr. Berkenstein to say. Ken, however, thought it was a little like telling a passenger on an airliner in which one engine had fallen off and the other was trailing smoke, that it wasn't time to start worrying about a crash just yet. Ken had been in a constant state of barely controlled terror ever since the words "mass on your liver" had crossed Bernstein's lips.

The needle biopsy had been six days ago. Meghan drove Ken to an outpatient surgery clinic right across from Marshall Memorial Medical Center in downtown Sacramento where, after receiving a hefty dose of Versed through an intravenous line, needles were inserted into his right upper abdomen to draw cells from both his liver and pancreas. Four days later, the call had come from Dr. Berkenstein, asking Ken to bring his wife for an appointment. And now, here he was, standing outside the office complex, sweating despite the forty-five degree chill in the air, holding Meghan's hand tightly in his, afraid to walk in the door.

Every instinct in his body was screaming at him to not go in there, to not listen to the news Berkenstein and his mysterious colleague had to share. If I don't know about it, I don't have to face it, he thought desperately. And if I don't face it, maybe it isn't true.

Meghan squeezed his hand when he hesitated, trying to make it feel comforting but actually grinding down hard enough to cause him pain. She was visibly frightened as well. "It'll be okay," she told him, her voice quiet and trembling. "Let's go in and hear what they have to say."

Ken took a deep breath, gathering his courage. Maybe it's a benign tumor after all, he thought. Maybe that's all they're going to tell me.

The tone of this thought seemed about the same a parent used when explaining to a ten year old that there really was a Santa Claus ... and a Tooth Fairy as well.

Meghan squeezed his hand again, a little gentler this time. "Even if it is ... is ... what we're afraid of," she said, "it's probably something they can get rid of. Treatment for ... for this sort of thing has come a long way in the past ten years."

"Yeah," Ken said, trying to cling to that thought but failing. He had already done enough research on the subject to know that if it was "what we're afraid of", as Meghan put it, it was pretty advanced.

"Come on, sweetie," Meghan said, tugging on his arm a little. "Let's go inside."

He hesitated a moment longer, fighting back an urge to rip his arm out of hers and go running off through the parking lot, to flee like his life depended on it. Finally, however, he nodded. "Okay," he said. "Let's do it."

He forced one foot in front of the other and a moment later came to the door. Meghan opened it for him and he stepped inside the building.

They went upstairs to the second floor where Berkenstein's office was located. The waiting room was moderately full of patients, every last one of them over the age of fifty, most pushing seventy. The receptionist knew them by sight. She greeted Ken by name and told him to wait right there for a second. She picked up her phone and said that Mr. and Mrs. Patterson were here. A moment later, Berkenstein herself showed up and opened the office door.

"Ken, Meghan, come on back," she said quietly. She was a short, somewhat dumpy woman in her late forties. She wore a white lab coat with her name stitched on the breast. Her curly red hair was tied up in a bun. Her face, while homely, was intelligent. Her brown eyes were unreadable but the fact that she was personally greeting them on arrival and inviting them directly back was perhaps the most frightening thing that had happened so far.

"Thank you," Ken said, his mouth suddenly feeling dry. It's not too late, his mind, near panic, informed him. Run! Run away from here as fast as you can and you won't have to know!

He did not run away. He held onto Meghan's hand and followed Dr. Berkenstein through the medical office. They passed several closed exam room doors and several more open ones without patients in them. Near the back, they reached a door with Dr. Berkenstein's name on it. She opened it and led them into a fairly spacious and tastefully decorated office. Her degrees—undergraduate from the University of Ohio and medical degree from Stanford University were all Ken had time to notice—hung on the wall behind an expensive mahogany desk. Two chairs sat in front of the desk. Two also sat behind it. One of the chairs behind was occupied by a balding man in his late forties. He was dressed in a charcoal gray suit. His face was unreadable as well.

"Ken, Meghan," Berkenstein said, pointing at her presumed colleague, "this is Dr. Robert Zander. He's another of our Marshall Medical Group physicians and I consulted with him on this case."

"How do you do, Doctor?" Ken said, finally letting go of Meghan's hand so he could hold it out to Dr. Zander.

"I'm fine, thank you," Zander said, shaking with him, not seeming to mind that Ken's hand was sweaty. He then shook hands with Meghan and greeted her.

Dr. Berkenstein invited Ken and Meghan to have a seat. She then shut the door and walked around the front of her desk and sat down with Dr. Zander. The two of them glanced at each other, passing some form of mental communication back and forth. Ken and Meghan's hands found each other again and they grasped tightly, bracing themselves.

Berkenstein let out a shallow breath and then looked directly in Ken's eyes. "Ken," she said, "the reason I asked you to come in today is that we have the results of the biopsy on your liver and pancreatic cells that were extracted. When we correlated the results of that test with the MRI images and the symptoms you've been experiencing ... well ... we were able to come to a diagnosis."

Run! Ken's mind screamed. You can still get away without hearing this!

He did not run. "And ... uh ... what diagnosis is that?" he asked slowly.

Berkenstein swallowed audibly and took another breath. "Well ... I'm sorry to have to tell you this," she said, "but the masses we discovered on your liver and pancreas are both tumors of a malignant nature."

Those words echoed in Ken's brain and he started to feel faint. "Tumors ... of ... of a malignant nature?" he asked, having to fight to get the words out. "Does that mean ... it's ... uh..."

"It means the tumors are cancerous," Berkenstein said, managing to sound sympathetic, apologetic and matter-of-fact all at the same time.

Ken felt Meghan's hand squeeze spastically on his. He heard her choke back a sudden sob. He squeezed her hand in return, trying to offer comfort, trying to be strong, even though he was feeling as if a cloud of doom was slowly descending on him. "Cancerous," he said. "So ... So I have liver cancer?"

"Well ... yes and no," Berkenstein said.

"Yes and no?" Meghan suddenly barked. "What the hell does that mean?"

"Easy, Meg," Ken said, giving her hand a few more squeezes.

"I'm sorry," Meghan said, her voice now quite choked.

"It's quite all right," Berkenstein said. "I'm going to let Dr. Zander explain about these tumors to you. He is more of an expert on them than I. That's why I brought him in for consultation. Dr. Zander, you see, is an oncologist."

An oncologist, Ken knew, was a doctor who specialized in the diagnosis and treatment of cancer. Berkenstein, he realized, had gone out of her way to avoid mentioning what sort of doctor he was during the introduction. "Okay," Ken said. "Let's hear it, Dr. Zander. Do I have liver cancer or do I not have liver cancer?"

"You have a cancerous tumor on your liver," Zander said. "It is not a primary liver cancer, however."

Meghan was shaking her head. "Can we stop speaking in medical language?" she asked, her voice still angry. "Give us the facts in plain English, please?"

"Yes, of course," Zander said, nonplussed by her outburst. "There are two tumors present in your case, Mr. Patterson. There is one tumor on your pancreas and one on your liver. The tumor on the pancreas is the primary tumor. That means it formed first and then spread to your liver. The cells we examined from your liver are not what we would find if the liver formed the tumor first. In other words, they are not cancerous liver cells. They are identical to the cells that formed on your pancreas, which tells us that that tumor formed first. What this means is that you have pancreatic cancer that has metastasized, or spread, to the liver."

"Uh ... okay," Ken said, still trying to accept that his worst fear had just been confirmed. "So what does this all mean? Does the fact that it started in my pancreas make it better than if it started in my liver?"

"I don't really like to speak in terms of bad and worse," Zander told him. "I'm just trying to explain what sort of cancerous tumors we're dealing with and help you understand the diagnosis."

"I understand," Ken said while another brief sob escaped from Meghan's mouth. "I have pancreatic cancer and it's moved to my liver. You've made that clear. Now..." He took a deep breath. "How bad is it? Is it going to ... to ... am I going to ... die?"

Meghan sobbed again, this one longer. Tears began to run down her face. Zander and Berkenstein shared another look. "It's really impossible to give you an answer to that question right now, Ken," Zander finally said. "All we have at this point is confirmation that you have cancerous tumors on these organs and an identification of the primary cancer site. We need to get an ultrasound and another MRI done. We need to do some more lab work to see just how these tumors are affecting you."

"Uh huh," Ken said. "You've treated people with pancreatic cancer that has moved to the liver before, haven't you?"

"Well ... yes, many times," Zander said. "It's actually a fairly common form of cancer, although you are well below the median age for developing it. Usually we see this presentation of the disease in men and women in their late fifties to late sixties."

"I guess I'm just lucky," Ken said. "Anyway, based on your experience, what is my prognosis? Can surgery get rid of these tumors? Can chemotherapy?"

Another look passed between the two doctors. "Look, Ken," Zander said. "Every tumor is different, every case of cancer is different. Until we have a better look at what we're dealing with, we can't start formulating a treatment plan."

"But you can tell me what you think based on your past experience, can't you?" Ken said firmly.

"I don't like to speculate, Ken," Zander said.

Ken sighed. "Look, doc," he said. "I know you're trying to avoid giving me any hard information right now. I understand that and I respect it. But I also suspect that you have a pretty good idea how this is going to turn out. I was terrified to come into this office a few minutes ago because I didn't want to hear what you had to say. Now that I've heard it, however, I need to know how bad this really is. I can't go another two or three weeks of not knowing what to expect."

"Ken, believe me, I appreciate your fear," Zander said. "Really I do. I just cannot ethically give you a prognosis without further diagnostic information. I can't."

"But you can answer some generally questions about tumors of this type, can't you?" Ken asked.

"Well ... general is a very ... uh ... general word," Zander said.

"Doc," Ken said pleadingly, "I need a little more information than what you're offering. Just answer a few questions for me ... if you can?"

Zander slowly nodded. "If I can," he said.

"Thank you," Ken said. "Now, based on your past experience, can these tumors be removed or destroyed?"

Zander didn't answer for a few moments. It was obvious he was trying to formulate another vague, non-committal blathering. Finally, however, after looking into Ken's eyes, after seeing the tears running down Meghan's cheeks, his expression softened. "No," he said. "The tumors cannot usually be removed at this stage."

Ken nodded. That was what he'd suspected. Meghan stopped trying to control her sobs and began to openly cry. Ken put his arm around her and pulled her close to him. "So you can't go in and cut the tumors out?" Ken said. Why not?"

"We haven't completely ruled that out yet, Ken," Zander said. "That's why we need to do more tests and scans."

"I understand," Ken said. "So why can't you usually remove these tumors surgically?"

Though clearly uncomfortable with the discussion, Zander answered the question. "Usually," he said, "when a malignant pancreatic tumor has gotten big enough to spread to the liver and establish itself there ... well ... it's quite intertwined with the very structure of the organs and the blood supply feeding them. Surgery is not an option because the removal of the tumors would inevitably destroy the organs themselves."

"So these tumors are not just sitting on top of the liver and the pancreas?" Ken asked.

"No," Zander said. "By the time they are discovered they are generally found to be an integral part of the organ itself."

Meghan got herself under control enough to ask a question of her own. "What about radiation?" she asked. "What about chemotherapy? Can those get rid of the tumors?"

"Radiation is almost always ineffective against this sort of tumor in this stage of development," Zander told her. "Chemotherapy, on the other hand, usually is able to both inhibit further growth of the tumors and shrink them to varying degrees."

"But not eliminate them?" Meghan asked.

"There have been cases where the disease process has been put into remission by the use of chemotherapy," Zander said brightly. "That's why it is usually the first line of defense."

"How often does that happen?" Ken asked.

Zander began to hem and haw again. "I don't have exact statistics here in front of me," he said. "And, as I said earlier, every tumor and every case is different."

"In general," Ken said. "How often?"

Zander sighed. "Not very often," he admitted.

"But it is possible," Berkenstein said.

Ken ignored her, keeping his attention focused on Zander instead. "Have you ever seen it completely eliminate tumors of the size that I have?"

"Ken ... really," Zander said. "You're talking in generalities again. I am but one oncologist out of thousands in this country. You can't correlate my personal experiences with your situation."

"So that would be a no then?" Ken asked.

Zander nodded slowly. "That would be a no," he admitted.

Meghan started to cry again, her sobs deeper than they had been before. Ken pulled her tighter against him, almost grateful for her breakdown as the need to comfort her kept his brain occupied enough to keep from breaking down himself. His fear and grief was building in his mind, he could feel it like a thunderhead gathering strength before the onslaught, but it remained behind a wall for the time being.

"Okay, doc," Ken said. "We know that I've got tumors in my liver and pancreas and we highly suspect that we're not going to be able to get rid of them, right?"

"Well ... uh..."

"Right?" Ken repeated.

Slowly Zander nodded. "Right," he said.

"So where does that leave me?" Ken asked. "If I do chemo and it shrinks these tumors down, what is the outcome from that?"

"Well ... the tumors are reduced in size, of course," Zander said. "That will delay the onset of further symptoms such as jaundice, liver failure, and ... well, death."

"Delay," Ken said. "That means I'm eventually going to have to deal with those things?"

Again, Zander wanted to hem and haw. Again, Ken refused to allow this. Zander reluctantly admitted that, yes, unless the chemo miraculously managed to destroy the tumors completely, they would eventually continue to destroy his vital organs and probably spread via his lymph system to other parts of the body.

"So how long are we talking?" Ken asked.

"I cannot give you an answer to that, Ken," Zander said firmly. "We simply do not have enough information yet."

"But sooner or later, this thing is going to ... to kill me, right?"

"Ken," Zander said, "I can't..."

"Doc, please," Ken pleaded. "I'm trying like hell to stay in control of myself here. As you can see, Meghan is pretty much done for. You've already told me enough to let me know what the score is, but I just need ... I need to hear it from your lips to make it real so I can start trying to face it. In all likelihood, this is going to kill me, right?"

Slowly, Zander nodded. "I'm sorry, Ken," he said. "We usually let the hospice program handle this part, but ... well ... you're forcing me into a corner. Yes, in all likelihood, we're looking at a terminal case of cancer."

Twenty-four hours later, in the living room of her rented house in Columbia, South Carolina, Josephine hung up her phone and sat staring at the wall before her. There were tears running down her cheek and a heaviness around her heart. It had been Meghan she had just talked to for more than thirty minutes, a tearful, sobbing Meghan who had given her the news that Ken was dying of pancreatic cancer.

This news was not unexpected. Ever since the discovery of the "mass" on Ken's liver her correct destiny lovers had kept in daily touch with her. She had been informed every step of the way, knowing within a day of every appointment, every new piece of information as the horrifying situation went from concerning to scary to terrifying and now, to catastrophic. Jo, like Ken, had long since done the research on the internet and at the library and had suspected the entire time just what the ultimate diagnosis and prognosis was going to be. But still, having confirmation of the suspicion, hearing Meghan break down on the phone and sob in grief now that it was official, had come as quite a shock. Ken really was dying.

"How long?" she had asked Meghan. "How long does he have?"

Nobody knew at this point, or at least nobody was saying. Jo did not pretend to know either, but she knew what the statistics were. Of the thirty-seven thousand or so people diagnosed with pancreatic cancer every year, less than five percent were still alive five years later. And even among that small percentage that made it to the five year mark, complete remission of the disease was so rare it was almost unheard of. Barring an out and out miracle, Ken would not see his forty-fifth birthday. And the odds were he wouldn't even see his forty-second.

It wasn't right. Ken and Meghan were a correct destiny couple. Out of all the thieving, back-stabbing, lying, cheating, untrustworthy, and outright useless people that made up the vast majority of the race of human beings, they were two of the rarities who were infected with actual humanity, common-sense, empathy, and goodness. They were two people who truly deserved happiness in their all-too-short lives and who, through whatever miracle of fate, had actually managed to find it. And now, because of some simple rogue cells in Ken's body, they were being ripped apart, made to suffer. Why? Why would something like this happen to such good people? Such good people that she happened to love as much as she loved her own mother?

"It's not fair," Jo said, shaking her head, feeling anger and frustration well up inside her. "It just isn't fair."

She stayed in her chair for another thirty minutes, just staring straight ahead while her mind pondered a thought that had been developing over the past two or three weeks, since she'd started to realize that what she feared might actually come to pass. Now that it had, she took the thought out and examined it in more detail, wondering if it was nothing more than a pipe dream, highly suspecting that it was.

It's a chance though, isn't it? her brain kept insisting. The worse that can happen is that things remain just as they are now.

Both sides of her brain—the part concerned with emotion and the part concerned with logic—were forced to agree with this statement. And so, with a trembling hand, she reached over and picked up the handset on her antique phone. She dialed a number that had long since been committed to memory.

She heard the sound of ringing in her earpiece. It rang four times and was picked up. A female voice, alerted to who she was by a caller identification screen, greeted her by name. "Hello, Josephine," it said, the tone one of pleasant surprise.

"Hi, Mom," she said. "How are things in Calgary?"

"Cold, dark and beautiful," her mother responded. "The sun will be down in another two hours. Your father and I have a few human guests coming over for dinner tonight, a couple we met at a dance club last night."

"That sounds great, Mom," Jo told her.

"I'm sure it will be," her mother said. "They are quite attractive and well bred. He's a real estate developer and she is a member of a prominent Toronto family. I expect it will be a meal to remember."

"Sounds like it," Jo said.

"You sound troubled, Josephine," her mother said next. "Is everything okay?"

"Well ... no, not really," Jo said.

"What is it?"

"Nothing I can discuss on the phone," Jo said. "I'd like to fly out to see you."

"Fly to Calgary?" her mother said, surprised.

"Yes," Jo said. "There's something I need to talk to you about ... in person."

Arranging the time off for her trip proved to be no problem at all. Jo simply went to see Stuart Beck, the flight manager for UPS's Columbia operation, in person. Being a heterosexual male, he had no problem accepting that Jo had a family emergency involving her mother and that she needed at least two weeks off the flight schedule in order to fly to Calgary. He commiserated with her, wished her the best of luck, told her to call him if it turned out she needed more time off, and then, just for good measure, asked her is she would like to go out to dinner with him sometime.

Two weeks without a scheduled flight meant she actually had eighteen days off. If things worked out in her favor that would probably be enough time. She didn't want to dawdle, however. Instead of saving money and using her jump seat privileges to deadhead her way to Calgary—a process that would have taken her the better part of twenty hours to get there, assuming she was not bumped by a higher seniority pilot at some point—she bought a commercial airline ticket for $640. Even so, it was a long trip. She left her house at noon the next day and drove one hundred miles to Charlotte-Douglas International Airport where she parked her car in long-term parking and then boarded a 737 that flew her to Newark Liberty International in New Jersey, just a few miles south of Manhattan. There, she waited in the terminal for almost two hours before boarding an Airbus 319 that took her to Calgary International, touching down at 8:20 PM, local time.

Her mother, dressed smartly in a pair of business slacks, four hundred dollar shoes, and a genuine fox-fur coat, was waiting for her just outside the security checkpoint. They embraced warmly, sharing a brief kiss on the lips.

"How was your flight?" her mother asked as they headed for the baggage claim area.

"Long," she told her. "Very long. I'm used to two hour short hops."

"No cognate should ever be used to anything about flying in those instant death traps," her mother said disapprovingly.

"Mom," Jo said tiredly. They'd had this discussion before.

"I know," Gertie said. "It's the safest form of travel. And for humans that is true. But you, my dear, are not a human."

Jo didn't respond to this. It would only lead to more discussion. "You look good, Mom," she said instead. "Sorry to drop in so suddenly like this."

"It's always a pleasure to see you, Josephine," she said. "You know that. Are you hungry?"

"I'm good for now," Jo said. "I grabbed a bite while I was waiting for my connection in Newark. I may need something later on though."

"I'm sure we can arrange that," Gertie said. "Can you tell me anything about what this is all regarding?"

"Not here," she said. "It's too public. I'll tell you and Dad together when we get to your house."

Gertie nodded. "Fair enough," she said.

One of the benchmarks of success in the world of the cognate was the ownership of both a northern and a southern hemisphere home. Assuming one has achieved this goal, another benchmark was the latitude at which the respective homes were located. The higher the latitude number—be it north or south—the more desirable was the location. Since cognate had to live in cities—or at least very large towns—and since only a certain amount of cognate were allowed to live among any given population of humans—the current ratio was one cognate per twelve thousand humans—certain high latitude cities in what was considered the western world needed to have population regulation enforced by the Cognate Ruling Council to keep that ratio in check. Calgary was one such city. It was, in fact, one of the most desirable cities for a cognate since it boasted a metropolitan population of more than one million (for most cognate, the bigger the city, the better) and was located at 51 degrees north latitude. Since admission to Calgary was based on cognate seniority and financial success, the fact that Harold and Gertrude Baxter were allowed to reside there (as well as in Christchurch, New Zealand, which was a large modern city located at 43 degrees south latitude) spoke volumes about their time of service to the cognate. Their actual house spoke volumes about just how financially successful they were.

It was located in the Elbow Park section of Calgary, perhaps the oldest and wealthiest of the inner city neighborhoods. Built in 1915, it was a two story, six bedroom of classic Victorian architecture. It sat on a lot that was nearly four acres in size and overlooked the Elbow River. The house contained well over five thousand square feet of living space, not including the detached garage and the servant's quarters (which weren't used—cognate could not employ live-in human servants and no cognate would ever put him or herself into this sort of servitude to another). Most of the house was filled with a collection of antiques, everything from furniture to clocks to writing tools to art. Most of the higher seniority cognate were great admirers of antiques. No matter how many times Josephine saw pictures of her parents' northern home, she was always awed by seeing it in person. It was the embodiment of all she hoped to someday achieve in her own life.

Her father was dressed for comfort rather than to please the human eyes. He wore a pair of maroon silk pajamas imported from China. He hugged her and gave her a kiss as greeting and then, in deference to his wife, made sure to denigrate her choice of profession for a few moments and then hound her about the unnecessary waste of money her commercial flight had constituted.

"And I'm glad to see you too, Dad," she said, leaning in and giving him one more kiss on the cheek. "I like the silk. Although you really should put on underwear when your daughter is coming to visit."