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10/24/13 Update: Nicole Davis: In Memoriam
Nicole Davis was sitting behind the Wells Fargo drive-through window, counting cash and processing deposits, when she noticed her cell phone buzzing on the counter. Each time she turned to pick up the phone, another car pulled up. She tried to focus: The lunchtime rush at the Littleton bank meant a long line of cars snaking in from the intersection at Bowles Avenue and Wadsworth Boulevard. The phone buzzed again. Nicole knew it was the hospital.She rested one hand on the tight, round dome of her belly. It was January 20, 2009, and Nicole was 25 years old and almost six months pregnant with her first child. Her round face, blue eyes, and thick, long, blond curls brought to mind “The Birth of Venus,” the Italian Renaissance painting by Botticelli that depicts the Roman goddess of love and beauty emerging from the sea.
Nicole had dreamed of being a mother since she was a little girl, and, like all mothers-to-be, she’d wanted everything to be perfect. She’d perused the Babies “R” Us website and registered for her baby shower, poring over fabric and paint hues for the nursery, and she’d carefully read What to Expect When You’re Expecting. Her high-school sweetheart, Tyler, whom she’d married six months earlier in the flower-filled courtyards of the Terrace Gardens, a special events center in Ken Caryl, was just as excited. As soon as they found out the baby was a girl, Nicole’s tall, broad-shouldered, football-loving husband began talking to the belly and laying his head on her stomach to listen for signs of life. Nicole decided she wanted to name their daughter Abigail, which one of their five baby name books explained was Hebrew for “father’s joy.”
A third missed call yanked Nicole from her reverie. She grabbed the phone, heaved herself off the stool, and her co-workers took over for her at the drive-through window. The bank’s break room was less than 30 paces, but it felt like a mile. With each step, she whispered to her belly: It’s going to be OK. We’re going to get through this.
Eight days earlier, during an exam at the Kaiser Franklin Medical Center, Nicole had pointed out a painful lump that she’d noticed in her left breast. Her doctor ordered an ultrasound. She reminded herself that breast changes during pregnancy were normal—more than one doctor had said that—but the ultrasound revealed an “inconclusive” mass. One week later, a doctor inserted a strawlike needle into her breast to extract a small tissue sample, and Nicole signed a form giving the doctor permission to share the biopsy results via phone.
Now, leaning against the table in the break room, Nicole listened to the message. It was the surgeon who did her biopsy. He said it was “extremely urgent.” Nicole suddenly felt twice as heavy, as if she were filled with lead and fixed to the floor. She willed herself to walk to the manager’s office. Her boss took one look at Nicole’s pallid, terrified face and guided her across the room to a large desk chair. Nicole sat down and dialed.
“I’m so sorry to tell you this,” the doctor said. “But you have breast cancer.”
Of the roughly 250,000 women diagnosed with breast cancer each year in the United States, most are well over 50. Only five percent of new cases are in women under 40, according to the American Cancer Society, and just 2.4 percent are in women under 35, according to the National Cancer Institute. Even so, that tiny group is growing slightly. According to NCI data, the number of women diagnosed in their 20s rose by an average of nearly three percent a year between 2000 and 2008. This increase has happened amid a steady spread of breast cancer throughout the world. The incidence of the disease in the United States has jumped from roughly 105 of 100,000 women diagnosed in 1975 to 125 of 100,000 in 2005, NCI data show. And although breast cancer was once an affliction of the industrialized world, recent years have seen a marked upswing of diagnoses in developing countries.
The increase is partially a result of additional screening via mammograms, improved ability to diagnose cancer earlier, and the fact that more women are living longer. But researchers also cite a number of lifestyle factors: Obesity raises breast cancer risk in post-menopausal women, for instance. And the longer women wait to start families—and the fewer children they have—the greater their likelihood of getting breast cancer. (The more children a woman has before the age of 30, the less likely she is to develop breast cancer.)
But there is a cruel twist. Pregnancy actually elevates a woman’s risk of developing breast cancer temporarily. “The interaction between pregnancy and subsequent risk of breast cancer is very complex,” says Dr. Virginia Borges, an associate professor at the University of Colorado School of Medicine who specializes in young women’s breast cancer. “We know that any pregnancy at any age causes a period of time when that woman is at increased risk of getting diagnosed with breast cancer. How long that period lasts depends on age: If she’s under 25, she’ll be at a small increased risk of getting breast cancer, and then it will go away and she’ll be protected by virtue of having had a baby. If a woman is over 30, and certainly over 35, that risk is elevated. We’re not sure why.”
Twenty-five thousand cases of breast cancer were diagnosed in American women under the age of 45 in 2009, with 30 to 40 percent, Borges says, diagnosed in association with a recent pregnancy. Around 70 percent of all breast cancers are hormone-positive, which means estrogen and/or progesterone feed them. So in pregnant women, the hormones critical to a fetus’ growth can also fuel cancer. As Dr. Otis Brawley, an oncologist and chief medical officer of the American Cancer Society, puts it, the estrogen surge that comes with pregnancy is like “putting a tumor on caffeine.”
Nicole and Tyler arrived at their condo near Chatfield Reservoir at almost the same time. Standing in the driveway, they collapsed into each other. “I’ll go through any fight with you,” Tyler told her, “no matter what.” Nicole clung to him, her awareness narrowed down to two short thoughts that slid across her mind like ticker tape: Will I die? Will I lose Abigail?
Tyler and Nicole met as teenagers. He spotted her at 16-and-over night at a club called Hollywood Legends, near Sixth Avenue and Sheridan Boulevard. He looked at her, she looked away, and he figured he’d missed his chance. But then there she was in front of him.
“Why aren’t you dancing?”
“Because no one asked,” he said. He was transfixed by her eyes, hair, and smile, but there was something else that captured him—a sense of playfulness and pure joy, as if any place could be illuminated merely by her presence.
Two days after the phone call, family members joined the couple at the Kaiser Franklin Medical Center to meet with Dr. Steve Panian, the general surgeon who diagnosed Nicole’s cancer. The group was too large for an exam room, so Panian led them down a hallway and into a conference room. Along with the anxiety about Nicole’s diagnosis, there was the usual tension that arose when Nicole’s extended family was in a room with her parents.
Nicole’s mother and father had wrestled with alcoholism while she was growing up, and after one violent clash between 13-year-old Nicole and her mother, Child Protective Services threatened to place her in foster care. Her aunt and uncle, Marilyn and Ted Medina, took her in, and she grew close to them while her relationship with her mother remained volatile.
They were all there that day: Aunt Marilyn and Uncle Ted, Nicole’s father, and Tyler’s mother. Panian explained what cancer was, how it spreads, and which treatments could be used to fight it. While Marilyn and Tyler’s mom scribbled notes, Nicole could barely comprehend the words: “cell,” “invasive,” “lumpectomy,” “mastectomy.” She was supposed to be picking out baby clothes and painting the nursery, not looking at diagrams of the multiplying cells that, left to their own devices, could kill both her and her daughter.
The first decision was whether to get a lumpectomy and remove the tumor and surrounding tissue, or to remove the entire breast. Mastectomies were standard until the ’80s, when studies showed that lumpectomies with radiation were just as effective; women began opting for the less-invasive surgery. Many young women still choose mastectomy, though, to decrease risk for recurrence. The less breast tissue, the less long-term risk.
Because the more extensive surgery required prolonged general anesthesia—potentially dangerous for both her and the fetus—she chose to have the lumpectomy. Tyler brought her to Exempla Saint Joseph Hospital, near Kaiser Permanente’s complex on Franklin Street. Nicole was nearly seven months pregnant, three months from her due date, and she was about to go under the knife. The doctors assured her that her baby would be OK while they put her under general anesthesia and operated, but she was so terrified that they wound up agreeing to station a nurse in the operating room expressly to monitor the baby’s vitals.
Before she was wheeled into the operating room for the eight-hour surgery, during which Panian would slice away the tumor against her chest wall, Nicole pleaded with her husband and doctors to save the baby if for some reason the operation went awry. The fear, the dread deep in her gut…she’d felt it before, years earlier, when she was a student at Columbine High School.
On April 20, 1999, Nicole, then a freshman, was sitting with friends in the back of the Columbine cafeteria when they heard shouting and saw dozens of classmates sprinting in terror. As bullets tore through the lockers that lined the walls, Nicole and her friend Julie Naslund ran up a nearby staircase with a stream of people. As they climbed, Nicole turned to glimpse two figures in black trench coats approaching the stairs. The girls reached the top, and Julie tripped and fell. The crowd, crazed, surged over her, and it was all Nicole could do to stand firm and resist getting carried away. She leaned down, throwing elbows to keep Julie from getting trampled, and yanked her friend to her feet.
Nicole glanced back and saw the gunmen. She draped her friend’s arm over her shoulders and pushed ahead, half-dragging Julie. In one direction was a long hallway that led outside. In the other, and much closer, was the library. “Let’s hide in the library,” Julie said, her voice strained with panic and pain. “No,” Nicole replied, calm and resolute. “We’ve got to get out of here.” They half-limped, half-ran toward the exit. Eric Harris and Dylan Klebold eventually wandered into the library, where they shot 10 of the 13 people killed that day. “Nicole was my hero before she was anyone else’s hero,” Julie says. Each year on the anniversary of the shootings, Julie’s sister calls to thank Nicole for saving her sister’s life.
The anniversary of the shootings was April 20, less than three months away. Nicole’s due date was April 23. She prayed she wouldn’t go into labor on the 20th. Since her diagnosis, Nicole had been haunted by this thought: She had eluded death once, but had it returned to claim her and her unborn child?
On a bright day in February 2009, about two weeks after the lumpectomy, Nicole and her Aunt Marilyn arrived at the Kaiser Franklin Medical Center for her first oncology appointment. Uncle Ted would soon join them, but Tyler had to work. He’d taken off nearly a week during the lumpectomy, and they desperately needed the income from his job as a financial planner at Citigroup, as well as his health insurance. He hated not going—he had gone to every appointment so far—but he reminded himself that this was a routine initial exam to discuss the treatment options for after the baby was born.
In a white-walled exam room, Dr. Catherine Azar introduced herself. A no-nonsense woman, Azar glanced over the pathology report on the tumor removed from Nicole’s breast. When she looked up, her face had changed. “Nicole,” Dr. Azar said slowly, “I need you to trust me right now, with your life and your baby’s life. We need to start chemotherapy today—right now.”
Nicole and her aunt looked at each another. Nicole clutched her belly, feeling as if her airways were closing. She heard whimpering, and it took her a moment to realize she was making the sounds. “If we don’t start today,” the doctor said, “I can’t guarantee you’ll make it through this pregnancy.”
Azar explained that the cancer threatening Nicole and her baby was Stage 2B out of 4, which in Nicole’s case meant it had spread to a lymph node. It was both estrogen and progesterone positive, which meant that as the hormones surging through her body primed her uterus for childbirth and helped her baby grow, they were likely also feeding the destructive cells that, if unchecked, would multiply until they halted her body’s basic functions.
And, as if all that weren’t scary enough, there was this: Nicole’s cancer was a particularly aggressive type called HER2-positive. This meant it tested positive for a protein called human epidermal growth factor receptor 2, which roughly one in five breast cancers produce in abnormally high amounts as a result of a gene mutation, and which causes cancer cells to replicate at an especially high rate. HER2-positive cancers aren’t limited to breast cancer, and they’re especially difficult to deal with because they require very specific types of treatment.
Yet there was one encouraging possibility: a revolutionary drug called Herceptin. Developed specifically to slow, or stop, the growth of HER2-positive cancer cells, Herceptin has enabled 85 percent of patients diagnosed in the first two stages to live to at least five years, compared to roughly 70 percent before its release in 2006.
Aborting the pregnancy is typically not an option for pregnant women with breast cancer, because, according to the NCI, it’s not likely to increase chances of survival. However, it is possible to treat the mother with chemotherapy in the final trimester—Nicole was in her third trimester—without hurting the fetus, which by then is nearly fully formed.
Pregnancy complicates a woman’s treatment, but age is actually the most critical factor when it comes to survival. Scientists don’t know precisely why, but the cancers found in young women tend to be especially aggressive. Women diagnosed under 40—pregnant or not—have increased risk of recurrence, and by extension, death. The tumors in these women are often fast-growing and therefore harder to detect early, which makes them potentially more lethal. Because mammograms are less effective in young women and younger breasts are more sensitive to radiation, the best way for young women to find cancer is to practice “breast awareness”—to know what their breasts normally feel like and to get anything abnormal checked out.
Azar said they would begin with a standard chemotherapy regimen called AC, follow that with additional chemo drugs and radiation, and fight the cancer with Herceptin. Nicole would be in treatment for more than a year. She was just two months from her due date, but the doctor said this first round of chemotherapy was unlikely to harm her baby because she was close to fully formed. Nicole kept turning that word over in her mind. Unlikely?
That same day, Nicole and Tyler were led into the oncology/hematology department on the Kaiser Franklin Medical Center’s 12th floor. An open room with breathtaking views of the skyline and big, comfy-looking recliners, it resembled a salon but for the numerous IV poles. As the sun shone yellow-white outside and made the city glitter, a nurse took Nicole’s trembling hand and guided her to one of the cushioned chairs. Most of the women hooked up to IVs were frail, middle-aged, and bald. Though Nicole resisted the image, they reminded her of Holocaust victims.
Tyler sat next to her and held her hand. The nurse found a vein in the other hand and inserted the transparent plastic tube. Connected to the tube was a syringe full of bright-red Doxorubicin (known in the United States as Adriamycin), part of the standard chemo combination known as AC. It was the color of all manner of poisons: dangerous berries and toadstools, the spot on the back of the deadly redback spider, the tainted apple given to Snow White by the evil queen. This link between the chemotherapy drug and a witches’ brew of toxic chemicals is not far fetched: The treatment was born of a deadly weapon.
As described in “Systemic chemotherapy for cancer: from weapon to treatment,” published in a 2008 issue of the scientific journal the Lancet, scientists discovered during World War I that mustard gas lowered people’s white blood cell counts and could shrink tumors. By the ’40s, researchers were using nitrogen mustard as the first effective chemotherapy. Doxorubicin is one of its descendants, and its mission was clear: Infiltrate Nicole’s cells, insert itself into the helix of her DNA strands like a crowbar propping open an elevator door, and halt the fast-paced replication of cancer cells threatening her life. Nicole watched with horror as the ruby-colored fluid inched slowly toward her vein. Her breathing grew ragged and her heart pounded, reverberating in her ears like the sound of someone sprinting up a staircase. The nurse told her to calm down. Soon, a strange toxic coldness spread up her arm; she tasted metal in her mouth. After a few minutes, the baby moved. It was different from anything she’d felt before—sudden and violent, as if the infant was pummeling her mother’s uterus with tiny little fists.
By March 2009, the Davises’ family members were taking turns driving her to the Kaiser Franklin Medical Center every three weeks and sitting with her for hours as the drugs seeped into her veins. Afterward, she would be drained and nauseated. With her due date approaching, she was constantly holding her belly and talking to Abigail. “Don’t worry,” she’d tell her, “I’ll always keep you safe—I won’t let you see fighting and yelling like I did when I was a kid.” She often felt angry with God; still, she prayed and attended church. She asked that her baby be born healthy, that her family find comfort, and that she make it through the next chemo treatment. Often when she felt sick, she would go into the nursery, which friends and relatives had helped paint pink and light green. There, surrounded by stuffed animals, painted dragonflies, and the crib filled with a red ladybug comforter, she would sit by herself and imagine what Abigail might look like.
Her hair remained the same for weeks, and she thought she might be some sort of anomaly and get to keep it. But by the beginning of March, it had started to come out—in the shower, onto her pillows, in her brush. Nicole’s aunt took her to a cousin’s salon. They tried to make it a festive opportunity for a stylish new haircut, but as Nicole watched in the mirror as her long, blond curls fell to the ground, she held back tears. Two weeks later, huge clumps of hair began coming out, and she had her hair buzzed. Two days after that, Tyler used a razor to shave her head clean.
On April 4, 2009, a week and a half after her third chemo treatment, Nicole and Tyler were getting ready for a friend’s party when her water broke and she began having contractions. Within an hour, Tyler, Aunt Marilyn, and several other relatives stood by at Exempla Saint Joseph Hospital as Nicole labored. Doctors were concerned by the timing since her white blood cell counts were lowest seven to 10 days after chemo, making her body less effective at fighting infection and clotting blood. After three or four pushes, Nicole’s baby emerged at 9:58 p.m. with a full head of hair, which made everyone laugh since Nicole was completely bald. Abigail was 18 and three-quarter inches long; six pounds, three ounces; and healthy.
All Nicole wanted to do was stay home and care for her newborn daughter, but she was only two months into a 15-month treatment plan. She did 12 weeks of a chemo drug called Taxol and began taking Herceptin. For months, she barely left the house except for trips to the hospital and spent most of her time sitting in bed rocking Abbey.
One day at the chemo center, as Nicole sat in her usual chair overlooking the city, a new woman walked in. Close to Nicole in age, she smiled and walked with a confident bounce in her step despite her bald head and flat chest. Her name was Crystal Dean, and the two began scheduling their treatments on the same days and times. They would pretend they were at the salon for pedicures, and when the nurses gave them Benadryl to minimize adverse drug reactions, they’d relax into the loopy buzz and joke around. During one such session, they coined a term for those who ushered them to and from treatment: Kemo Sabe, the Native American term for “trusted friend” immortalized by Tonto. “Who’s my Kemo Sabe next month?” Nicole would ask with a laugh.
One warm summer night when Abbey was a few months old, Nicole felt searing pain in her lower back. She couldn’t urinate. It was a nasty side effect that had happened to her before and had required a trip to the hospital to have a catheter placed. She was exhausted from caring for Abbey and trying to keep the house clean while low on energy, and going to the hospital was the last thing she wanted. She couldn’t even imagine walking to the car. For four or five months she’d been driving back and forth, getting pricked and prodded and sliced open and filled with poison. “I can’t do this anymore,” she said, sitting on their bed with tears trickling down her cheeks. Tyler called Uncle Ted, who arrived at their house minutes later. Ted, a tire salesman, was one of the family’s most sought-after patriarchs, a devout Christian who coined the term “Each of Us is All of Us,” or EOUIAOU, which soon began appearing on the Facebook status updates of his children, grandchildren, nieces, and nephews. Tyler let him in, and Ted walked up the stairs. “Nicole,” he said, “I know this is hard, I know that you feel like you can’t do it. But you’re strong.”
Nicole began radiation weeks later, when Abbey was four months old. While each treatment was shorter than the hours-long chemo sessions, they were five days a week for nearly two months. She and Tyler mass-mailed family and friends to help with Abbey, and they kept a complex babysitting schedule to keep track. As the months dragged on, Nicole felt as if her treatment would never end. She watched women like Crystal—who finished her treatment and today is cancer-free—come and go. When the nurses threw goodbye parties for patients, Nicole looked forward to her own.
In May 2010, after 15 months of treatment, Nicole was finally done. For her last chemo session, Aunt Marilyn brought a white, raspberry-filled layer cake to the clinic. The nurses wished her well with a rousing rendition of “Hit the Road, Jack.” Yet amid the celebration, Nicole was surprised to notice a new, creeping anxiety. During all those months of treatment, while getting blood tests and taking medicines designed to kill cancer, she felt as though she was actively fighting an insidious and sneaky enemy, and she worried that in the absence of the regular treatment…well, she couldn’t help thinking about it.
With her treatment behind her, Nicole began to focus on the future. Abbey’s sandy blond hair had grown long enough to fashion a Pebbles-style ponytail, and the chubby-faced toddler developed a profound devotion to Ariel from the Little Mermaid. Some days, the three of them stayed home, ignored the phone, and cuddled while watching the Mickey Mouse Club. If Tyler and Nicole argued, they’d stop after a few minutes, realizing the point of contention was trivial considering they’d nearly been separated by death. Yet whenever there was down time, when they were watching television or sitting in bed, Tyler noticed his wife feeling her breasts, obsessively searching for lumps.
Doctors had put Nicole on Tamoxifen, a standard post-treatment drug designed to block the effects of estrogen and curb cancer growth. As she endured side effects like hot flashes and mood swings, she tried not to worry. Doctors and friends alike repeatedly mentioned that studies show optimists are more likely to survive cancer than pessimists. But the fear lingered. Would she be part of the 85 percent of HER2-positive patients who lived five years or more, or would she be part of that unlucky 15 percent who didn’t?
One afternoon, Nicole and Tyler barreled north on I-25, silence between them and Abbey asleep in the back. They were bound for Loveland to visit Tyler’s mother, and they’d been discussing the fact that both birth control pills and another pregnancy would be too dangerous for Nicole because of the increasing hormones. Nicole and Tyler planned to adopt, but they had to decide how to prevent another pregnancy. Tyler spoke up, cutting through the silence. He would get a vasectomy, he said. “No,” Nicole replied. She would get a tubal ligation. “You’re 27 years old,” she told her husband. “If God forbid something happens, I want you to be able to have more kids. I want Abbey to have a mom.”
Of course, Nicole was determined to avoid that, and her mind kept returning to the question of a bilateral mastectomy. There was the same range of opinions, with some studies showing little difference in outcome between a lumpectomy with radiation and a mastectomy, and others suggesting that removing the breast tissue entirely could lower the chances of recurrence, especially in a young woman facing decades of risk. While her doctors stressed there was no guarantee the operation would eliminate another bout with cancer, Nicole opted for the surgery. As she put it: “I wanted to be taking care of Abbey and cooking dinner, not feeling myself up all the time.” The operation was scheduled for January 24, 2011.
As 2011 approached, Nicole looked forward to putting cancer behind her for good. At the same time, she wasn’t the person she was before the illness, and she didn’t want to be. Not only did she appreciate her husband and child more than she could have imagined, she also felt a profound connection to the few other young survivors she’d come to know, and there was a certain strength and sisterhood that she didn’t want to forget. She and Tyler spent New Year’s Eve with a friend, a tattoo artist who, in Nicole’s honor, attempted to break the Guinness World Record for the number of tattoos done in a 24-hour period. He wound up shy of the record (801) at 656. Nicole left with five pink ribbons near her ribs, while Tyler’s tattoo covered his entire right side: a chain of Celtic-style ribbons linked to form one huge ribbon.
On the afternoon of January 24, Tyler paced in the waiting room at Exempla Saint Joseph Hospital. He and a half-dozen family members had been there since 6 a.m. Because radiation had reduced blood flow to the breast area and made it less able to heal, implants weren’t an option for Nicole. Dr. Royal Gerow, a plastic surgeon, would remove fatty tissue from each side of her belly and fashion it into breasts, which required a tedious process to link the microscopic blood vessels in the transplanted tissue to the ones in her chest. Tyler supported the mastectomy, but left the reconstruction up to her. “I don’t care if you have boobs” was how he put it. “I just want you.”
It was past midnight when Gerow finally emerged to say he was done and Nicole was doing well. The surgery had taken 18 hours. Nicole was groggy for most of the next day. She sat in a hospital bed, hooked up to an IV pole and surrounded by “Get well!” balloons and fresh flowers. Underneath her gown, the thick, ruddy incisions that snaked across her belly and encircled each breast resembled a giant, unsmiling face.
One day, not long after the procedure, the surgeon who removed her breast tissue came to her hospital room. “Nicole,” the doctor said, “you’re never going to regret this decision.” Nicole looked at her, waiting to see what she meant. When they removed the breast tissue, the doctor said, they found and removed a lump. She paused, and Nicole, dazed from exhaustion and pain medications, strained to comprehend what she was saying. “It tested positive for cancer,” the surgeon said. The doctor handed her a copy of the pathology report. Dated 1/26/2011, it read, “Invasive carcinoma with combined ductal and lobular features. 1.2 cm size.” Nicole’s first reaction was Thank God I had the surgery. The surgeon assured Nicole that she’d removed the entire tumor. Her oncologist, Dr. Azar, was out of town but would contact Nicole when she returned. While she waited a week to meet with Azar, Nicole busied herself by watching American Idol, giggling at the videos her mother-in-law sent of Abbey banging away on a piano and talking on the phone. She told her family and friends about the new lump but assured them the surgeon had removed all of it. She had fleeting thoughts about what it might mean.
The incisions ached where gravity tugged at them, but the pain lessened each day. She couldn’t lift anything, though, for six weeks. When relatives brought Abbey home, the toddler sprinted upstairs. Nicole heard her before she saw her. “Mama!” Abbey squealed in a high-pitched voice. When she burst into the room and saw her mother sitting on a couch in the family room, Abbey was so excited she could barely breathe. Nicole hated that she couldn’t reach down and pull her daughter onto her lap.
Tyler placed Abbey onto the couch. They explained again that Mommy had been at the doctor’s, and that Abbey would need to be gentle. As Nicole hugged her daughter for the first time in a week, she felt hot tears spill down her cheeks. Abbey, now almost two, looked up, her hazel eyes filled with sorrow. “Be happy, Mama,” she said.
Days later, Nicole arrived at the Kaiser Franklin Medical Center to meet with Dr. Azar. Like so many times before, the room was packed with family. Azar told them she didn’t know why the cancer had spread, but it was likely resistant to Tamoxifen. She ordered Nicole to stop taking the drug immediately. Azar said cancer had likely grown since Nicole had had MRI scans and an ultrasound in October, both of which were clear. It was HER2 and estrogen and progesterone positive.
Though the surgeon had removed the tumor, as with most cancers, it was impossible to tell if any rogue cells had spread, so Nicole would need another year of treatment (this time with a different type of chemo, since repeating the AC regimen can increase the risk of congestive heart failure). According to experts, some HER2-positive cancers just don’t respond to treatment, even Herceptin. Various types of cancer—not just HER2-positive ones—can be similarly stubborn, undeterred by chemotherapy. Scientists are developing new drugs to target them, usually by blocking the activity of specific proteins. As Nicole sat in Azar’s office, she thought about how she’d just grown her hair to a length she liked, and now she would lose it again. Her entire body tightened taught as a bow, and she wanted to scream. She wanted to unleash a fiery trail of angry destruction through the hospital and the parking lot and the entire city.
She wanted to know the worst that could happen. And no matter how disconcerting, she wanted the straight facts. “What if the cancer has spread?” she demanded to know. There was so far no indication it had, Azar told her, but if it did spread to distant organs, there would be no cure. Azar asked if she’d noticed any new symptoms. Actually, Nicole said, she did have pain on her right side, under her ribs. Azar ordered a PET scan for February 11, 2011. The call came a few days later, while Nicole was making Abbey breakfast. It was a nurse from Azar’s office whom Nicole now knew well. She told Nicole to come in to see the doctor that day at 3 p.m.
“Why?” Nicole asked. “What did my PET scan show?”
“What did it show?”
After another pause, the nurse spoke, and she was weeping. “It’s in your liver.”
Nicole screamed. Tyler caught her as she collapsed. All he could say was, “Please, no.” Nicole walked past Abbey, who was watching a video in the living room, and into the bathroom. She sat on the edge of the tub, gripped the porcelain, and tried to breathe. She called her aunt, her father, and a friend, who was a breast-cancer survivor, and that afternoon they all arrived at the Kaiser Franklin Medical Center. Just like that first day of chemo two years earlier, it was bright and sunny, with a cool breeze. A somber Dr. Azar explained that the cancer had taken over more than half of her liver. Liver failure would eventually kill her; it might be in several months, or it might be a couple of years. A series of oral chemo drugs—some 13 pills daily—could prolong Nicole’s life, but it was impossible to know for how long. Without the drugs, she would likely die within months.
Azar told Nicole and her family she wasn’t sure why earlier blood tests that can indicate whether cancer has spread to distant sites had shown no signs of metastasis, though Borges, of the CU School of Medicine, and several other oncologists say such tests sometimes don’t. The guidelines for follow-up care after breast cancer include physical exams, review of any new symptoms, and standard blood work twice a year, all protocols that were followed in Nicole’s case. Scans are the best way to discover metastases, but the tests are only given after something raises the doctor’s concern. “It is uncommon for a triple-positive breast cancer to recur as soon as hers did, but we do see it happen,” Borges says of Nicole. “It gets very complicated when you overlap her young age and that she was pregnant.”
Aunt Marilyn wept and stared out the window. Tyler and Nicole’s father sobbed openly. Nicole, numb, watched Azar’s mouth form words—asking if she would take the oral chemo drugs. Tyler touched her shoulder. “What do you want to do?” he said. In that split second Nicole felt a deep rage overtake her. “Yes!” she yelled. “I’ll take them!”
The next afternoon, on February 16, Nicole sat in her living room drinking coffee and resurrected her CaringBridge.org website from the year before (the organization provides free websites for people enduring major illnesses). “The final outcome will ultimately be liver failure,” she wrote. “It will be fast. I don’t know how much time I have. Abigail keeps me holding on to everyday that I am granted here on this earth. … My husband is going to raise my baby girl and love her always. He has promised me he will never ever let her forget who her mommy was. … My baby girl will need lots of women in her life to help her shop for dresses, and bras, and talk to when she needs a mother.”
In the following days, while she was feeding Abbey her Cheerios or coloring with her, Nicole would watch her daughter and wonder about all the things she would miss. Would she be here to take Abbey to preschool in two years? Kindergarten? First grade? A parade of milestones flickered in her mind, taunting her: Abbey learning how to write, going on a first date, graduating from high school. Sometimes when the two-year-old wandered up and snuggled her on the couch, Nicole would find a reason to get up and walk away. People said it was a normal reaction, but she felt like a bad parent.
Nights, she would close herself in her closet, sucked into a spiral of unanswerable questions, not about the future, but about the past. Could she have done something at some point that would have landed her on a different square on the board of Life? Maybe if she’d insisted on getting a mastectomy right away, instead of waiting, the cancer wouldn’t have come back, she thought. Azar had stressed repeatedly that this was a terribly aggressive cancer and that she did nothing wrong, but Nicole couldn’t keep the questions at bay. She wondered about her diet, if eating healthier could have helped, and about stress. Did her childhood play a role? Did Columbine?
Sometimes, Nicole demanded explanations from God, saying she didn’t deserve this, that her daughter and husband didn’t deserve it. Other times, she took comfort in what Uncle Ted said: that God had a plan, and while they might not understand it, they could choose to trust that in the end, all would be well. As Nicole stood in a private prayer room one Sunday after church, a group gathered around her.
“We pray for Nicole and her family,” they said. “We pray for healing.” They anointed her with oil and appealed to Jesus. Nicole closed her eyes. She felt as if she were being carried. After days of chest-tightening tension and anger, she could finally breathe.
On a Tuesday in late February, Nicole sat in a Highlands Ranch cafe. She wore a loose-fitting sweat suit because her incisions were still healing. She said she was glad for a break from the planning (finalizing her will, considering her funeral), the phone calls, and the revolving door of friends and relatives. A few days ago, Nicole’s cousins surprised her and Tyler with airline tickets and hotel reservations for Disneyland. They even arranged a special lunch for Abbey at Ariel’s Grotto, a Little Mermaid–themed restaurant inside the theme park. “I’m so excited,” Nicole said, her eyes shining. “It’s not till March 18th and I’ve already started packing—how silly is that?”
Once Nicole, Tyler, and Abbey entered the Magic Kingdom, with its castles and princesses and ubiquitous cartoon characters, the two-year-old didn’t fuss or throw fits, even while waiting in long lines. As Nicole and Tyler watched the wonder on their daughter’s face and enjoyed quiet moments together as she slept, it was as if the past and the future had disappeared and all that remained was the three of them, together.
Back in Denver, Nicole got her first encouraging piece of news from the doctor: Scans showed her liver tumors had receded and disappeared. While this did not reverse her terminal diagnosis—the doctor stressed that the tumors would return—it did mean the oral chemo drugs were buying her time. In May she met with Dr. Borges, who’s running multiple clinical trials, several of which focus on experimental drugs aimed at treatment-resistant breast cancers. Because Nicole’s liver tumors were responding to the oral medication she was taking, there was no reason to change her treatment. Even so, she hoped she might live long enough to benefit from new drugs being tested or qualify for a different clinical trial. She hoped the hours and weeks might become months and years, long enough to watch Abbey’s topknot grow into a long ponytail, to take her to school, and to sit with her on the big-kid rides at Disneyland. She hoped….
Megan Feldman, who wrote about Scott McInnis’ gubernatorial campaign in the November 2010 issue, lives in Denver. Her work has appeared in magazines including Details and Glamour. Email her at firstname.lastname@example.org.