Getting on Stage(s)

Did you ever notice how you don't hear of many people with early
stage cancer?
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Yeah, I've got cancer.

Bummer. When'd you find out?
This morning.
I mean . . . like . . . uh . . . what's going on?
I dunno . . . it's cancer.
Are they sure?
Yeah, pretty sure. I had lots of tests and stuff.
Well, what's gonna happen?
I dunno.
Well, are they going to treat it?
Yeah, I guess. I gotta find out.
Well . . . I mean how far along is it?
It's measured in stages.
Yeah, know . . . and what stage are you?
Stage zero.
What the fuck? You're telling me you've got cancer and stuff and
I'm feeling all sorry and stuff and you're Stage Zero? I didn't even know
they HAD a Stage Zero. Isn't that called 'well' ? I think Stage Zero means
you don't actually have cancer. You've got a cold or a cough or you're
constipated or something,
Hey, man, I don't make up the numbers, awright. I don't stage
this shit, right? All's I know is that they told me I have cancer.
Look, if you've actually GOT cancer and it's Stage Zero, I gotta
figure there's something wrong with their calculator or their numbering
system . . . either that or you're gonna be around here for a long time.
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Although it seems a little crazy there are indeed a Stage Zero

cancers. And those are presumably the ones you want if you get cancer.
For example, some breast cancers are Stage Zero where the the breast
mass is noninvasive. At Stage Zero cancer of the breast, there's no
indication that very localized tumor cells have spread to other parts of
the breast and at this early stage such cells would not have spread away
from the breast either. Some physicians refer to Stage Zero as
precancers. One cancer center writes, Stage 0 cancer is difficult to
detect That's definitely the kind I want, the one that is so small it's
impossible to detect.
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If you want to really impress your friends about how bad off you are tell
them you are Stage 4376. Stage zero impresses no one. Four digit cancer
stage numbers elicit the deepest kind of compassion, even if it's an entire
fabrication.
You have to be careful though. Sometimes a high cancer score
might just have the opposite effect that you're looking for. Just ask the
Germans. They have a word schadenfreude, which essentially means,
Holy shit, I'm so glad that it's him and not me with cancer. Actually I'm
so damn glad I realize that I never really liked him anyway and I now
realize that I'm glad he has cancer. He was always so perfect. Fuck him.
He's finally getting his due. President of his class, captain of the football
team, youngest partner ever at Goldman Sachs . . . that's the kind of
person that cancer supposed to get, not schmucks oops, a mensch - like
me.
The brilliant and outrageously funny Russian scholar Nicholas
Valentine Riasanovky used to tell about the difference between Russians
and Americans, describing their reactions to the same competitive social
situation: In American, he'd say, If your neighbor drives home in a
brand new Mercedes and you look out and see it in his driveway next
door, what you want is to get up and get to work early the next morning
and work late and work extra hard so you can get a Mercedes, too.
When that happens in Russia, what happens is that the Russian does not
change his behavior, he just wants for you NOT to have a Mercedes.
That's schadenfreude , you not only don't feel compassion for the person,
his misfortune actually makes you feel good. It's like seeing a smart-ass
ovolactovegetarian nobody likes him anyway - being told that he just
ate a pork tartar appetizer. Even seeing your competitor's stock price
crash . . . you offer a terribly insincere Oh man that's awful, all the while
grinning deeply inside. Guilty pleasure at another person's woe. Your
pain is actually, on a relative basis, my gain.
A nicer sort of psychological reaction is Mudita, a Sanskrit word
that means sympathetic or vicarious joy, the gaining of your own
pleasure at another's well-being. In this case, if your neighbor got a
promotion or bought a new Mercedes, you would actually be gratified,
feel pleasure, as his success. You could and would applaud the chap
at work who got a long sought after promotion instead of you. Yeah,
mudita is some seriously joyful stuff. Your self-interest becomes non self-
interest. The absolute absence of self-interest is your joy.1
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Stage 0 cancer is referred to as noninvasive. I'm figuring that if
you have cancer it's pretty much invasive. What is it if it's not invasive?
But that's medical terminology for you. Stage 0 cancer is, as they say,
early stage, as if we could not have figured that out ourselves through
our early stage recollections of the cardinal numbering system.
Remember cardinal numbers?
Stage 0 cancer is just still sitting, trying to make up its mind,
making nefarious plans for what, when and how it is going to prolong
1 Fifth century Buddhist scholar Buddhaghosa wrote about the development of
mudita in his Path of Purification. (It's good to know that mudita can be learned,
that's it's not entirely an innate gift.) He writes that a person who is just learning to
develop mudita, shouldn't focus on someone who is already deeply loved, that one
needs to gain mudita with respect toward someone who is, preferably, disliked or
even hated . . . but at least someone toward whom one feels neutral. I think, if
religion and philosophy and cancer weren't already difficult enough to comprehend,
that mudita might be a word that Christ picked up on his Indian sojourn . . . or which
maybe he taught the South Asians. But then I think that there's transcendental love,
which is at the core of mudita and Christianity knows few physical boundaries. And
not unlike us, getup tomorrow and the the same think all over again.
itself, take over, through cell multiplication. The existential questions of
how an organism originates, reproduces, survives and thrives are nothing
if not curious.
Especially so with cancer. It's quieter . . . more stealthy . . . your joy at
another misfortune may be silent, but it's profoundly fulfilling.
Panthera leo's goal is to find, track, take down, kill and eventually
consume a gazelle! Eventual success at the hunt doesn't put the African
lion at any risk. There are quite a few around.2 But cancer doesn't think
that far out. Success for most cancers means suicide. Cancer's ultimate
success is killing its host, which means its own demise.
An early stage cancer is in situ. It's stayed localized and confined to
the layer of tissue from which it first developed. It's not yet moved on
metastasized to the surrounding tissue or other body parts. Stage 0
cancer is sometimes referred to as precancerous. Abnormal cells exist
but they're not really tumor-sized yet. But they are likely thinking about
how to become State One Conspiratorial.
I asked why no one ever says, I've got Stage 0 cancer. Saying that
Stage 0 cancer is difficult to detect is an understatement. Feeling and
finding Stage 0 Cancer is highly problematic because it's so small and just
doesn't cause you any problems . . . at least that you know about . . . yet.
Cancer has to get to Stage 1 or 2 or 3 or 4 before you feel bad, find a
lump, cough, etc.
Surprisingly, once you're tagged with a Stage, the docs don't
change your staging number. If you originally were diagnosed with Stage
2 cancer, at your deathbed you are still Stage 2. That seems a little silly to
me. What the heck . . . the guy died of Stage Zero cancer? Plus, I'm dying
of cancer,3 I'd want the docs to accord me a high number. I think I'd
earned it.
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2 There are five hundred and fifty thousand Thomson's gazelle's and that number
doesn't include any of the other six species of gazelles. If they run low, there are
1.5 million wildebeests. There are 50,000 to 75,000 lions in Africa. Few in the U.S.
3 Which, right now, I may be.
 When I was diagnosed, I was Stage IV. Not so good, but the nurse
explained that in my kind of cancer, HPV oropharyngeal cancer of the
tonsil, there were five stages, meaning there was a Stage 5. So that's
good news, I'm only Stage IV. Wow, this was getting more and more
complicated.
There's five stages anyway, (zero, one two, three, and four . . .
that's five total.) My nurse was telling me that there are really six stages,
five plus zero, for a total of six. I've learned that there are no cancer
scoring systems that recognize this fact.4
What nurse Cathy was probably referring to was the existence in
many staging systems of a, b and c to further delineate how
advanced is a cancer. Staging is better described by using the TNM
system which is more descriptive and definitive, but which itself is even
a little bit crude. Cancer docs don't usually refer to cancer by stages, they
use TNM letters and numbers. TNM is a code, a special language, but
with a few tries is one that easy for the beginner to decipher.
T is the size or extent of the primary tumor. N indicates the spread
to nearby lymph nodes. And M is the presence (or absence, of course) of
metastases or spread to other areas of the body away from the original
site. The number is added on to indicate the size or extent of the primary
tumor and the degree to which it has spared. The system thus tells how
large is the primary tumor and where is it located and presumably where
it's been and where it's heading.
Staging and TNM try to capture in a few numbers and letters: How
big is the cancer (usually in the form of a tumor)? Has the tumor spread
to the lymph nodes?5 Has the cancer spread, or metastasized, to other
parts of the body?. Where did it start and where is it now? In what

4 When I asked one famous oncologist about the existence of Stage V, he calmly
replied, Well, there might be a Stage 5, but no one meaning me is going to be
around to testify to its existence. Got it . . . cancer and the joke.
5 The lymph system is another one of those body parts and systems that is grossly
under-appreciated, like perhaps the Circle of Willis, the philtrum or Dua's layer.
Like Joni Mitchell said, You don't know what you've got til it's gone. Like my
thryoid.
tissue? How aggressive? How far has it gone? How far gone are you?
So-called head-and-neck6 cancer is not atypical of the physical
division of labor in medicine, i.e. the development of specialties. Staging
is usually a consistent system among different types of cancer.
In head-and-neck cancer Stage IVA, my stage of, cancer is:
T4a, N0 or N1, M0: any size and is growing into nearby structures.
Cancer cells aren't present in the lymph nodes, or they may have
spread to one lymph node, located on the same side of the neck as
the primary tumor and is smaller than 1.2 inches, and not spread
to distant sites7, or
T14a, N2, M0: the tumor's size and may or may not have invaded
nearby structures, not spread to distant sites, and one of the
following is true:
cancer cells are present in one lymph node, located on the
same side of the head or neck as the primary tumor and
measuring 1.2 to 2.4 inches across (N2a)
cancer cells are present in one lymph node on the opposite
side of the head or neck and measuring less than 6.4 inches
(N2b)
cancer cells are present in 2 or more lymph nodes, all smaller
than 2.4 inches across and located on either side of the head
or neck (N2c)
In Stage IVB, it's either:

6
There are now, especially in oncology, sub-sub-and so forth seeming endless -
specialties. What the recognition of cancer and therefore cancer treatment is
many centuries, perhaps thousands of years old, cancer as specialty didn't start
until the early parts of the 20th century. The professional association for radiation
oncology wasn't founded until 1958. Today, there are thousands of head-and-
neck radiologists that usually don't venture lower than the esophagus or into the
brain.
7 For lots of reasons, head and neck cancers like the lungs and go there first.
That's why for head-neck cancers, oncologists check your lungs for cancer as a first
step.
 T4b, any N, M0: the tumor has invaded deeper areas and/or tissue
and may or may not have spread to lymph nodes and has not
spread to distant sites.
or
Any T, N3, M0: the tumor is any size and may or may not have
grown into other structures. It has spread to one or more lymph
nodes larger than 2.4 inches across, but has not spread to distant
sites.
Or, to complicate matters even further,
Stage IVC:
Any T, Any N, M1: The tumor is any size, may or may not have
spread to lymph nodes , but cancer cells have spread to distant
sites.
Making all of the above more complicated is that every cancer staging
system, while similar, has its own idiosyncrasies. At least I could be sure
that I knew where I was in the system . . . quantitatively . . . if not
subjectively. Ultimately the grading system would be pass / fail, but at
the date when I was assigned my grade, the odds were already stacked
against me.
When I asked a doctor about my chance of living . . . how long . . .
and in what kind of condition . . . the answer became a haunting mantra:
Every patient is different. Well, hell, I know that.
Will I be able to climb K2? Every patient is different.
How about a Nobel . . . could I win one? Every patient is different?
Am I going to live until this afternoon? Every patient is different.
As the game evolved, when I asked any question about future
prospects or expected outcomes, I'd try to predict the answer. After a
few months, I got perfect at the game. Never lost. Every patient is
different.
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 The treatment success measure for most cancers is the five year
survival rate, or whats the percentage chance of your being around in
five years. The five year survival rate for my kind of cancer was around
30%, but that required adjustment because HPV cancers in men are more
curable than other throat cancers. Later information and complications
would further change the chances of my being alive in five years. But,
suffice it to say that I'm writing quickly.