Chapter One ONE


Advance Genetics Lab

Walters, New York

A VOLCANO ERUPTING IN the open jaw of a shark.

As Lydia Susi leaned into the monitor, one half of her brain identified the image for what it was, a PET-CT scan of the chest of a twenty-nine-year-old male with extensive stage small-cell lung cancer. The cross section, which cut the patient’s rib cage in horizontal slices, showed the tumors in the right lung, which seemed bigger to her, and two new masses on the left side. Given that this was both positron emission tomography with F-fluorodeoxyglucose in conjunction with computed tomography, the growths were well visualized, but also appearing as hot spots given the highly metabolically active abnormal cells.

It was a very clear and helpful diagnostic picture of a dying man’s respiratory landscape, and yet, her Ph.D. in biology aside—as well as forgetting about the last six months of looking at similar images—she was nonetheless struggling to stay connected to what she was looking at and what it all meant: i.e., that the traditional immunotherapy, just like the chemotherapy, hadn’t worked.

“Daniel…” she whispered as the doctor beside her cued up the next cut and continued to drone on.

Instead of properly processing any of the information, her brain continued to treat the slideshow as a Rorschach test of avoidance, her thoughts skipping away from the grim news to pull random pictures out of the oblong frame of red-tinted shadows and yellow-and-orange clouds. It wasn’t stage four cancer run amok, no, absolutely not. It was a first-generation video game, where you could drop a crudely pixelated soldier onto an alien planet and use the boulders of tumor growth to take cover behind while blocky monsters chunked around and tried to eat you. No, wait, it was a plate in a psychedelic buffet line, with only the baby new potatoes part of the Grateful Dead entrée having been spooned on. How about Jackson Pollock, in his little-known oncology period? Sofa slipcover pattern? Bowl of fruit.

The visual extrapolation that finally stuck was that of a volcano, her mental cracked-up-Krakatoa seated where the spine formed a little triangular notch on the bottom of the chest cavity’s slice, the ghostly point of the vertebra seeming to launch an eruption that was tinted with that angry Kool-Aid red and the comic strip yellow and the autumn hearth orange, the whole of it contained within an outline that reminded her of that scene in Jaws, when Chief Brody goes to Quint’s to hire the contractor to kill the shark.

All those boiled, open jawbones hanging around, their graceful contours like the shape of the rib cage.

Here’s to swimmin’ with bowlegged women.

“I beg your pardon?”

Lydia looked over at the white-coated doctor who’d been talking at her. Given that the man was staring over in surprise, she’d clearly shared that little ditty about genu varum out loud—and what do you know. She hadn’t properly processed him, either. Trying to remember his name, she failed, and if she had to describe him ten minutes from now, she knew she’d suck at that, too. Then again, he had anonymous looks, his thinning brown hair side parted, his unremarkable eyes myopic behind rimless glasses, his facial features functional rather than attractive. With his surgical scrubs hanging loose on a thin, nonathletic body, it was like his IQ was so high, his brain co-opted all of the available nutrients and calories out of his digestive tract before they ever got a chance to fill him out.

The one thing she did know about him, and that she would never forget, was that he was a brilliant oncologist.

“Sorry,” she mumbled. “Please continue.”

He pointed to the screen with the tip of his Montblanc pen, the little white star on the top making the rounds of the tumor growth like a fly trying to decide where to land. “As you can see here, the primary site has increased by—”

“Yeah, yeah, she knows that already.”

As the booming voice cut through the narrative, Lydia thought, Thank God.

Turning away from the monitor, she clung to the eyes of the man who marched up to them. Augustus St. Claire was unlike every other researcher and clinician. Standing well over six feet tall, with an Afro and a wardrobe that consisted solely of t-shirts from the sixties, he looked like someone who belonged in Jimi Hendrix’s band. Instead, he was the leader of this privately financed facility that was exploring medical advances well under the radar of the Food and Drug Administration.

Today Gus was wearing a well-washed H. R. Pufnstuf number, the pattern seafoam green, the background mustard yellow, the name done in those trippy, melt-y sixties letters.

“I’ll take care of this,” he said. “Thanks.”

The other doctor opened his mouth to argue the dismissal. No doubt he was the type who had succeeded at everything academic and professional in his life and was more used to people welcoming him into discussions, especially if they were about life-and-death medical issues. But when Gus stared him down, he clipped that black pen with its icy bathing cap back into the pocket protector on his white coat and ambulated himself out of the boardroom.

The glass-and-chrome door eased shut, and for a moment, Lydia looked through the bank of floor-to-ceiling panes that ran down the front of the space. The underground laboratory on the far side was so vast, she couldn’t see the end of the facility, all the workstations and equipment in shades of gray and white, all the people who bent over microscopes, and put liquid into tubes, and frowned into the screens of laptops, in bright blue and white blocks of scrubs and doctor coats.

“How long’s he got, Gus.”

Even though she knew. Still, some stupid desperation on her part tossed the question out into the air, the fishing expedition for some kind of hope, any kind, guaranteed to come up with an empty hook.

Guess she had internalized these new scans, after all.

Gus went around the long black table with its stable of leather chairs. There were projector screens at both ends of the room, and she imagined the scans being reviewed here by the senior staff. They were not going to be surprised. Small-cell lung cancer, especially in its late stages, was an absolute bitch.

“You want something to drink?” Gus said.

Down the long wall of the room, a layout of sodas, sparkling waters, and fruit juices had been arranged on a credenza, everything from the labels on the branded bottles and cans, to the crystal glassware, to the ice cubes in their refrigerated dispenser, lined up with OCD precision, a platoon of libations reporting for duty in the war against dehydration.

“So do you want anything?”

“No, thanks,” she replied.

Gus helped himself to a room-temperature Coke, popping the top of a can and pouring the Real Thing down his throat like he was dousing a fire in his abdomen.

Lydia waited until he took a break halfway through to catch his breath. “I want to know how much time. And enough with the I-don’t-answer-questions-like-that and every-patient-is-different bullshit. We’re way past that point now, and you know it.”

She turned back to the view out into the laboratory. All those brilliant minds working around the clock, trying to create a future that wasn’t going to come fast enough. At least not for the person she cared about.

As Gus came across to her, she braced herself, but all he did was glance over his shoulder at all the drinks like he desperately wanted to bring something to her.

Crossing her arms, she nodded at the laptop on the table. “FYI, I will launch this thing at you if you try to offer me an orange juice.”

“Vitamin C is important for a good immune response.”

“Then let’s infuse Daniel with twenty gallons of Tropicana. How’s that for a protocol.”

Gus finished his Coke, and when he put the can down, there was a declarative sound to the impact. “I’d say two months. Tops. He tolerated the immuno-therapy like a champ. The chemo as well. He’s extraordinarily healthy, except for the cancer.”

Other than that, Mrs. Lincoln, how was the play.

And “tolerated”? That was not a word she would use to describe the way the man she loved had had to endure the brutal side effects of all the courses of drugs.

“Is there anything else we can try?” She put her hand out. “Except for… well, you know he doesn’t want Vita-12b.”

“I told you, I’m not going to argue with him about his decision.”

“You’re a better man than I,” she muttered. And yet could she blame Daniel?

“Here’s the thing.” Gus picked up the can and brought it back to his mouth, a hissing sound rising into the silence as he tried to find another sip in the empty. “He should be able to choose whether or not he wants to be a guinea pig—”

“I’ve never said the choice wasn’t his—”

“—but now that we’re out of conventional options, maybe he changes his mind. Or maybe he doesn’t.”

Drowning in frustration and sorrow, Lydia ripped the tie out of her hair. Then she recaptured everything she’d just freed and wound the loose bun right back up.

Sometimes you just had to do something with your hands. Other than throw things.

“Daniel has to make the call soon, though, right? I mean, he’s as good as he’ll be today—”

“Actually, he’s going to rebound some now that the immunotherapy’s going to be stopped. As I said, he’s a healthy man in his prime underneath it all, and we’ve always been on top of his symptoms and complications. And we can do CyberKnife on his liver again and put in a stent if we have to. The bone mets in his spine and hip are what they are, but they haven’t gotten much worse. Of course, his lungs are the real problem. Bilateral is a bad new development.”

No, shit, Dr. St. Claire.

Lydia pulled out one of the executive chairs and all but fell into the baseball-mitt-like seat. As she stared at the laptop screen, she wanted to cry, sure as if she were already at Daniel’s wake. She wanted to weep and gnash, pound the glossy table with her fists, stamp her feet, kick the glass wall, throw the computer so hard that it splintered into a Dell-branded jigsaw puzzle. But you only fought what you did not accept, and as a numb helplessness started to wrap her in cotton batting, she realized that she was finally putting down her sword.

How had it come to this, she wondered. Then again, if the pair of them were walking down the aisle together, her in a white dress, him all tatted up in a tuxedo, she would have had the same sense of confusion. Awed, rather than awful’d, of course.

“Do you tell him or do I,” she said softly. Then she looked up sharply. “And if it’s going to be a doctor, it has to be you, not one of those other… well. Anyway.”

“Not one of those über-compassionate, windup toy researchers? I’d be touched by your request, but they set a low bar at the bedside, don’t they.” He held up his forefinger. “They are exactly who you want in the lab, however.”

“I believe that.” Lydia shook her head. “I need to go tell him. Probably best coming from me.”

“You want me to be with you?”

“It’s not going to be a news flash.”

When Gus got quiet, she glanced over. The man was staring off into the distance between them, his eyes not really focused, like he was reviewing the case for the seven millionth time in his head and looking for something, anything, they could try.

“It’s not your fault,” she said.

“Sure feels like it is on my side.” He fired the Coke can across the space, pegging the wastepaper basket at the far end of the credenza like it was a basketball rim. “I’m going to grab a break. You can always text or call, ’kay?”

“You, taking some time off?” She tried to smile. “Unheard of, even if it is ten at night.”

“I’m going to get shit-faced, actually. Care to join me? You can invite that boyfriend of yours.”

“I’ll take a rain check, if you don’t mind.”

“Fair enough. And remember, call me. Day or night.”

As he headed for the exit, she murmured, “You’re a good man, Gus.”

He stopped with his hand on the door. As he looked over his shoulder at her, his dark eyes were grave. “But not good enough to save him.”

Before Lydia knew what she was doing, she was up and out of the chair. When she embraced the doctor who had been right on the front lines with her, there was a split second—and then he hugged her back.

“I’m sorry.” He cleared his throat. “This is not the outcome we want.”

A moment later, they parted, and he squeezed her shoulder before leaving. Out on the far side of all the glass, he made his way down the rows of workstations—and the other researchers stole glances at him, like he was a rock star striding through a public place, a unicorn among mortals.

The back of the t-shirt had a series of faded dates, like Pufnstuf was on tour. It was hard to know whether the top was an actual vintage one or something created to look period. Knowing Gus, it was probably the former. He seemed like the type who would blow off steam by collecting relics he’d hunt-and-pecked for.

Returning to the laptop, Lydia went through the chest images again, looking at the clear evidence of disease progression. There were other locations on Daniel’s body that had been scanned, but she had no interest in going through them, at least not right now. If there was nothing more to be done, it didn’t really matter how much things had advanced in his spine and hip. In his liver. The only good news was that there was still nothing in Daniel’s brain. The doctor with the anonymous features had led with that announcement, as if it had been preplanned. Or maybe it was just alphabetical, “brain,” starting with b, before “hip,” “liver,” and “lung.”

“Dr. Walter Scholz. That was his name,” she said absently as it came back to her.

Lydia closed the laptop.

When the best case was that you didn’t have cancer in your brain—yet—that pretty much said it all, didn’t it.

She needed to go find Daniel.

And tell him it was over.