David P. Steensma, MD
The call from the dermatologist came at noon on Good Friday, just after my wife left with our two young daughters for a week on her family’s tree farm in Northern Michigan. I was on call for the hospital inpatient leukemia service, so I could not join them. When the dermatologist solemnly began, “I normally don’t give this kind of news by phone, but since you are an oncologist, you would know what it meant if I just said I needed to see you in the office to talk about your biopsy,” I guessed what she was going to say next.
Two weeks earlier, I had seen the dermatologist in her office for a routine examination. When she looked over my skin, she noticed two moles she thought were worth cutting out: one on my arm that worried her, and another on my lower back that she thought should be removed “just in case.” A few days later, I exercised the privilege physicians had at our hospital to look at our own medical records and logged into the hospital pathology computer. The report for the arm biopsy was already signed out: an atypical nevus without any concerning features. The pathology report for the less worrisome back lesion remained blank. I assumed it looked so benign it was not even worth mentioning and did not think about it again, until the dermatologist surprised me with her call.
My gut churned as she described the depth of the melanoma and noted that one of the biopsy margins had tumor cell involvement. I immediately worried that it was not the only site of disease. A few weeks earlier, I had undergone an abdominal scan for an unrelated problem, and the radiologist had noted a small lytic lesion in the iliac bone. Frighteningly, he had reported, “In the appropriate clinical context, this lesion could represent metastatic disease.” My primary care physician and I had discussed this, but because the iliac crest is a strange place for metastasis, and I was young and had no cancer history, we dismissed the finding. But a biopsy-proven malignancy just a few inches away abruptly changed the clinical context, and I likely had stage IV melanoma. A computed tomography–guided biopsy was scheduled for the following Monday to confirm my fate.
A Feathered Visitor
A few hours later, I found myself sulking in a chair at our kitchen table in an unnaturally quiet house, feeling sorry for myself. I wondered whether I should bother with high-dose interleukin-2 or with a clinical trial. I mentally ran through a list of palliative care colleagues and decided whom I would ask to care for me when that time came. I was angry, feeling cheated of the chance to see whether my research ideas would ever amount to anything, and irrationally upset at my mother for allowing me to play in the New Jersey sand so many hours every summer weekend 3 decades earlier, despite pale skin and regular sunburns. Most of all, I was disappointed I would never get to grow old with my wife and to watch what kind of women our little girls would one day become.
We are told that life consists of 10% what happens to us and 90% how we react to it.— David P. Steensma, MD
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As I ruminated on the seeming unfairness of it all, out of the corner of my eye, I noticed a massive dark bird land on the lawn outside the kitchen window and take a few hops across the grass. The bird was huge, and I had never seen anything like it. Peculiarly, it ignored the seeds in the feeder we had built to lure the songbirds that our girls loved to watch and name. The dark creature turned its shaggy feathered neck to stare at me.
I smiled sardonically. Just what I needed: a raven as black as my melanoma, to taunt me in my dark hour. I recalled the infamous raven that drove a weary scholar mad as he mourned for his lost Lenore in an Edgar Allan Poe poem with the same title as this essay. As the bird continued to stare at me, I imagined it would tap at the windowpane and croak, “Nevermore!” Irritated, I banged on the glass and yelled to make it go away. The raven ignored my noise.
I got up and walked to the living room, only to have the bird follow and stare at me from a new perch on the patio a few inches away. Thinking it may have been attracted by the reflection of my watch, I tossed the watch on the floor, wondering at the same time whom I should give it to when I died. I went to sit in the bedroom. After a few moments of birdless peace, a flutter of jet-black wings appeared on a ledge outside the living room window. I moved on to the study, where a prognostic analysis I had been working on for months now looked like a waste of time. Again, the raven followed silently.
For that whole weekend, the raven remained an eerie presence outside my home. It stirred tribal memories. I recalled learning about my ancestors, eking out a hard existence on the damp mounds they built along the stormy North Sea, who believed ravens were manifestations of damned souls.
The Art of Reframing
I wanted to be rid of it. The next day, Easter Sunday, instead of going to church as I had on every Easter since infancy, I stepped outside only far enough to throw rocks at the raven. Every time a stone came near, the bird just raised one of its wings and hopped a few steps, continuing its unblinking stare. After some more fruitless yelling, I sat down on the porch and wept, feeling completely defeated.
In 13 years of living in Southern Minnesota, that was the only raven I ever saw. And the memory of the raven’s visit has provided comfort to me in other dark times.— David P. Steensma, MD
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When I finally went back inside the house, I noticed a paper on a countertop that my older daughter had brought home from kindergarten a couple of weeks earlier. She had colored in a line drawing of the prophet Elijah sitting next to a desert brook and had added a few dark V signs, the universal child symbol for birds in flight, to the sky. At the bottom was a quote from the Book of Kings, describing divine provision for the prophet as he waited in the wilderness for a message:
The ravens brought him bread and meat in the morning and bread and meat in the evening, and he drank from the brook.
Psychologists often talk about the importance of reframing, how reconsidering a negative event or situation in a different light can promote health and resiliency. We are told that life consists of 10% what happens to us and 90% how we react to it. When I saw the crayon picture of Elijah being attended to by birds as he waited in the wilderness for a message, I realized how lonely I was. I had not felt up to calling my wife or any of my friends with the news, and I planned to keep my diagnosis secret from my coworkers as long as possible. The world of the ill shrinks quickly. The only living creature who was with me on that weekend of solitary misery was a bird, which, I then realized, was asking nothing of me except not to be driven away. At that moment, the raven that had been a terror became a strange comfort.
Luckier Portion of the Population
When I woke up the next day, the raven was still there outside my window, standing guard.
Later that morning, as I left for work and the bone biopsy, the raven finally departed, soaring into the sky as my car pulled out of the driveway. On Tuesday, my doctor called to tell me that the bone biopsy showed an uncommon but benign fibrous dysplasia, with no evidence of malignancy. Scans showed no other sites of disease. I underwent a wide local excision at the end of the week, and despite involved margins on the original biopsy, there was no evidence of disease at the time of more definitive resection. I declined adjuvant therapy. Thirteen years after the visit from the raven, my Kaplan-Meier survival curve is back to within touching distance of the luckier portion of the population, who have never had a melanoma cut from their trunk.
The ASCO Post is pleased to reproduce installments of the Art of Oncology as published previously in the Journal of Clinical Oncology. These articles focus on the experience of suffering from cancer or of caring for people diagnosed with cancer, and they include narratives, topical essays, historical vignettes, poems, and photographic essays. To read more, visit jco.org and search “Art of Oncology.”
The week after my encounter with the raven, I was bringing trash to the curb and saw a neighbor raking winter debris from his garden; he was an elderly man who had lived in the same house since that neighborhood was first carved out of the Minnesota prairie in the late 1950s. He looked up from his rake and asked me, “Hey, did you see that great big black bird around your house last week?” He shook his head in wonder. “I have seen some pretty big crows over the years, but that must have been a raven. Never seen one of those around here. It seemed to want something at your place.” He died the following year, without seeing another raven. In 13 years of living in Southern Minnesota, that was the only raven I ever saw.
It has taken me 13 years to gather up the courage to tell this strange story to colleagues who may, understandably, be skeptical. And yet it happened, and the memory of the raven’s visit has provided comfort to me in other dark times. As Hamlet reminded Horatio, “There are more things in heaven and earth than are dreamt of in your philosophy.” ■
At the time this article was published in the Journal of Clinical Oncology, Dr. Steensma was Associate Professor, Medicine, Harvard Medical School and Attending Physician, Hematologic Oncology, Dana-Farber Cancer Institute, Boston.
Disclaimer: This essay represents the views of the authors and may not necessarily reflect the views of ASCO or The ASCO Post.