My phone rang on March 17, 2014, at seven P.M. It was Thursday, and I was at Yancy’s, a pub and sports bar in San Francisco’s Inner Sunset, hanging out with my college roommate and watching the NCAA basketball tournament. My phone screen read: Jason Greenstein. “I’ll be right back,” I told Erik.
“What’s up, J?”
“Who do you think is going to win the Syracuse game?”
“No clue. I’ll take whoever you don’t want for five bucks.”
“You’re on.”
We wagered.
“How’re you feeling?”
“Great. Sitting in a sports bar, surrounded by TVs. If I didn’t know I had cancer, I wouldn’t know I had it.”
So it went. Every few weeks I’d hear from Jason or check in with him, and it was always the same: I feel good and I don’t want to go back to chemo and suffer. “How are you doing, Rick?”
I would keep it brief. “All systems go.”
“How is Prodigy 2?”
Prodigy 2 was the nickname that Jason had given to my son, Milo. At that point, Milo was seven, and Jason had nicknamed him Prodigy 2 because Milo was proving to be a very good athlete. Especially in baseball. I’d experienced occasions when people would pause to watch him catch and throw and hit when we were playing at the park. On his teams, he tended to play a year up and often was chosen for the glory positions—shortstop, pitcher, and catcher. Once an older girl watched him whack a ball and yelled “You’re going to be in the hall of fame!” and Milo turned bright red. It was waaaay too soon to know if Milo had the gifts that Jason had, but regardless, Jason loved to see videos of Milo and hear stories. At this stage, conversing with Jason was a little bit like talking to an aging grandparent who wanted to hear about the kids but mostly wanted an ear to bend.
“What’s the doc say, J?”
Dr. Brunvand had been clear with Jason that the longer he waited, the worse his chances of catching the growing tumor. But Jason was following his own gut and his internal meter. If he didn’t feel bad, he wasn’t going to suffer any further. He’d had enough of that.
Besides, he had the same sense of invincibility he’d always had. “I never really thought I was going to die,” he would later tell me.
He surely was testing that theory.
By the time Jason decided he was ready to return to treatment, it was the leading edge of summer 2014. Jason finally dragged his exhausted, bloated, cancer-ridden body back to Dr. Brunvand. “There had been an explosion of Hodgkin’s.” That’s how Dr. Brunvand put it in his note on their meeting that day, observing that Jason had a 10-centimeter mass on his neck, cancer of between 10 and 15 centimeters around his armpit, with the lymphoma beginning to stitch together as a quilt in and around the left side of his chest.
This time Dr. Brunvand told Jason there could be no messing around. He told Jason that the best shot was trying to use a three-drug regimen, including brentuximab, to get the cancer into remission, and then to undergo a different kind of stem-cell treatment called an allogeneic stem cell transplant. The stem cells would come from his sister. The use of his sister’s cells would theoretically enable the rebooted immune system to recognize his cancer’s subtle differences and attack it. His own immune system was clearly not up to the task. They’d need a stronger one, uncompromised by this virulent Hodgkin’s strain, and even then, Jason couldn’t get the transplant unless he was in remission first.
During this period, Jason would bring his brother-in-law, Paul, in with him for meetings and treatments. Paul was a molecular biology PhD, a patent lawyer, and a great listener with his science background. One day they found themselves sitting in the waiting room, and Jason started talking. “Do you want to know what it’s like to be a cancer patient?”
“Let’s hear it.”
“It’s like all the people in the world live in a Tahitian village on a beautiful beach. And I live in this canoe, and the canoe is attached to the pier by a rope. I can still see the village, and sometimes I’m allowed to come to rejoin the village. But I always have to go back to the canoe. One day I’m not doing so well, and I notice that the rope is longer and I’m farther from the pier. Then the doctors in the village pull on the rope and bring me back to the pier.
“Over time, I drift farther and farther from the village. After a while, I don’t think I have the rope anymore. All around me are people, but they’re not in canoes, they’re in coffins. And I realize my canoe has turned into a coffin.”
By the end of his story, he’d talked twenty minutes.
Paul was crying. “It was the most telling isolation story I’ve ever heard.”
The oddest thing would happen, though, at these meetings with Dr. Brunvand: Paul could see Jason cling so optimistically to the rope. After Dr. Brunvand would give his assessment, Paul would think to himself: “Oh my God, that’s grim.”
“But Jason would always find the one to ten to twenty percent positive thing that Brunvand had said and turn it into ninety percent. I’d say, ‘Jason, you’re exactly right.’”
Part of Paul wanted to believe it, even did. “Cancer is a very resilient thing. It reminds me of an NCAA basketball game, and sometimes someone like Jason hits that buzzer beater.”
In August, Jason finished his third cycle of chemo. The cancer, while it had shrunk in some places, had increased in others. To extend the basketball analogy, he was down by double-digit points in the game’s final minutes.
On September 4, he went to Las Vegas to deal with his business, the best that he could. He came back September 20 to start more chemo.
He met with Dr. Brunvand on December 10, a year after he thought he’d at last been in the clear and free of all medications. Now he was on fifteen medicines, an alphabet soup of acyclovir, brentuximab, pain medications fentanyl and oxycodone, Zofran for nausea, and others.
The balance of Jason’s immune system was more damaged than his cancer at this point. To support his defense network in its ineffective attack on cancer, he took chemo and targeted therapies that echoed throughout the body. With his ecosystem out of balance, he took drugs to dull the effects of inflammation, pain, stress, and depression, which themselves reflected the imbalanced immune system. Jason’s repetitive cytotoxic chemo had damaged his ability to make normal blood cells. He was neutropenic, with a severely low level of neutrophils, the white blood cells that are the first line of immune defense. Without neutrophils, Jason could die of any infection because bacteria double every twenty minutes. Imagine that, beating cancer only to die of a common infection.
Jason’s analogy built around the Tahitian village makes a lot of sense to me. Another fair analogy to what was happening inside Jason’s body and to his immune system might be the war in Vietnam. Chemo was napalm, creating scorched earth. But that wasn’t the real problem. The crux was that the plan to use napalm in Vietnam in the first place grew from a desperate and complex set of circumstances that seemed otherwise impossible to untangle. Of course, there was one simple answer: Stop prosecuting the war.
Jason was increasingly tempted to take that course. He was having suicidal ideations.
“When you say that, Jason, are you saying you have a plan?” Dr. Brunvand asked him.
“No. I just . . . sometimes it crosses my mind. I just don’t want to die in this much pain. I can’t take this.”
They talked about whether to stop therapy. Jason said he wanted to go on. They’d need yet another new tactic. The brentuximab and other drugs given in combination were not working. But any new therapy could not be primarily cytotoxic, killing rapidly dividing cells, because that would further lower his white blood cells. Dr. Brunvand found one that had a slightly less toxic profile.
“I am concerned that his marrow is stressed enough and might not be able to recover from standard . . . chemotherapy.”
Jason still insisted, in spite of all of it, that he would “beat this thing.”
One thing he’d come to terms with was his relationship with Beth. Dr. Brunvand’s doctor’s note, at long last, reflected what had been true for years: “He does have a long-term monogamous partner.”
He also continued to keep his sense of humor, somehow, even in his darkest, near-death moments.
On January 17, 2015, Jason, in Vegas, felt like shit. Everything hurt. Exhaustion overtook him. His vision blurred. Jason decided he probably should see a doctor. So what would you imagine Jason might do? He drove an all-nighter to the Colorado Blood Cancer Institute. He kept himself awake with chewing tobacco and a furious certitude that he could make it alive to Denver—the kind of will that once had earned him terrific respect from basketball coaches and foes. He drove over two mountain passes in excess of 12,000 feet with a quarter the amount of hemoglobin needed to carry oxygen.
Somehow he pulled his van into the parking lot of the cancer center, whereupon he passed out.
In and out of consciousness, he pulled out his cell phone and dialed the clinic. The team hustled out to the lot with a wheelchair, rushed him inside, and discovered his blood pressure and pulse were too low for the machines to get readings. They had to take his pulse manually. By the time they got to the elevators, Jason was able to get some words out. That’s when Dr. Brunvand appeared.
“Hey, doc.”
“Jason, tell me what’s going on?”
“I’ve been spending all my money in Vegas on hookers.” Jason smiled, let out one of his patented squeals. He was kidding, of course.
Dr. Brunvand laughed, commenting, “We have bigger fish to fry right now. You are going to the hospital once we find a bed.”
“It’s hard not to love a guy who sees God with one eye and the seedy side of life with the other,” Dr. Brunvand told me.
Jason’s red blood cell count had been so low—20 percent of normal—that he well could’ve died en route. The Steel Bull, as Dr. Brunvand called him, was admitted to the hospital and treated.
A few days after Jason had been admitted, he was visited by the medical team’s social worker, Melissa Sommers. Jason was still in the ICU and Melissa came in, trying to be somber and compassionate, and asked him how he was doing. He started to complain. After a few sentences, he ripped off the covers and burst out laughing. “You thought I was naked under here, didn’t you?”
She couldn’t help but laugh.
“Sorry,” he said. “I had to lighten the mood.”
“I wish I could believe in God,” he told me.
“Not your thing?”
“I just envy people who can believe. I can’t find it. I’ve tried. It’s not for me. I think it would be comforting. I see it comforting people. But I just don’t see any evidence for it.”
“I’m agnostic myself, J. No idea what’s out there.”
“Sometimes I think about my dad being up there, somewhere out there. I’ll see something weird, like a light out on the highway, and I’ll think it’s a sign from him.”
“What kind of sign?”
“Like maybe whether I should bet on the Broncos.” High-pitched squeal.
“Love you, man,” Jason said. He’d started telling his friends he loved them. This was uncharted language for a group of Colorado boys steeped in jock culture.
The end was near.
On March 4, Jason came for his regular visit. Dr. Brunvand examined him, with Poppy Beethe, Jason’s longtime oncology nurse navigator, looking on. Empathy poured from her face, punctuated by eyes that mist up when she watches sappy commercials. She’d grown to cherish Jason.
He was complaining of a new symptom, pain and swelling on the left side of his chest and back.
Dr. Brunvand had a good idea what that meant, and he began feeling the weight of his own emotions. He gave Jason a broad clinical exam and discovered Jason couldn’t move his inflamed left hand, with the muscles impinged by the tumor’s growth into the nerve that fed them. He looked jaundiced. It was hard to hear Jason breathe on the left side, and his inhalations cackled. His skin was leatherish and discolored from his left pelvis to his left shoulder.
“Jason, will you excuse me for a moment?”
Dr. Brunvand opened the door of the boxy exam room, closed it behind him, and stood for a moment in the hallway, arms crossed. This was going to be very difficult. He took several deep breaths. He went back into the exam room and pulled up a stool beside Jason, sitting in the oversized chemo/exam chair.
“Jason, you are going to die.”
Jason started to cry. Poppy started to cry.
“As your friend, it’s my job to make you as comfortable as possible.”
Jason knew one thing for sure. Dr. Brunvand wasn’t a quitter. Dr. Brunvand was built to be Jason’s oncologist, the two of them a pair who would sweat together and sprint, climb, and fight, and not give up or in. This oncologist wouldn’t say the words “You are going to die” unless Jason had reached the end.
“There’s nothing left to treat you with. Chemotherapy is doing more harm than good.”
Jason cried.
“Jason, do you understand what I’m saying?”
He nodded.
“I’d like to get your family here as soon as possible to talk about next steps.”
“What about that one drug?”
That one drug was called nivolumab. It was leading-edge immunotherapy. It had been approved by the FDA in 2014 for treatment of late-stage melanoma. The drug unleashes the body’s immune system. It’s a monoclonal antibody treatment built on the shoulders of all the years of immunology, and it works by disrupting cancer’s nasty trick of bringing our elegant defenses to a standstill. At the time, the drug was not approved for use in Hodgkin’s lymphoma, Jason’s cancer.
But also in 2014, an article in the New England Journal of Medicine presented powerful evidence that the nivolumab could prolong life for Hodgkin’s patients. The article highlighted just twenty-three cases of increased survival in a clinical trial of patients with late-stage Hodgkin’s, but the findings gave a sliver of hope where there had been no hope at all.
Jason’s brother-in-law, Paul, and Dr. Brunvand had previously discussed the treatment, known as a PD-1 inhibitor. Dr. Brunvand told Jason he’d bring information about the “experimental treatment” to the family meeting, planned for the following Friday. By all rights, it would be a meeting to tell Jason’s family to get ready to say goodbye.
Jason carried his wisp of himself back to his van.
In his doctor’s notes, Dr. Brunvand had outlined what he’d tell the family. “The most reasonable approach at this point, as emotionally taxing as it is, is to consider Mr. Greenstein for hospice care,” he wrote. “Palliative or supportive care would be another option, in which he can get transfusion support, but not be resuscitated and not receive any more chemotherapy.”
In the intervening days, Dr. Brunvand planned for an “end of life” talk. He also spoke to a clinic administrator to find any loopholes that might allow Jason to take nivolumab. Merck agreed to allow Jason to take what was called a drug replacement, basically allowing a onetime exception under extraordinary circumstances. The hospital would not “mark up” the drug and the company would provide them with a free replacement dose for each subsequent dose Jason might receive.
Still, someone would have to pay for the initial dose. Plus, Jason was in such poor health that he wasn’t even an ideal candidate, as Dr. Brunvand was poised to explain to the family.
The whole Greenstein clan gathered in a vanilla conference room at the clinic. The mood was bleak. Dr. Brunvand explained Jason’s condition. They talked about the likely outcome. The question on everyone’s minds was: How much time does he have? No one put it so finely, but the answer was that he had weeks, maybe a few months, to live.
At the meeting, Dr. Brunvand explained about the Hail Mary treatment, nivolumab. He told them that the evidence in the New England Journal of Medicine was not enough data for FDA approval, and informed consent would be required to begin a treatment with the drug. It was “experimental” at best, but had few toxicities compared to the deluge of prior therapy he had endured. Before Jason could receive this type of treatment, he had to understand fully the unknowns.
“Jason, you don’t have enough platelets to do any treatment, and it’s not approved.” Platelets help the blood to clot and contribute to inflammation. To start treatment, he’d need a platelet count of 75,000, preferably, but maybe could get away with 50,000. His count was 8,000, indicating that Jason’s marrow had been damaged by the years of relentless chemotherapy. If they could get the platelet count up, they could try. Cathy said of course she’d pay for a first dose. Jason didn’t need much convincing, but Dr. Brunvand gave him a pep talk, reminding him of a story from Denver Bronco lore. The Broncos were in Cleveland facing the Browns in the 1987 AFC Championship Game. The Broncos needed to go 98 yards in two minutes. One of the Broncos is reported to have said in the huddle, “Boys, we have them right where we want them.” The Broncos won.
Anyone for a miracle?