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                                    Matt Tullis

Moles dominate the landscape of my body. They are like stars in the galaxy, making up constellations on my arms and face and back. On my left arm, the letter P is formed in moles. Take away the curve of the P and I have the first five planets of the solar system perfectly aligned, correct in scale. Mercury, the smallest, is just below and to the left of my elbow joint. Then comes Venus, a little larger but no more dark. Earth and Mars sit next to each other, identical in size, Mars a little lighter than its sister mole. Jupiter is the fifth and largest, with several moons orbiting it.

Saturn, however, is on my right arm, also near the elbow joint. The tiny brown mole has a perfectly symmetrical oval around it that does not tan. This ring of baby-white skin is what a dermatologist called the halo effect. Eventually, he said, the white would overtake the mole, and the brown fleck would disappear, a planet sucked into the vortex of a black, or rather white, hole. I expect that one day I will glance down at my arm and it will be gone. I will be sad, which is ironic, considering the number of moles I’ve purposely had cut off my body.

I’ve got moles on my face, a large one on my right cheek, several smaller ones where my sideburns once grew long—to cover them up. I’ve noticed a new mole forming just under my left eye. I don’t like it. When I can have moles removed for cosmetic purposes, I will have that one taken. This might be because it’s new and I haven’t had time to accept it. Or maybe I’m just fed up with the moles, especially in places where they are highly visible. At any rate, the new mole is not long for this world.

There are moles on my neck and moles on my legs. There is a mole on my left pinkie toe, the first mole I remember noticing as a youngster. There are large moles and small moles, light moles and dark moles. There are moles shaped like random splotches of brown paint and moles of perfect circles.

Large moles reside on my chest and back, fewer now than years ago thanks to several dermatologists’ scalpels, but still more than a person ought to have. I try not to take my shirt off in public, mostly because I know the sun is not good for my moles, but partly because I don’t like the way my back looks. I have been approached at swimming pools by little kids who want to know what all the spots on my back are. I’m not embarrassed, but it is hard to explain moles to a young child who has never seen such a collection. And I know people are looking and maybe even thinking, as I might think if I saw someone unfamiliar and strange, what a freak.

Moles begin as benign skin spots, formed by nests of pigment forming cells. While sun exposure can increase the number of moles, family history is the main factor when it comes to determining whether or not you can play connect the dots on your forearm or upper back.

Family history also plays a major role in whether or not one will get skin cancer. So does having atypical moles, fifty or more moles, impaired immune systems, and moles that are present at birth. Additionally, people who have had other cancers are at a higher risk of developing skin cancer than those who have not.

Twice in my life, I have been working jobs totally unrelated to moles and been asked if I get my moles checked regularly. Once it was by a pediatric oncologist. I had interviewed him for a story I was writing for the Columbus Dispatch, and, as he escorted me out of the massive hospital, he took me aside, pulled out a pen, and pointed to the moles on my face. He asked if I had ever been diagnosed with neurofibroma, to which I answered I had not. I hadn’t even heard of it. He didn’t explain the condition, only added that the number of moles on my body was a good sign that I had NFB, and that I should definitely see a dermatologist regularly.

The other time happened several years earlier and was far more jarring. When I was in graduate school in North Carolina, I worked at Barnes & Noble. One day, I was ringing up a handful of books and a magazine for a man dressed in khaki shorts, a white golf shirt, and a baseball cap. He asked me if I ever had my moles checked. I was a bit taken aback. When you’re a cashier, you’re often asked questions that range from the logical (What kind of discount do you get here?) to the theological (Do you believe in God?). I had never been asked, however, about my moles, at least not when scanning books and searching for the price on a magazine cover. Still, I did my best to make it look as though this were the most logical question I had ever been asked, that I indeed was asked it hundreds of times a day.

“Yeah, I do,” I said, punching some numbers into the register.

“Good,” he said.

He took his change and walked away before I could say something like Why do you care? Or Are you a dermatologist looking for new patients? The hat was a good sign of his being a dermatologist, being as how every dermatologist I have ever seen suggests wearing a hat. But he was also wearing shorts and a t-shirt. And his skin seemed to be fairly tan, a far different shade than the dermatologists I have met, men who walk around with pasty white skin and recommend going outside only if you are wearing long pants, long sleeves, and something covering your head and face, all while wearing sun screen with an SPF of 45 or higher.

But how could he not be a dermatologist? Who else would go around asking people about their moles? And how did he expect me to reply? I simply sputtered out my answer because I knew the long, drawn-out one would elicit criticism and a warning from this man. I’ve been criticized by dermatologists before, and I was in no mood to hear another tirade about how I was at a higher risk for skin cancer than most other people—especially when I was standing behind a cash register at my eight dollar an hour job.

Then I wondered if he had seen a red flag on my face or arms, something that looked like skin cancer. If so, why wouldn’t he have pointed it out? I eventually convinced myself that he was just a man concerned with others’ skin, a dermatologist who wanted people like me to know it was smart to see a doctor like him.

What I told him, after all, was technically true. My moles had been checked by skin doctors. When I’d lived in Ohio, I had them checked every six months or so, and at every visit the doctor removed at least three moles for biopsy. He cut moles from my left eyelid, my throat, and my face. More than twenty moles removed, all tested for cancer, and my dermatologist said I still had more moles than most of his patients combined. He always said it with a laugh, and offered his amazement at how large some of my moles were, how they seemed to maintain their shapes and colors.

Many of my moles are irregular in shape, which is usually a sign that something is wrong. But mine are so often irregular that it has become regular, the abnormal normal, making a diagnosis of melanoma that much more difficult. Still, all the moles that were removed came back from the pathologist as benign, negative for any signs of melanoma or other skin cancers.

But now I had lived in North Carolina for more than one year and had yet to visit a skin doctor, despite the increased amount of sun I saw.

As all of this was running through my head, the man reappeared at my register, this time with a woman. She handed me a book and he handed me a credit card. Underneath his name was the name of a dermatology practice. For a second, I thought about asking him where his office was. His question had me thinking that maybe it was time for a check up, just to make sure none of my moles had mutated into something deadly.

He was out the door before I could say a word, though. I was left to stand and wonder, as I sold books and magazines, if I needed to see a doctor again. I hated seeing doctors. For me, one visit always turned into two or three. And while I had health coverage through my job, I wasn’t in the mood for filling out forms and paying deductibles just to have a couple slices of skin scraped off my back or forehead.

Before this man walked into my bookstore, I would occasionally worry about the way a particular mole looked. I would ask myself, when was the last time I really took a good, close look at that mole on my chest. I see most of these moles every day, so I lose the distance needed to recognize changes. I ultimately convince myself that they haven’t changed, that they are the same as they have always been. This is always easier. It doesn’t require finding a dermatologist in a new state, going to said dermatologist and having my back and chest cut up. It also doesn’t require hearing news I don’t want to hear, bad news.

But this bookstore dermatologist’s image tortured me for the next six months, and I finally made an appointment with a local doctor. The waiting room was bright. There was a painted portrait of three physicians hanging on one wall, and I began to wonder exactly what type of practice I had stepped into. I scanned the faces to see if one of the people in the painting was the bookstore doctor, but didn’t recognize him.

When I was called back to a room, I stripped off my shirt and pants. I put on a paper gown and sat on the examination table, waiting for someone to come in. The woman who did wasn’t overly impressed with the number of moles on my body, even though I tried to convince her that I had far too many. She responded by saying she had seen people with more. I started wondering exactly what it was I was so defensive about. Did I want her to recognize the importance of the large number of moles on my body? Did I really want to be the mole man?

She called in an assistant and began removing moles, four to be exact, because that was all my insurance would cover at each appointment. She took three off my back and one off my forehead, near the left temple. While she worked, she and the assistant talked about American Idol. I thought about jumping into the conversation but decided to stay quiet. I had started to smell my flesh burning—this would have been when she was cauterizing the wound shut—and I wasn’t about to distract her with my witty banter about Fantasia Barrino while she was setting fire to my forehead.

When I answered the phone a few days later and realized it was the dermatologists’ office, I assumed the secretary would just tell me everything looked good and schedule me for an appointment in six months. Instead, she said the three moles on my back were fine, but the one on my forehead was a basal cell carcinoma. She said they were referring me to a plastic surgeon to have it removed completely, and that I should be awaiting a call.

I panicked. I didn’t know what a basal cell was, but with the word carcinoma attached to the end, it couldn’t be good. I started thinking about how long I had ignored that splotch on my forehead, how long I had stared at it in the mirror. Was it two years? Three? If it was cancer, it had surely spread by now. Was it in my skull? My brain?

I thought of all the times I had gone outside without a hat or sunscreen. I thought about the times I dismissed my wife’s admonitions to get the spot checked, but I hadn’t listened and now it was too late.

Obviously, it wasn’t too late. A basal cell is the skin cancer to get, that is, if you want to get skin cancer. It was removed by a plastic surgeon on an out-patient basis, and while my head ached for a few days (and an attendant at a McDonald’s drive-thru looked at me and said, “Whoa, what happened to your head?”), before long, the stitches came out and I was left with a lightening bolt-shaped scar on my forehead, kind of like Harry Potter.

Which is fitting, because like Harry Potter, I am a boy who survived.

I was fifteen when I was diagnosed with acute lymphoblastic leukemia. ALL is a cancer that forms in the bone marrow, the mushy insides of bones that create white and red blood cells and platelets. The disease causes the marrow to go berserk, to start producing thousands and thousands of immature white blood cells that can no longer fight off infections, their primary job function. As these white cells flood the blood stream, production of healthy white cells, red cells and platelets, stops. The blood starts carrying the leukemic cells throughout the body, to organs like the lungs, liver, spleen, kidneys, and testes. Sometimes the cancer will invade the central nervous system.

I’d gone to the doctor thinking I had mono. I was tired all the time, but I was also experiencing sharp pains in my back. The doctor ordered a blood test, and it came back with an abnormally high number of white blood cells.

I spent nearly seventy days in Akron Children’s. Because chemotherapy destroys all white blood cells in the body, good and bad, I had no immune system. I developed brain abscesses and bacterial meningitis despite the doctors’ and nurses’ efforts to keep my room free of germs.

One of the medicines I received was called Cytoxan, a drug that, when given in high doses, increases the chances of the patient developing a secondary cancer.

Less than a month after I left the hospital, I started radiation treatments. Radiation was pointed at my skull ten times over the course of two weeks, burning my left ear as if I had been out in the summer sun.

Radiation was the one tool that had initially allowed pediatric oncologists to successfully treat childhood leukemia. Starting in the mid-1970s, they blasted everything from the abdomen up to the head, and just like that, survival rates started climbing. There are dangerous side effects to radiation, though. Initially, those who receive radiation suffer from nausea, hair loss, fatigue and low blood counts. They also suffer minor burns on their skin.

The long-term effects, though, began reducing the amount of radiation childhood cancer patients received. Radiation is a carcinogen. It causes cancer. Doctors were killing cancer with something that causes cancer, and they were effectively spraying the top half of thousands of kids’ bodies with it for more than a decade. The result? Many childhood cancer survivors, from that first generation of survivors, are now developing tumors throughout the area that was irradiated. Females have been the most affected, according to some late-effect studies. Women who survived leukemia as a baby or child are now learning they have breast or ovarian cancer at a fairly high rate.

Radiation was limited to my head. The goal? To kill any leukemic cells that had crossed the blood-brain barrier. For ten days, Mom drove me to Akron General, where I waited in a room that invariably played host to Bob Barker and The Price is Right.  I would be called back, lay on a table, covered with a heavy blanket, have an instrument pointed at my head, watch everyone else flee the room, and then wait for thirty mostly silent seconds.

Cancer is a mole on the face of my writing. In everything I write, whether it’s an essay on my parents’ divorce or one on our move south, whether it’s about baseball or the ice cream stand where I met my wife, somehow cancer burrows to the surface. It can be one sentence, one paragraph, in an otherwise non-cancer essay, and yet there it is. Begging for attention, grabbing the spotlight, connecting the dots to every story I have to tell.

When I mention to someone that I am writing a book, they rightly ask me what it is about. I am left with nothing to do but reveal the fact that I had leukemia in high school, a statement that usually stops the conversation until I fill the silence by saying something like, well, it sucked at the time, but it gives me plenty to write about.

Sometimes I actually catch myself believing that cancer is a gift to a writer. When I was told my grandfather had colorectal cancer, I thought I could write a great essay about the young cancer survivor, myself, helping the old cancer patient, my grandfather. I told myself to remember conversations we would have on the phone so I could use them as dialogue in the essay. Then I thought about how family history is a major risk factor for colorectal cancer. I imagined myself, at the age of sixty, having triumphed over leukemia, then skin cancer, then colorectal cancer. I had taken on three cancers and survived, and now I had great stories to tell. Cancer Trifecta, I thought, has a nice ring for a book title.

I was reminded of these foolish thoughts years later when I read an article in The Onion, the on-line satirical newspaper. The headline said it all: “Over-Competitive Lance Armstrong Challenges Cancer to Rematch.” In the faux-article, The Onion said Armstrong was going to take three months to prepare for a rematch against cancer.

One of Armstrong’s fake quotes in the story read, “I want cancer.… I want cancer so bad I can almost taste it.”

I brought the article home because it had made me laugh and I wanted it around for future readings. At the same time, I wondered if, as a cancer survivor, I was allowed to laugh at something like this. I thought, isn’t that what I do every time I imagine myself defeating another form of cancer? Isn’t that what I do when I think about the things I could write about if and when that next cancer strikes?

By the time I actually called my grandfather, he had finished his radiation treatments and was trying to regain his strength. He had to wait a couple weeks before he would hear whether or not more treatments were necessary. I remember little about the conversation, other than telling him he would be fine, that he would make it through stronger than ever. He did, although after seeing him at a Christmas get-together about four years after our conversation, it was obvious old age and a life of hard working—farming, driving semis and raising horses—was catching up with him. It was a stark reminder, seeing him move so slowly and watching him do breathing therapy for emphysema, that surviving cancer does not make one invincible.

When faced with adversity, I often say, “This is nothing. I beat cancer. Nothing can get to me.”
That voice gets in a shouting match with my logical self, but my invincible, cancer-survivor self always wins. It shouts the loudest, just as it has in every arena of my life, my writing, my jobs, my marriage, my family.

Studies upon studies are now coming out regarding the long-term side effects of chemotherapy and radiation therapy in childhood cancer survivors. For instance, the Dana Farber Cancer Institute found out that one in eight survivors report suicidal thoughts or attempts to take their own lives years after they were treated.

In the October issue of the New England Journal of Medicine, a study was published that looked at the chronic health conditions in adult survivors of childhood cancer, and found that among 10,397 survivors, more than 62 percent had at least one chronic condition and 27.5 percent had a severe or life threatening condition. One of their conclusions was that damage to organ systems caused by chemotherapy and radiation may not become clinically evident for years. They also concluded that the risk for chronic conditions is high, particularly for second cancers, cardiovascular disease, renal dysfunction, severe musculoskeletal problems and endocrinopathies.

Another study showed that survivors of childhood leukemia and brain tumors are at an increased risk of stroke years after their treatments have ended. In October 2006, The Journal of the National Cancer Institute published a study that said female childhood cancer survivors may face pregnancy problems, including early deliveries and low birth-weight children. One month later, the same journal published a study that said children who received radiation treatment for cancer face an increased risk for brain and spinal column tumors later in life.

Doctor Philip M. Rosoff said in “The Two-Edged Sword of Curing Childhood Cancer,” also published in the New England Journal of Medicine, that, of the 20,000 children diagnosed with cancer a year in the United States, 75 percent of them now survive, a stark contrast from the 1950s when nearly all those children died. But, he added, and as a cancer survivor, I wonder if he wasn’t understating things a bit, “There is a dark side to being cured of cancer as a young person.”

Four years ago, I went back to Akron Children’s Hospital, to the late-effect clinic. There they checked me for just about every malady imaginable. In the following weeks, as results from all my tests filtered in, I learned that my testosterone level was low, a direct result of the chemo I had received sixteen years ago. I learned that patients who are fifteen to twenty years out are seeing their hearts and bones begin to break down, so I needed to exercise a lot, and no, walking from the parking lot to my office was not enough exercise, even if it was a half-mile each way. I learned the enamel on my teeth was thin, and that my inability to understand basic instructions included with toys and put-it-together-yourself furniture likely stems from the radiation I received. I learned I was at a high risk of developing glaucoma and that my lungs showed the early stages of chronic pulmonary lung disease. I was told to get a colonoscopy in the next year, something I still have not yet done.

As for my moles, well, there wasn’t anything the clinic workers could tell me that I didn’t already know.

Three scars loiter on my left temple, all within about one inch of each other. The oldest, at five years, is the most faint. The lightening bolt suggests the delicate hands of a plastic surgeon who took the time to make sure the spot would not be noticeable in the future.

The second and third scars cut through my hairline. They are most noticeable when I shave my head nearly bald, which I do on a regular basis because the rest of my hairline has been retreating like a losing army for the last four years.

At one point in time, these scars were all moles. They were innocent looking and part of me. They had been part of me for a long time. This makes me think of the tiny mole on my son’s lower abdomen. It showed up when he was two or three, and I pray it never becomes a scar like those on my forehead.

Those scars mark the spot where radiation was pointed so long ago. They are visible reminders of who I am, where I’ve come from, and what I will no doubt go through in years to come. In some ways, they are disturbing, reminders of the unknown, of a future that involves scalpels and drugs. In other ways, though, they are comforting. They say, you have survived. You will continue to survive. But only if you care enough to.

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