The Last Option

Hope washed over Dave and Mary Musso one day in 1992, a warm sensation that felt peculiar to the Northridge couple accustomed to the gloom of battling cancer minute by minute for almost a year.

It came in September, just after Dave opted against having his tongue surgically removed. He had been forced to consider such an operation after the tumor on his tongue--which stripped him of his ability to taste, smell or swallow--resisted chemotherapy and radiation treatment.

Instead, Dave chose another round of painful, nauseating chemotherapy. When the time came to die, he figured, with his tongue intact he would at least be able to say “goodbye.”

Then Dave was reborn.

The cancer vanished as abruptly as it had appeared 10 months earlier during a long vacation.

Pals cheered, including the nurses at UCLA’s Jonsson Comprehensive Cancer Center who’d been won over by Dave’s stoic demeanor.

“We dodged a big one,” Mary said, beaming.

Dave, dizzy with joy, said, “Man, this is it!”

From now on, he would savor every moment. Things great and small--from his grandson’s first step to the newest drama in the sports pages--all became momentous to him. To mark their fresh start, the Mussos filled their large house with the ebullient presence of a small dog, Nicky. Dave learned to swallow again, one slow teaspoon at a time.

The world shimmered with possibility for--as Mary put it--three “fat, lazy and happy” years.

Then in summer 1995, the coughing returned. Like an assassin in the night, it clutched at Dave’s throat.

“Oh, God, here we go again,” Mary said.

The Mussos were tossed back into their sea of despair, only now it was darker.

Waiting for them there was Fairooz Kabbinavar, Dave’s new physician. Smiling, the stout, black-haird doctor greeted the couple in a lilting voice flavored by the Urdu he spoke in his native India.

He tackled Dave’s illness armed with the usual arsenal of physicians, plus a secret the Mussos would learn only later.

‘Maybe It Will Give Me a Fighting Chance’

Shortly thereafter, new tumors were found in a sector of Dave’s left lung, causing him to cough up blood specks. Kabbinavar ordered the entire segment surgically removed. The following summer, the cancer had moved on to Dave’s larynx. Out it came, leaving him voiceless. In 1997, two parts of his right lung went.

“It has all been so hard,” Mary sobbed.

This summer, Dave found out his left lung was again riddled with tumors--one the size of a fat baby’s fist.

Surgery was not an option, Kabbinavar said. The tumors covered too much of Dave’s lung. Nor could they be eliminated with chemotherapy, radiation or any other available cancer treatment.

Dave--reduced to speaking with an artificial larynx and gasping for air through a hole in his throat--was marching inexorably onto the list of 160,000 Americans who will die of lung cancer this year. His life expectancy? “Between seven and nine months,” Kabbinavar said.

But that made Dave a perfect candidate to enter a realm closed to most of Kabbinavar’s other patients.

Kabbinavar had for years been making great strides in his second role at UCLA’s cancer clinic: researcher.

Dave’s condition--beyond all other remedies, with nothing to lose--appeared ideal for testing the effectiveness of angiogenesis inhibitors, a new class of drug being investigated by Kabbinavar and cancer specialists across the nation.

The drug starves tumors by depriving them of oxygen and other nutrients they need to grow. Where chemotherapy works like a nuclear bomb, blasting tumors with chemicals that also destroy other healthy cells nearby, the inhibitors operate like smart weaponry. They target specific blood vessels the way Dave, as an Air Force bombardier in World War II, picked off factories and warehouses that supplied the German war machine.

The new compounds sparked a frenzy in May when reports circulated that successful tests on tumor-ridden mice had been conducted by Dr. Judah Folkman, who pioneered angiogenesis inhibitor research in the early 1970s. The news sent cancer patients around the country flocking to their doctors, pleading that they be given the new compounds.

Because Dave was in remission at the time, the Mussos had paid scant attention to the clamor. Later, though, the couple listened with interest as Kabbinavar informed them that one of several varieties of angiogenesis inhibitor was ready to be tried on a small group of humans. For about six years, it had produced impressive results in mice with lung cancer, sometimes eliminating the tumors.

Now, Genentech Inc.--the South San Francisco company that developed the compound--was launching an experiment on 99 patients in five states. Kabbinavar invited Dave to join 29 others in testing by UCLA.

The compound, derived from a mouse antibody, could in fact kill humans. But Dave accepted.

“Maybe it will give me a fighting chance,” Dave suggested, his voice droning through an electronic voice box dangling from a cord around his neck. “If not, well, maybe it will help others out down the road.”

The July afternoon before he went in for his first dose of the new compound, Dave sat beneath his orange tree--enjoying a few deliciously coughless moments in the Northridge heat.

“I have hope,” he said. “We’re going to prove the doctor’s research is correct.”

Mary smiled. “We’ll show them.”

‘One Year Is All I Need’

Brimming with enthusiasm, the couple showed up at the Jonsson Cancer Center at 8:30 a.m. July 16. The crowded clinic was one of 17 Southern California sites overseen by UCLA in the experiment.

“It’s going to be a long day,” Mary said, cheerfully toting a crossword puzzle, a newspaper and a book. “We’re used to it by now.”

Dave wore a pair of loose jeans and a powder-blue shirt that opened with a yank of its zipper, giving nurses easy access to his tumor-plagued torso.

“He likes to show off his [belly] button,” Mary joked.

The subjects of the experiment were randomly split into three categories: a control group that received standard chemotherapy only; one injected solely with the angiogenesis inhibitor; and another treated with a combination of chemotherapy and the angiogenesis inhibitor. Dave wound up in the third group.

Two pint-size bags of chemotherapy compound and a smaller bag with 0.022 ounces of the new drug were injected into one of Dave’s veins, dripping through an IV unit every five seconds. The treatment lasted past 6 p.m.

To pass the time, Dave flirted with the nurses and bantered with Mary and Kabbinavar, who checked on him sporadically.

To Kabbinavar, Mary promised: “We are going to prove to everybody that this works.” In an effort to remain optimistic, she would make similar promises to nearly everyone she met at the clinic.

Dave told Mary: “We can plan on my [76th] birthday,” which is Nov. 3.

“We can plan on your birthday, Christmas and everything else,” she responded.

Dave considered his future.

“One year is all I need,” he said.

Mary changed the subject.

Eventually, that first day, he fell asleep. Mary, the nurses and Kabbinavar all stared at him in silence, watching the slow drip of the experimental compound entering his vein.

When he opened his eyes, Dave said, “I feel like I should do something to entertain you. I’ve never had such a captive audience.”

At that, Mary burst into a laugh that shook through the clinic, causing others to glance their way.

“You can do a tap dance,” she suggested.

A few days later, Dave became an even greater focus of attention, much to the distress of his wife. Chemotherapy had weakened his immune system, and when a fever flared, Kabbinavar admitted him to UCLA’s main hospital for a night. “Just a precaution,” the doctor assured Mary.

When he awoke the next morning, Dave lay in his hospital bed for a few minutes and watched a hawk circling the treetops outside his 10th-floor window. Then, he got up to shave.

Susie Wallace, a UCLA nurse, entered Dave’s room and heard him in the bathroom, wheezing and coughing uncontrollably. She pushed open the door. Streams of blood spewed from Dave’s breathing hole, crimsoning his nightgown.

“Oh, my God!” the nurse screamed. In seconds, a team of doctors and nurses surrounded Dave, running tubes into him to suction the blood and trace its source.

As suddenly as it began, the bleeding, which came from Dave’s tumor-filled lung, stopped. Summoned to the scene, Kabbinavar could not figure out what happened.

“The tumor is either rapidly shrinking and ulcerating blood or growing and bleeding on its own,” he said. “It’s too soon to tell.”

Either way, Kabbinavar said, “If it happens again, we may not be able to stop it.”

Mary had arrived by this time, expecting to take Dave home. “You weren’t supposed to do this,” she scolded her husband.

Dave looked at her guiltily. “It’s never happened like this before,” he droned. “I want to go home. I feel fine. I want to go home.”

‘She Thinks I’m Going to Live Forever’

Instead, Dave was wheeled to another section of the hospital, where he would be examined--again--by a team of doctors.

Hours later, Karo Arzoo, an internal medicine specialist, informed the couple that they would have to seal off Dave’s bad lung to guard against choking in case of future bleeding. Perhaps, he added, Dave’s good lung would be connected to an artificial respirator.

“That tube will come out, won’t it?” Dave asked about the respirator. “It won’t be permanent?”

Arzoo--tall, slim, with watchful eyes--answered that it might be permanent, depending on whether the bleeding resumed. As for the cause of the bleeding, “we’re hoping the new medicine is working, only too well,” he said.

“That’s what I hope,” Dave said.

Then Arzoo delivered his bomb.

“This doesn’t mean you shouldn’t be thinking about end-of-life issues, because you should,” he said. “We need to know if you are. . . . Do you want to pull the plug? We want to honor your wishes.”

The question was standard hospital procedure for a patient facing the possibility of an artificial respirator, but it sounded like a death warrant to the Mussos.

“What?” Dave asked.

Mary dashed out crying. “I’ve got to call my daughter,” she said. Weeping into her cellular phone outside the hospital, she told their daughter, Sharon, “We’ve been ready for this for the last seven years, but I didn’t think it was imminent.”

Sharon, who lives in Moorpark, was also crying.

Back in the hospital, Dave resigned himself to whatever he would face next. About Mary, who was still outside, he said, “She’ll be all right. She thinks I’m going to live forever, and I’m not.”

Still crying, Mary returned to the hospital, cursing Arzoo and apologizing for her tears.

“He was very blunt,” she said to Kabbinavar about Arzoo.

“I’ll go talk to him and make sure he doesn’t ask that question again,” Kabbinavar promised.

“You know that this is life-threatening,” he told Mary, an arm around her shoulder. “It is not something we can take lightly. But nothing has changed since this morning. We’re still not sure what is causing the bleeding.”

“I know,” she said, drying her tears before returning to Dave’s room.

“He’s such a nice guy,” she said of Kabbinavar to nobody in particular. “Nothing has changed. That other doctor has got a lot to learn about tact.”

Dave studied his wife, her face sagging with grief.

“Hey, Mary, how about a smile?” he said.

Mary forced a grin. She kept it while watching her husband being carted into the intensive care unit, where he was hooked up to a jumble of machines that monitored his condition around the clock. Doctors still did not know whether he needed the artificial respirator.

Alone that night at home in Northridge, she cracked open a beer and tuned into the Dodgers. They lost. The game was never even close.

Nicky, the dog, sniffed through the house in search of Dave. She looked in the kitchen, the living room, the bedroom and outside near the orange tree before curling up next to Mary.

TOMORROW: Flecks of hope