A cello for Michayla.

DOI: 10.1200/JCO.2010.30.0681 When you are 9 years old and your world and its comforting routines have been disrupted because your mother has leukemia, and you want to do something to help but you feel small and scared, what can you offer? Just as for the little drummer boy in the classic Christmas carol, what Michayla— whose 32-year-old mother, Angela, became my patient 3 months ago—found she had to give was her music and, with it, her heart. Angela had not known she was ill. She was long overdue for a physical examination, but she had been postponing a visit to the doctor, because she could not find the time. The endless labors of a mother with two young children kept getting in the way. When her husband, Ken, lost his job as a machinist, Angela also became the sole provider for the family. She found little satisfaction in her work as an assistant service manager in an auto parts center, and she abhorred the constant scent of burning rubber in the garage. But at least she no longer had to do some of the dirtier jobs that had been her responsibility when she had first started the job more than 10 years earlier—unpleasant tasks that had included cleaning out solvent trays containing benzene or other toxins. When Angela finally made time for a visit to the doctor, she mentioned that she had been feeling more tired than usual. Although she minimized her symptoms and thought that they might be due to the stress that the family had been going through in the 2 years that Ken had been out of work, blood tests were ordered. The results suggested a more sinister explanation for Angela’s fatigue: her WBC count was low, and her blood contained a few atypical cells that might indicate leukemia. Angela’s doctor urgently referred her to the cancer center in Boston where I work so that her bone marrow disorder could be evaluated further. The arrangements for the appointment were made more difficult because Angela and Ken have no health insurance and they live in New Hampshire—a state whose “Live Free or Die” motto appeals to a spirit of Yankee independence and self-reliance, but where respect for individual liberty and low state taxes mean that health care is not guaranteed. The oncology fellow and I obtained a bone marrow sample from Angela’s hip, which revealed a particularly nasty variant of acute myeloid leukemia. In addition to abundant primitive blast cells, there were numerous dysplastic forms and fibrotic scar tissue, and the chromosomes of the leukemia cells were broken or missing in a complex fashion. We told Angela she would have to spend a month in the hospital receiving chemotherapy and recovering from its effects. We started a search for a stem-cell transplant donor, and the oncology social worker began looking for a way to pay for the treatments. Ken shaved his head in solidarity with his wife. Two-year-old Liam was too young to understand anything other than that his mother was sick and would be away from home for a while, but Angela was honest and spoke in a matter-of-fact tone when she shared the news of her diagnosis with Michayla. She told Michayla that she had leukemia and that leukemia is a dangerous disease; she did not omit the fact that she might not come home from the hospital. She told Michayla that money—already so tight for the family that they had to borrow a 17-year-old automobile from a relative in order to travel to Boston—would be even harder to come by for a while. She also told Michayla that a month in the hospital was far too long to go without hearing Michayla play the cello. Michayla had started taking lessons the year before on an inexpensive rental instrument. Although Michayla’s playing was still quite basic, when Angela returned home from the auto parts center in the evenings exhausted from work and worry, she enjoyed hearing her daughter practice, filling their small home with the escape and promise of music. So a few times each week, when Ken and Michayla and Liam came to visit Angela in the hospital, Michayla brought her quarter-size student cello to her mother’s room, set up her metal music stand, peered through her thick eyeglasses at the notes in her beginner’s music book, and played the few songs she knew. When the nurses of Oncology Unit 5A heard “Ode to Joy,” “Baa Baa Black Sheep,” “The Can-Can,” “Good King Wenceslas,” and “Merrily We Roll Along,” they asked Michayla to come out into the hallway to play for them. Then other patients heard the mellow, resonant sound of JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y VOLUME 28 NUMBER 28 OCTOBER 1 2010