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The Fault in Our Stars | Context

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Cancer

Diagnosis and Treatment

The Fault in Our Stars deals with teenagers who suffer from serious cancer conditions. The disease in all its forms is the result of out-of-control cell growth due to mutations during cell replication. It often, but not always, results in tumors, and it can occur in any portion of the body. The initial location designates the type of cancer an individual has. When tumors appear elsewhere in the body other than the original location, they are called metastasized tumors, or mets, and they are the result of the disease spreading through the bloodstream or lymph node system to areas other than where the cancer first developed.

When the cancer is first identified, it is given a stage from 0 to IV that refers to the type of treatment that is necessary. Stage 0 refers to a cancer that has only just formed and has not moved elsewhere in the body. Stage IV refers to a cancer that has already spread elsewhere in the body at the time of diagnosis. The stages are dependent on the type of cancer and are mainly used in order to discuss treatment with other doctors. Once a patient has been given a stage and begun treatment, the treatment processes proceed, usually without reevaluation.

The three most common forms of cancer treatment are surgery, chemotherapy, and radiation therapy. Surgery can include exploratory measures to see where and how far the cancer has spread, procedures to remove the entirety of the cancerous tissue, or a partial removal of the cancerous tissue in order to increase the effectiveness of chemotherapy or radiation therapy. Chemotherapy is the use of drugs that kill both cancerous and noncancerous cells, targeting not a specific area but affecting the whole body. Radiation therapy is the use of radiation on a specific, cancerous portion of the body, limiting the effect on the noncancerous cells in the body.

Taking part in clinical trials is another treatment option; generally, individuals only take part in clinical trials if they are extreme cases. The trials usually consist of new drugs or treatment methods. This provides access to potentially new, effective drugs but with the understanding they are still being tested.

Hazel Grace and Thyroid Cancer

Hazel Grace Lancaster, the narrator of John Green's book, is initially diagnosed with Stage IV thyroid cancer, primarily affecting the thyroid gland located below the thyroid cartilage, or Adam's apple, in the front of the neck. After being diagnosed, she has a radial neck dissection, which involves the removal of cancerous lymph nodes from the neck. She is then treated with radiation and chemotherapy for the tumors in her lungs. These tumors cause pleural effusion, or the buildup of excess fluid in her lungs, which requires regular draining of fluids. In Hazel's case the tumors initially shrank, then increased dangerously in size.

At this point the doctors begin palliative care, or care to increase the quality of life remaining for the patient. Unfortunately, Hazel catches pneumonia and, combined with the fluid in her lungs, it seems as if she will not be able to recover. However, she is saved after the fluid is drained from her lungs. After she recovers she is put into a clinical trial using a new experimental drug called Phalanxifor, which is able to shrink her tumors. At that point Hazel is able to resume a relatively normal life along with the supply of oxygen and daily dosages of Phalanxifor she must take to control the disease.

During the course of the novel, Hazel suffers from worsened edema, or swelling of a portion of the body as a result of excess fluid, to the point where she is hospitalized in the ICU, or intensive care unit. This is most likely a result of the Phalanxifor; however, as she has received the drug for the longest time compared to other trial subjects, the doctors are unsure what the outcome of the treatment will be. The novel itself is silent as to Hazel's ultimate fate.

Gus and Bone Cancer

Augustus "Gus" Waters, the other main character in the novel, has been diagnosed with osteosarcoma, a cancer that begins in the bone matrix. Prior to meeting Hazel, Augustus was diagnosed with osteosarcoma that took his right leg. This type of cancer often requires the removal of a limb because it starts in the bone matrix and is thus difficult to remove other than by amputation. Gus later has a recurrence of the cancer, this time spreading throughout his entire body. His condition and Hazel's form the focus of the book.

The second half of the novel occurs during Gus's treatment. Prior to going on a charity-supported trip to Amsterdam with Hazel, Gus had started palliative chemotherapy, but it had no real effect on the cancer. After returning from Amsterdam, his doctors decided to intravenously administer "two chemo drugs and a protein receptor that they hoped would turn off the oncogene [a gene that turns cells into tumors] in Gus's cancer." From this last-ditch effort, his energy quickly declines, and he is restricted to a wheelchair and a G-tube, or a gastrointestinal tube that is used to pass nutrients and drugs into the stomach. By the end of his life the treatment is restricted to palliative care and pain management until the cancer ends his life at 17.

Amsterdam

Within The Fault in Our Stars, the setting of Amsterdam acts as the counterpoint to Indianapolis where the majority of time passes in the novel. Whereas Indianapolis is represented by the mundane aspects of everyday life and the cancer treatment that constricts Hazel's movements, Amsterdam is a vivacious city that represents Hazel's freedom from her cancer. The history and context of the city serve to inform the reader of Amsterdam's importance to Hazel.

City Built on Water

Water is an important symbol throughout the novel for both its life-giving and life-taking properties as illustrated by Hazel's struggle to breathe through the fluid in her lungs. Amsterdam itself is built upon the sea. Originally a fishing village, the city became an important port city with the 1648 Treaty of Munster. In the 17th and 19th centuries, the city slowly expanded, building the three major canals seen today, using a system of dykes, mounds of earth used to create areas of dry land above the sea level, and other methods of reclaiming land from the sea in order to accommodate the expanding population of the city. Much in the same way that Hazel finds it necessary to tend to her lungs through the regular draining of fluids and oxygenation, Amsterdam has been constantly reworking and reestablishing itself as the sea attempts to reclaim the land built for the city, an issue that has reemerged and become increasingly problematic in the past few decades with the advent of rising sea levels.

As Hazel's lungs fill with fluid, so too do the canals of the city. At the same time, the city is beautiful because of the canals that run through its body. The city is known for its water, and thousands of tourists visit in part for its unique city plan resulting from the system of canals. Hazel feels a similar relationship in which, on one hand, she struggles to remain afloat, but in the eyes of others and eventually herself, she is also beautiful despite the cancer that floods her lungs.

City of Liberalism

The city is also known for its liberal nature. While the roots of a particular city are always multifaceted, Amsterdam's position as an international trade and market center starting in the 17th century plays a large role in how regulations are enforced and in shaping the mindset of the population that lives in the city. The city's focus in the job market has only recently shifted from market to service-based industries and speaks to its long history as a multicultural location.

Amsterdam's liberalism also stems from its position as one of the centers of the Enlightenment prior to the end of the 17th century during the Dutch Golden Age, in its emphasis on religious tolerance during the 18th and 19th centuries, and through its adoption of regulated brothels in the red-light district and legalization of marijuana during the 1960s. More recently, the city has adopted a model of government known as the polder model, or the idea that the government operates with cooperation between all parties in an interaction despite any massive differences between them. Thus Amsterdam has cemented itself as one of the most liberal cities of the Western Hemisphere, a fact that is not lost on Hazel.

The city represents the idea that anything is possible, which is why it is so important to Hazel to visit—she needs to believe that there can be more to her life than the cancer that restricts her every movement. While in Indianapolis, Hazel is restricted in where she can go and what she can do. Once in Amsterdam, these restrictions seemingly vanish. Rather than constantly hover over her, Hazel's mom allows her to go first to Oranjee for dinner, then to Van Houten's home, and then to the Anne Frank House Museum alone. Hazel has a romantic dinner, drinking champagne for the first time, and then later in the Anne Frank House, she kisses Augustus for the first time. As the cab driver states when they first arrive, while Amsterdam is known for the red-light district (where prostitutes work) and liberal views, "in truth it is a city of freedom."

City of Anne Frank

Anne Frank is well known for her diary detailing her time between 1942 and 1944 when Frank and her family went into hiding in the annex of her father's shop along the Prinsengracht (Prince's Canal), the third largest in Amsterdam. From her birth in 1929 until 1933, her family lived in Germany until her parents, Otto and Edith Frank, became worried by the rise of fascism and anti-Semitism.

In 1940 they moved to the Netherlands; however, in 1942 the Germans invaded the country, and the Franks went into hiding for two years, supported and taken care of by their loyal employees and friends until someone reported them. Upon their arrest the family was taken first to camp Westerbork before transportation to Auschwitz, where the men were taken to Auschwitz I and the women to Auschwitz-Birkenau, or Auschwitz II. Anne and Margot, her sister, were eventually transported away from their mother and taken to Bergen-Belsen in Germany where they died of typhus in 1945. Anne's father, Otto, was the only member of the family to survive. In 1945 Otto returned to Amsterdam where he recovered his daughter's diary. Two years later, he decided to honor the wishes of his daughter and publish the diary.

In 1960 the Anne Frank House Museum was officially opened, and in the 1980s the museum was modified in order to accommodate the high number of visitors. The museum currently takes visitors through the house, highlighting the hiding place, along with exhibits such as reflections about Anne Frank, a display for her original diary and other manuscripts, and temporary exhibits, rotating every six months, such as a gallery of family portraits and an exhibition of Jewish refugees from Nazi Germany.

The Anne Frank House Museum stands today as a testament to the horrors faced not only by Anne Frank but also by other Jews during the time of Nazi occupation during World War II. Over a million people now visit it each year. In The Fault in Our Stars Hazel feels a connection to Anne Frank not only because of her suffering but also because of Frank's attempt to define herself in contrast to it. Anne Frank believed, as does Hazel, that one can live a full life despite suffering.

Illness and Metaphor

An important concept in The Fault in Our Stars is how cancer is discussed and perceived by both the afflicted and nonafflicted. John Green is one of many writers to discuss how serious illnesses are treated by the public. However, one of the most influential writers on this topic for the medical community, as well as one of the largest influences in John Green's work, was Susan Sontag, the author of Illness as Metaphor (1978). Based on Sontag's experience with breast cancer, she concluded that "cancer sufferers are shamed and silenced by metaphors." One of the strongest metaphors surrounding cancer is the war metaphor—people "battle" cancer; cancer cells "invade" the tissues; tumors are "bombarded" by radiation; and chemotherapy "wages war" on tumors. Sontag concluded that metaphors need to be removed from the discussion of cancer and other illnesses because they silence the ill and create harmful misconceptions about the nature of illness.

In contrast, John Green makes the argument in The Fault in Our Stars that metaphors are empowering. Throughout the novel, Gus and Hazel create metaphors that help define their world and allow them to take control over their illnesses. From the outset, Gus places a cigarette in his mouth specifically because of the metaphorical significance: "It's a metaphor, see: You put the killing thing right between your teeth, but you don't give it the power to do its killing." Hazel often uses novels, poetry, and words to give voice to her feelings. For instance, she claims that An Imperial Affliction, a book about a young girl dying of cancer, is "as close a thing as I had to a Bible." She gives Gus the book to read because it represents her view of the world.

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