A cruel reminder crept in alongside the joy that overcame Shauna Erickson-Abou Zahr and Abdallah Abou Zahr at the birth of their daughter, Nadia Carmel, on Jan. 11.
Its specter is never far: 40-year-old Abdallah, a hematologist/oncologist at Sanford Roger Maris Cancer Center in Fargo, ND, is in treatment for recurrent myxoid liposarcoma, and it’s terminal.
“Obviously, there is happiness, but there is the background of sadness, fear of the uncertainty of the future,” Abdallah said to me a few weeks later. “We’re trying to capture every moment with her.”
Cancer has been a part of Shauna and Abdallah’s lives since the start of their marriage.
First, Shauna was diagnosed with stage 1 breast cancer in March 2021, at age 32. Then came the IVF treatments that were expensive, but manageable on an oncologist’s salary.
Abdallah’s first diagnosis of a sarcoma, in June of 2021, was an event no one plans on. Abdallah knew his cancer was not curable when it returned two years later. Upon recurrence, when Shauna was three months pregnant, doctors estimated he had one to two years to live. There were no guarantees that he would be alive to meet his daughter.
Nadia Carmel was born at seven pounds, nine ounces.
“I was feeling this increased love toward Abdallah, watching him become a father to our baby,” Shauna, now 35, said to me. “And then having cancer be a factor of that, and now having cancer not only impact his and my story, but now being a part of Nadia’s story is just so challenging.”
By sharing their story with me over the past six months, Shauna and Abdallah pulled back the curtain intended to shield personal information of any family, driving home the terrifying point that for nearly all of us, financial collapse can be just one doctor’s appointment away.
The chasm that has opened beneath the feet of their family is an attribute of a healthcare system that works for no one, not only overlooking the poor, but also failing people like Shauna and Abdallah, a young couple living on a doctor’s salary in a Midwestern city.
In July, Abdallah had to give up his practice—and $450,000-$550,000-a-year income—due to treatment demands. This loss of income isn’t something you can budget for. By comparison, the cost of IVF—$145,000— seemed modest, and it was a necessary procedure if Shauna and Abdallah were to have a child.
Now, the amount Abdallah makes on disability is less than half of his salary. All semblance of financial security has been shattered.
They dread the day Shauna becomes a single mother. On the modest income she earns as a family therapist at a Fargo non-profit, how will she cover the mortgage, leftover IVF bills, and future child care?
“The main pressing factor now is what things will look like while he’s still on disability,” Shauna said. “And when Abdallah is gone, what will that mean for me and our child?”
The day Abdallah dies, will Shauna have to list the family’s house in order to support herself and Nadia?
“I’ve gotten into this economic situation where I could be facing daycare and a mortgage by myself, and raising the cost of rearing a child on my own, on a salary that’s less than a fifth of my husband’s,” Shauna said. “It’s so daunting.”
The new year also signaled a deductible reset, with an out-of-pocket maximum of $8,500. Abdallah met that with his first chemotherapy treatment of trabectatin Jan. 2, which was billed at $38,764.
Allison Harrison, a friend of the Erickson-Abou Zahrs and a nurse practitioner who specializes in obstetrics and gynecology at Sanford Southpointe Clinic, said the financial drain on Shauna and Abdallah is part of a systemic issue.
If an oncologist can’t guarantee their spouse’s financial future, then who can?
“Nobody is safe,” Harrison said. “You would think in their position—two stable jobs, with Abdallah being a doctor, I think people think of that as like, ‘Oh, they should be good.’—you don’t realize the money that is just sucked out of everything when you’re navigating all this.”
The bills are only one component of financial toxicity, said Fumiko Chino, a radiation oncologist and lead of the Affordability Working Group at Memorial Sloan Kettering Cancer Center.
Chino’s husband, Andrew Ladd, died of neuroendocrine carcinoma in 2007, prompting her to become a radiation oncologist and an expert on the effects of financial toxicity.
“The financial toxicity isn’t even the bills coming in—it’s a lack of income,” she said to The Cancer Letter. “It’s not just a hole you’re digging. It’s the fact that the paycheck that you depend on to keep your lights on, and pay back your student loans—you’re not getting that money going out and coming in.
Credit: Taylor Jane Photography
“And that’s something that’s really not reported well in the current financial toxicity literature.”
Shauna, diagnosed at 32, and Abdallah, first diagnosed at 37, and then again at 39, would be considered part of the population of young adults with cancer, Chino said.
A cancer diagnosis in your thirties has significant consequences financially, she said.
“The AYA (adolescents and young adults with cancer) population is the population that’s most at risk for financial toxicity from lost income,” she said. “Because we don’t tend to accumulate the savings most people do in their thirties.”
Each Sunday, Shauna inspects the lump on her husband’s shoulder before he receives chemotherapy.
She can feel the mass decrease in size, turning from a firm, immovable structure to something more gummy and amorphous—as though the tumor is disintegrating beneath her fingertips.
There’s a relief that goes along with this ritual, but also an anxiety.
Recently, Abdallah’s lab work indicated that the muscle enzyme level creatine kinase (CK) has gone up to a level that requires him to pause chemotherapy for a week.
From Abdallah’s last clean scan in June, it only took 30 days for his cancer to metastasize. In the case of such fast-growing cancer, every minute of treatment counts.
“Unfortunately, there’s no guarantee he can have chemo every three weeks,” Shauna said recently. “Now, we have to check the labs and go with what that says because the side effects of that level getting too high are pretty dire.”
If CK continues to rise, Abdallah faces a higher risk of paralysis or kidney failure.
“The hope is, obviously, we never reach that stage, and the hope that even if it goes high, it keeps trending down to allow for the treatment to keep going,” Abdallah said.
One day, Shauna will be the one to realize Abdallah’s treatment isn’t working before the scans, blood tests, or doctors do, by feeling the mass on his back grow in size.
“What am I going to find? What kind of news am I going to have to give my husband?”
First date
Shauna and Abdallah met in December 2019.
They came from different parts of the world. Shauna was born and raised in Fargo. Abdallah grew up in Lebanon.
He obtained his medical degree at American University of Beirut, did residency in internal medicine at University of Texas Southwestern Medical Center, became a fellow in hematology/oncology at Mount Sinai Beth Israel Medical Center, and a fellow in leukemia at MD Anderson Cancer Center, before landing at Sanford Roger Maris Cancer Center in Fargo.
They connected on a dating app and agreed to meet at a local brewery, her idea. Lovingly, she refers to Abdallah as a “super nerd—who was not really the type of person I’d been dating historically.”
The first date was a bit awkward.
Abdallah showed up late wearing his hospital badge, with a Kleenex stuck to his glasses. Shauna had almost canceled the date.
“What did I sign up for here?” she remembers thinking.
“He was so introverted, so cautious. I was so socially extroverted and not as socially cautious as him,” she said. “It was just this really interesting contrast that ended up being a really great balance as we got to know each other better.”
Abdallah wasn’t much of a drinker.
“So, he has this tiny tulip of beer and he was like, ‘Am I going to be able to drive after this?’”
There was something endearing about him, which caused Shauna’s interest to grow.
Credit: Nicole Midwest Photography
Credit: Nicole Midwest Photography
“He had this level of sincerity and gentleness to him that was just unlike any man I’d ever met,” she said. “I think that’s what curiosity really led me to wanting to continue to pursue him despite him being so far off from any person I’d pursued in the past.”
Abdallah thinks fondly of their first date.
“It was very good,” Abdallah. “I enjoyed speaking with Shauna. I felt I could clearly open up to her—I’m very glad she gave me a chance on the second date.”
Shauna and Abdallah made the decision to elope once she discovered her breast cancer in March of 2021. They married at the bridal shower, surprising everyone there.
“My sister and my best friend were the only ones that knew, because my best friend was officiating,” she said. “That was a really moving and cool experience… we were able to get our marriage certificate and everything in that short window of time, because there was still a lot of ambiguity about my prognosis at that time.”
Shauna’s friend Kaia Ehrmantraut, the wedding officiant, said she’s gotten to know and appreciate Abdallah over the years. They first met at a birthday party for Shauna’s sister, Ashley Campion.
“I just remember thinking, this man, bless his heart for dealing with this group of women who were loud and obnoxious and crazy,” Ehrmantraut said. “We’ve really gotten to know him, and he has opened up and he is quite funny himself—although we can’t tell Shauna that because she’s the funny one, but he is just the best man.
“And so perfect for Shauna.”
Shauna’s sister agrees.
“Once you get to know him, he’s so friendly and one of the most genuine people you’ll ever meet,” Campion said. “He was different from a lot of the other guys she dated previously—and so it was a nice change for her, to find somebody who was really invested in her—and a really sound wonderful man on his own.”
Before Abdallah met Shauna, he didn’t spend much time with friends, Campion said.
“Since they’ve been together, that’s really changed for him,” she said. “He’s developed a support system amongst Shauna’s friends and family too.”
Abdallah’s kindness is apparent, she said.
“He just is so genuinely kind,” Campion said. “I’ve never seen him say a negative word about anyone or situation.”
A lump on the leg
In February of 2021, Abdallah discovered a golf ball-sized lump on Shauna’s breast. The lump turned out to be stage 1 breast cancer.
“I didn’t want cancer to take away that opportunity to be a mom, or the way I wanted to become a mom,” Shauna said. “If you don’t have the privilege of fertility, any route of trying to become a family is really costly.”
Each round of IVF costs $20,000 to $25,000, plus medications of $5,000 to $7,500.
“Although it felt like such an insurmountable amount of money to be paying for something, we had a plan to take care of that within our means,” Shauna said. “Everyone should have access to this treatment. And fortunately we were privileged enough to have his salary to support that. All of this changed it.”
In vitro fertilization left the couple $145,000 in debt, but it was manageable. They spread the cost across two credit cards and a personal loan, with payments adding up to $2,500 each month.
Shortly after the May 2021 wedding ceremony, Shauna and Abdallah were spending their vacation lounging beachside in the Florida Keys.
With the end of Shauna’s treatment in sight, this honeymoon marked the start of a marriage that would soon not be complicated by doctors appointments, chemotherapy, and radiation.
Having already gone through with IVF just before Shauna’s treatment began, they were looking forward to starting a family, too.
Each morning, from their bungalow on the beach, they watched the sunrise. One day, in the bedroom overlooking the ocean, Abdallah showed Shauna a photo of himself from six years prior.
A friend of his had snapped the shot, which depicted him sitting near a computer. In the photo, Shauna could see the leg that now had a lump the size of a grapefruit.
Aware of her own unlikely diagnosis at a young age, Shauna remarked on how much the lump had grown.
“The cancer paranoia kicked in almost immediately,” she said.
Before this moment, Abdallah thought nothing of the lump. It had been there for more than a decade, and he had previously written it off as a lipoma.
I didn’t want cancer to take away that opportunity to be a mom, or the way I wanted to become a mom.
Shauna Erickson
Shauna’s observation prompted him to book a doctor’s appointment for the following week.
“The main thing that she pointed out to me—because in my mind, the mass has been there for years and years—I didn’t appreciate the change,” he said. “I assumed throughout the years that it was benign, and I got anchored on that, and in medicine we shouldn’t get anchored.”
At the time, the newlyweds had scheduled a physical exam to initiate a life insurance policy somewhere around $3-$5 million, taking into account their newly married status and their desire to start a family.
Abdallah’s subsequent diagnosis of myxoid liposarcoma precluded them from obtaining new coverage.
“I would’ve been able to stay in my house, I would’ve been able to keep paying any of our debts,” Shauna said. “As he got that red flag at that family practice visit, the life insurance physical was canceled, which would’ve been something that would’ve really pacified a lot of our economic fears.”
A treatment plan
The initial treatment for Abdallah’s cancer was not as straightforward as Shauna’s had been.
He spoke with colleagues at Roger Maris Cancer Center in Fargo, doctors at Mayo Clinic Comprehensive Cancer Center, and doctors at MD Anderson Cancer Center, where he had been a leukemia fellow.
“My breast cancer, because it’s so well researched and because it’s so well funded, there’s just one path. There was no question about what treatment was going to be,” Shauna said. “Well, that is not the case at all with sarcomas. It’s not as well funded. It’s not as well researched. And so he talked to five different colleagues at different cancer centers to try to devise what he should do. And none of the answers were the exact same.”
Some doctors recommended chemotherapy, others did not.
Even if you were to survive many more decades, the wealth shock of a cancer diagnosis in your thirties can sometimes never be recovered from. You are always sort of behind.
Fumiko Chino
Once Abdallah and his treatment team at Roger Maris decided to go in the direction of chemotherapy, some recommended different regimens than others.
No matter which option they went with, there was no way to know what the right answer was. Abdallah opted to receive intensive inpatient chemotherapy and radiation at Roger Maris to shrink the lump before a complicated surgery to remove the mass at Mayo.
“We ultimately went along the lines of Mayo, because that’s where the surgery was being done,” Abdallah said. “We wanted to do what they usually do prior to the surgery there—it was more or less the middle ground of what they suggested.”
Abdallah, who sometimes biked up to 50 miles a day before this, wanted to preserve his mobility as much as possible.
“They had to remove quadricep muscles and try to find a way to recuperate that,” Shauna said. “Mayo doctors were really creative in trying to figure out how to honor Abdallah’s mobility-loving ways. They called me the day of surgery and asked if they could use calf muscle.”
At the end of all of this, there was hope that Abdallah’s cancer was cured. Now, he and his colleagues face questions and regret about paths not taken.
“At his chemo appointment last Monday, because his oncologist is his friend, he said, ‘I wish I would’ve known to use a different chemo back then,’” she said. “Abdallah is so cared about by all these people, and I think there’s displaced guilt for a lot of people involved here—Abdallah included.”
What could he and his doctors have done differently? Why didn’t he get this mass checked out sooner? Why didn’t he do this other chemotherapy?
It was different to receive chemotherapy in 2021, Abdallah said.
“The main difference between now and then, even though it was tough from the chemotherapy and the surgery part, the main difference obviously is it was mentally more hopeful situation, because it was more toward the curative intent, compared to a stage 4—where obviously we cannot cure it,” he said.
Late this July, Abdallah appeared in the office door of his colleague Gerald Gross, a specialist in cancer and blood disorders at Sanford Roger Maris Cancer Center and a mentor and friend to Abdallah.
Abdallah had just read his most recent scan. Gross recalls his colleague’s face being devoid of color.
The results clearly indicated that his cancer had returned and metastasized. It had only been 30 days since his previous scan, which had been clear, except for a small lesion on the lung.
When that lesion first appeared that might have indicated metastatic cancer, why didn’t they get the mass biopsied?
That lesion didn’t have to be a big deal, just something to watch. It could have been a remnant of a common cold.
“It was just a tiny thing that could be attributed to a cold,” Shauna said. “All of these things that are heartbreaking, because they care about him, and he’s one of them.”
After one month of monitoring, it became apparent that the lesion was malignant.
Gross advised Abdallah to take a break from his practice and focus on his health.
“The emotional part has been equally difficult,” Gross said. “All of us were just really hit. Of course, we’re in this business.
“We know the ramifications of a relapsed sarcoma. We know the outcome, and he especially knew the outcome, immediately. I mean, he expressed that to me.”
Waves of financial toxicity
Financial toxicity comes in waves. The first is the cost of the disease. The second brings on the long-term financial sequelae, MSK’s Chino said.
Debt grows faster when you are out of work.
“That’s the next wave of financial toxicity research, to really look at lost income, lost earning potential, salaries that vary from person to person,” Chino said. “It’s not really been well documented how much people are losing just from not being able to work.”
A diagnosis can put you behind for decades.
“Even if you were to survive many more decades, the wealth shock of a cancer diagnosis in your thirties can sometimes never be recovered from. You are always sort of behind,” Chino said. “Let’s just say you’re 10 years out from a cancer diagnosis, and you still haven’t caught up to your peers, or your educational attainment has been sidelined, or your career can’t advance the way it should have, or what you expected it to, because of the cancer that presented even a decade ago.”
The couple’s house is more than a financial asset.
Down the line, when I’m not here, I’m leaving Shauna with a legacy of grief, but also without my income, and a legacy of a huge financial burden.
Abdallah Abou Zahr
“The house is a two-story 1985 brick home on a quiet street near the river that we fell in love with immediately,” Shauna said. “There are more kids on bikes than cars on the street. It backs up onto a green space where we have a big garden and watch deer, turkeys, and sometimes fox.
“I have huge flower beds I have personalized over the years.”
Abdallah proposed to Shauna here, surprising her on one knee in the kitchen during the summer of 2020.
They redid the place a year later, merging their tastes.
They envisioned being there for the next 30 years, “raising kids, watching them ride their bikes, run through the sprinkler, and shoot hoops with Abdallah on his beloved basketball hoop in the driveway,” Shauna said. “It’s hard to imagine not being here.”
The young family lives down the block from Shauna’s sister, Ashley Campion.
“Having quality social support right down the block was something that we were mindful of when we picked the location of our home,” Shauna said. “Which, when I think about potentially being a single mom one day, makes me not want to leave here even more, because I need that support even more.”
The sisters envisioned raising their families together, and this dream is being fulfilled—for now.
Campion sees Shauna and Abdallah several times a week. They take turns making dinner, and Shauna often babysits Campion’s children.
“You think you’re entering a partnership, or this journey, with your partner, and then that suddenly isn’t going to be the case,” Campion said. “And so, having her also physically move away from us will make it that much harder.”
In his practice, Abdallah is familiar with the burden grief imposes on a caregiver.
“Down the line, when I’m not here, I’m leaving Shauna with a legacy of grief, but also without my income, and a legacy of a huge financial burden,” Abdallah said.
Medical expenses aside, Shauna would have to support a child and pay for a mortgage on one salary, he said.
“When I’m gone, I’m gone,” Abdallah said. “But what she’s been going through, and obviously the economical legacy I’m leaving on the caregiver, I do feel the hijacking aspect of the diagnosis.”
“We are a community”
In this tale of a cancer diagnosis hijacking a young family’s future, another narrative has formed, one in which Abdallah’s colleagues—and the Fargo community—have come together to help one of their own.
Shelby Terstriep, medical director of the Sanford Cancer Survivorship program, member of the Sanford Health board of directors, and primary investigator of cancer care delivery research, sought assistance for the Erickson-Abou Zahr family on a Facebook page for women in hematology/oncology.
One of the members of the Facebook group suggested that Tersterip reach out to The Cancer Letter.
“We are a community of practitioners, hematology/oncologists, and what would that look like to all support one of our own?” Terstriep said to The Cancer Letter. “Community support is what our patients rely on a lot, and I wanted to activate the community to help this couple.”
In 2021, Terstriep was one of the physicians treating Shauna. In September 2023, she held a fundraiser for the couple at a Fargo restaurant she owns.
“Part of it is just really seeing the financial toxicity unfold in two people who have very good jobs, and really highlighting how devastating these diseases are financially,” Terstriep said. “It should start really getting us to look at ways to make this better, and to really think of it as a side effect of treatment, and how are we going to help impact that in the future.”
All of Abdallah’s colleagues have been affected by his diagnosis, Gross said.
“Any time you’re confronted with this with someone close to you, it starts to make you question so many things,” Gross said. “Maybe it just hits us harder when we have these wonderful people in the world, and they’re afflicted with such tragic diagnoses. It really just kind of tears your heart out.”
Patients feel the loss of Abdallah’s practice, too, Gross said.
“Even though we’re up in Fargo, I think he really delivers world-class cancer care to all of his patients,” Gross said. “That’s what I really respect about him, that he never really holds back on checking out other opinions and making sure the patient gets the right treatment.”
Patients have reached out to share stories about Abdallah.
“They’ve shared really powerful stories about people with really acute blood disorders—he really saved their lives,” Shauna said. “He’s too humble to put it that way, but that’s what the patients say.”
Watching Abdallah leave the practice adds to the grief.
“Helping people through cancer is his greatest passion,” Shauna said. “To watch him have to pull back from that because of this horrible diagnosis, and especially have it be cancer that’s keeping him from it, it’s heartbreaking.”
Abdallah’s diagnosis has hurt the entire Fargo community, Campion said.
“It’s not just one person or one family, it’s the whole community that’s really being affected here,” she said. “It’s not easy to get additional oncologists, locally. Of course, we have two beautiful facilities that are full of doctors—but he’s a great doctor too.”
Abdallah said he is heartened by the support.
“In the scheme of unfortunate situations, my colleagues here have been a huge support,” he said. “They had been a huge support at the initial diagnosis, from covering for me, especially on the recovery from the surgery, and obviously much more now given taking over my patients and covering and supporting me beyond that.”
Recently, a friend of Shauna’s, Kaia Ehrmantraut, a Fargo realtor, set up a GoFundMe campaign.
“When Abdallah’s disease came back, the least we could do was put together a GoFundMe—because I knew things were going to be really tough,” Ehrmantraut said to The Cancer Letter.
At this writing, the GoFundMe has raised $77,401, covering the bulk of payments for IVF treatment, Shauna said.
“The general public doesn’t realize—reality for them is that they were knocked on their butts so many times and are still clawing to get out of this,” Ehrmantraut said. “Not to mention the in vitro fertilization treatment that they went through after thinking this was all in the past—and now we get to have our love story really begin. They got hit with obviously the worst news that they possibly could.
“And so, while we’re trying to figure out the right now, it’s also so scary to think about the tomorrows and the next years and things like that, financially, as well.”
GoFundMe is filling in the gaps in the family’s finances.
“There are a lot of unknowns about how long this fast-growing cancer will respond to chemo and what other options there will be after chemo,” Shauna said last September, when we first began our conversation and she was still pregnant with Nadia. “It really depends on how long he’s alive, and what is raised by my community in terms of if I have to relocate or move, which is all really daunting when you’re pregnant and thinking about having a newborn.”
Most of the time, insurance doesn’t cover the cost of IVF, Sanford’s Harrison said.
“And for someone who wants a biological family, they deserve to be able to try to achieve that, and they should have that covered,” Harrison said. “It’s a medical diagnosis. It’s something that—nobody expects themselves to be put in that spot. And the fact that they have to pay out of pocket over and over for that is pretty unreal.”
Shauna and Abdallah’s situation points to a broader issue—that many people in the United States do not have the means necessary to pursue IVF in the event of a cancer diagnosis.
“There are people that can’t even get to that point of being able to do one round of IVF—that’s been really frustrating,” she said. “Infertility should be a medical diagnosis that is covered, but even more so for someone who has this next day infertility diagnosis because they’re about to go through cancer treatment.”
Nadia Carmel Abou Zahr
When Shauna learned she was pregnant this past May, the couple was thrilled. The days of cancer treatment were behind them, and they were fully prepared to embark on parenthood.
The recurrence of Abdallah’s cancer complicated things.
And so, while we’re trying to figure out the right now, it’s also so scary to think about the tomorrows and the next years and things like that, financially, as well.
Kaia Ehrmantraut
“This is something I’ve waited my whole life for, but it’s also been a bit sad,” Shauna said. “It reminds me of when I had breast cancer, and instead of going to get my hair done for my wedding, I was picking out a wig to wear to the wedding.”
In 2021, when the embryo was conceived, Abdallah and Shauna chose the name Nadia, a name that means “hope.”
“The name is of twofold significance now, as she is a ray of light, hope, and reason to fight for Abdallah in his facing of incurable cancer,” Shauna wrote in a journal entry on CaringBridge.
Her middle name, “Carmel,” comes from a weekend Shauna and Abdallah spent in Carmel-by-the-Sea, CA, early on in their relationship. It was a carefree couple of days—when neither of them could have fathomed a cancer diagnosis.
In those early days, they hadn’t yet professed their love for one another, but Shauna recalls a profound moment at a restaurant there:
“As the sun set on Abdallah’s huge smile I knew to my core that I loved him in a way I had never experienced and wanted to spend the rest of my life experiencing his safe, respectful, sincere, gentle, and adoring love.”
Illustration by Cyrus Finegan
