I was invited to deliver the St. Luke’s Medical Guild Oration on the 31st of January, 2016.
Incidentally, 2016 happened to be a landmark year for me. It marked 30 years since I first joined the Tata Memorial Cancer Hospital, way back in 1986, to begin a career in Surgical Oncology. It was also the year that I turned 60.
The oration takes a philosophical look at my professional experiences over the past three decades as a surgical oncologist.
A few friends suggested I upload the presentation on YouTube. And though I’m pretty sure the requests were borne more out of politeness or kindness, I decided to go ahead and upload it anyway…! This is the link: : Musings of an Oncologist: Looking Back
Reproduced below is the full text version of oration.
At the very outset I must thank Dr. John Rodrigues for inviting me to participate in this year’s St. Luke’s Medical Guild Oration
It was Christmas eve 2015
My wife and I had made plans to spend a nice relaxed new year in Goa and I was keeping my fingers crossed that no serious cases would get admitted over the next few days.
No such luck.
On that day I got two referrals. Two very critical patients from two different hospitals and I would like to share them with you today.
The first was a 55 year old female who presented with stridor or difficulty in breathing. She had large thyroid masses in the neck making a tracheostomy impossible and an endotracheal intubation was performed and the patient was put on a ventilator.
24 hours later a trial extubation was attempted but the patient went back into stridor and needed to be intubated again.
A CT scan of the neck revealed that there was a retrosternal extension of the right lobe of the thyroid that was causing the compression and the patient was referred to me for a thyroidectomy.
A thyroidectomy with retrosternal extension can be tricky but what sent the potential for complications skyrocketing was the fact that she had had thyroid surgery 25 years ago and though the details were sketchy it appeared that at that time a bilateral subtotal thyroidectomy was performed.
As most of us know, previous surgery always results in varying amounts of scar tissue that tends to obliterate natural tissue planes. In this particular case, the regenerating thyroid growing within the scar tissue furthered the potential for bizarre changes in regional anatomy. Making subsequent surgery all the more complicated.
The next case was an 80 plus year old man of God who had a bunch of co morbid conditions including Parkinson’s disease and bronchial asthma. He had been bleeding per rectum for the past few months and complained of constipation and nausea.
His symptoms had exacerbated considerably over the past few days and he was admitted to hospital where a colonoscopy and a CT scan was performed.
These revealed the presence of large malignant masses involving the rectum and the sigmoid colon that were giving rise to intestinal obstruction as evidenced by a distended proximal colon on the scan.
CT scan also confirmed the presence of liver metastasis.
So here was an elderly male with significant co-morbid conditions who had an advanced, incurable cancer of the recto-sigmoid. Unfortunately he had signs and symptoms of intestinal obstruction that could only be relieved by surgical means.
How does one proceed to make decisions in such complicated cases.
Do we give the patient an adequate conservative trial in the hope that the symptoms correct themselves, knowing fully well that the longer we wait the more we run the risk of the patient’s condition deterioting further increasing the risk of complications?
Or do we go in for early surgery and keep our fingers crossed, hoping all will go well, knowing that the risk of compliations, even death, is a distinct possibility?
Allopathy is a branch of medicine that strongly revolves around the practice of evidence-based medicine.
Where data from clinical trials, prospective and retrospective studies and even anecdotal case reports are studied and inferences from these are used to generate guidelines and recommendations for various clinical situations and diseases.
Obviously these guidelines are based on the theraputic and diagnostic options that are prevalent at that point in time.
As new therapies emerge and as new diagnostic modalities are introduced the guidelines are modified to reflect the changes. And so guidelines for a particular clinical situation or disease that are current are often dramatically different from those of say a decade or more ago.
A classical example is seen in the evolution of the surgical treatment of breast cancer over the millennia.
The first documented evidence for the surgical treatment of breast cancer was in 1600BC by the Egyptians.
They used these huge branding irons that they heated to red heat and then pressed them against the breast in the hope of fulgrating the cancer.
The Egyptians were the first to attempt the surgical removal of the breast also known as a mastectomy in the first century AD.
Over the next 19 centuries various civilizations attempted to perform a mastectomy for breast cancer.
This is an 18th century graphic of the French attempt at the surgery.
Underlying all these attempts was one common factor.
Anaesthesia was not yet available and one can only imagine the intense pain these poor women had to endure while undergoing their surgical procedures.
Then in the mid 19th century Anasthesia was invented and now surgery could be performed with far more precision and consistency.
And so in 1891 Halsted came up with his Radical Mastectomy surgery and for the first time ever a disease that was hitherto considered incurable, could now hope for a 50% chance of a cure.
Urban tried to improve the survival rates provided by Halsted’s mastectomy by advocating an even more radical surgery: the Extended radical Mastectomy. But not only was the morbidity of this ultra radical procedure unacceptably high, it did not improve on the cure rates offered by Halsted’s mastectomy. Needless to say the procedure was quickly abandoned.
Then in the mid 20th century Chemotherapy began to be used for breast cancer as did radiotherapy and hormonal therapy in the form of Tamoxifen and it was found that when these therapies were clubbed with surgery as adjuvant modalities the surgery could be less radical without compromising on survival.
And so in the 70s the modified radical mastectomy was approved and later in the 90s it was shown that, with appropriate adjuvant treatment it was not necessary to remove the entire breast to achieve good results.
Breast conservative surgery, that is simply removing the breast lump with, in selected cases, axillary nodal sampling as in a sentinel node biopsy is now the current standard of care.
Also, in the nineties mammography began to gain popularity as a screening test for breast cancer. Thanks to which we are now consistently detecting very early breast lesions, sometimes only a few millimeters in size.
Begging the question: do we really need to perform surgery at all? Can we get away with non-surgical treatment for breast cancer?
One of the non-surgical theraputic modalities under study, is radiofrequency ablation. Here a probe is inserted into the breast lesion under image guidance that delivers radiofrequency waves to the tumor. These waves are than converted to heat that in turn fulgrates or vapourizes the tumor. Reports of this modality of treatment from around the world are showing very promising results in selected cases.
It is interesting that almost 4000 years ago the Egyptians attempted using the same modality of treatment, that is the use of heat, for breast cancer, but because of the paucity of technology then their cure rates were diametrically opposite to those of today.
It is important to realize that the guidelines not only recommend a treatment but also a methodology for diagnostic evaluation that is designed to indentify and stage the disease based on which further treatmemnt guidelines are suggested.
So…whatever the symptom…be it a blood stained nipple discharge, a skin leion, an growth on the tongue or a incidentally detected renal tumor on imaging… each have a set of recommendations that will be specifically tailored for that particular problem.
One of the commoner steps in the diagnostic evaluation of most cancers is achieving a tissue diagnosis or biopsy. Where diseased tissue is sampled and pathologically examined to confirm the diagnosis.
I remember my very first attachment in the mid 80’s after I passed out of the Tata Memorial Hospital was St. Elizabeth’s.
There was this elderly male admitted under one of the senior physicians with abdominal pain. A sonography of the abdomen was suggestive of metastatic liver disease and a diagnosis of advanced metastatic liver cancer from an unknown primary was made.
This was in the mid 80s and though CT scan was available it was expensive and not done as routinely as it is today especially in the patients with financial constraints.
The physician was inclined to send the patient back to his village with purely symptomatic treatment but being the new kid on the block did send me incidental referral.
I had just come out of Tata Memorial Cancer Hospital and one of the dictums that was dinned into me was to achieve a tissue diagnosis no matter what.
In most cases it will only confirm what you already know but in the occasional case it will turn up something totally different. A suspected incurable carcinoma may prove to be a eminently treatable lymphoma or, as I have seen more times than I can remember, the diagnosis may turn out to be an infection and one that is notorious for mimicking cancer is tuberculosis.
So in this case I suggested we put in a needle into one of the liver lesions and, unexpectedly we got the typical pus suggestive of amoebic liver abscesses. A suspected incurable disease turned out to be totally curable. Simply by sticking to recommended procedure.
More recently I had this young 24 year old woman who presented with a fungating, locally advanced, malignancy in the right breast.
She informed us that she had had a lump excised 6 months ago. And when we asked to see the histopathological report we were told that though the specimen was sent for biopsy the report was never collected.
Purely out of curiosity, we took down the details and traced the report.
In the words of a fellow obsessive compulsive, and those of you who have seen the TV serial Monk with know what I’m talking about, Here’s what happened.
The girl presented to the surgeon with a lump in the breast.
Breast cancer is very uncommon below the age of 30. Breast lumps in this age group are more likely to be fibroadenomas; benign breast lesions that have nothing to do with cancer. The can however grow in size and hence often need to be surgically removed.
The surgeon, making a clinical diagnosis of a fibroadenoma, had the lump excised surgically and also and had it sent for histopathological examination.
So far so good.
That’s when he made his only mistake. He was so sure that it was a fibroadenoma that he did not bother to check the pathological report.
When we finally traced the report that was lying uncollected with the pathologist it revealed a 1 cm sized invasive duct carcinoma.
A tumor that had a very good prognosis was allowed to progress to one that was locally advanced purely because the treating physician missed a simple, but important step in its evaluation.
And that’s the beauty of evidence based medicine. All one needs to do is follow the guidelines methodically. And in most situations evaluation and treatment of a set of symptoms is a no brainer.
However in probably 10% of cases one will get a googly. A case that will expose grey areas within the guidelines where you are faced with a number of options, some in diametrically opposing directions, and you have the responsibility of making a call as to how to proceed.
In those situations 2 other factors come into play.
We need to be sensitive to the fact that patients are human beings with emotions and feelings and not random statistics to be relegated to the hospital archives after they are done with.
I’ve often had terminally ill patients in whom the guidelines suggest radical therapy but with little or questionable chances of success. On one hand a patient will tell me look Doc, I know I’ve got a terminal illness. I’ve lived my life and whatever time I’ve left on this earth I would like to spend it comfortably without having to suffer the side effects or morbidity of radical therapy. And I would respect that.
On the other hand I’ll have a similar case where the patient will insist that even though they understand the fact that they have an incurable disease and that the treatment options are unlikely to be effective, they are willing to fight the disease and would like to take the benefit of any treatment available irrespective of how questionable the success rate may be. And in those cases I will probably be more inclined to be more aggressive with treatment.
And the other factor is Medical ethics.
When I am faced with the responsibility of deciding of treatment options for the patient I need to be certain that the decision made are made purely with the patient interest in mind and not influenced by monetary gain, personal ego or other such factors.
A middle aged lady was suffering from a soft tissue sarcoma of the right upper thigh. She had undergone radical excision with radiotherapy at the Tata memorial hospital several years prior and now presented with a recurrence. This time around the tumor had involved the bone causing complete destruction of the upper half of the femur resulting in a pathological fracture and subsequently severe intractable pain.
Attempts to fix the fracture were, not surprisingly, unsuccessful and the patient continued to be in severe unrelenting pain.
Since it was not possible to fix the fracture the only other option was an amputation. In her case a disarticulation at the hip joint would have meant going through the tumor and the potential of subsequent fungation that would have compounded rather than solved the problem. So, very tentatively I suggested a hemipelvectomy.
A hemipelvectomy is the mother of all amputations. Also known as a hindquarter amputation, this operation involves removal of not only the entire lower limb but also half the pelvic bone as well.
This was early in my practice and I was skeptical about offering such a major surgery for a primarily palliative reason and I guess that must have shown on my face for she flatly refused the surgery.
Three months later unable to bear the pain, she came back, literally begging to do what ever was necessary to rid her of the pain. She underwent the hemipelvectomy and within a fortnight the pain had all but gone.
In her case we got an additional bonus.
Soft tissues sarcomas are aggressive cancers make no mistake, but a significant percentage of them tend to be loco-regionally aggressive. The are reluctant to metastatize to distant organs till fairly late in the disease. And in such cases even in seemingly advanced cases a cure is possible if the entire tumor is resected.
This surgery was performed in the early nineties. The patient is still alive today. She is pain free and equally importantly disease free. She has a prosthetic limb and lives an active and full life.
This 83 year old male had a large fungating growing out of the right side of his neck. It was first noticed a couple of years ago when it was much smaller. An FNAC was performed which suggested that it was a metastatic deposit in a lymph node from an unknown primary site. And the patient was advised symptomatic treatment.
It gradually grew over the past 2 years and was now fungating. His main symptoms were pain, bleeding and infection.
The patient landed up at one of our Holy Spirit Hospital tumour board meetings primarily with a reference to see if there was any role of palliative radiotherapy.
I happened to be sitting in at that meeting and noticed that the tumor was unusual it that it was almost polypoidal. Clinical examination confirmed that this was almost cutaneous in nature and not involving the deeper structures of the neck and highly unlikely to be a metastatic lymph node and, though it meant further tests and expenses, I suggested we investigate further.
And a CT scan and biopsy confirmed that this was a pilomatricoma, a rare, but benign tumor arising from the hair follicles
the mass was surgically excised successfully and there is no reason to expect anthing but a complete cure.
More recently, 6 months ago there was this elderly gentleman who was referred to me with a large abdominal tumor. When I first saw him he was bed ridden with massive distension of the abdomen. He general condition was very poor and had a number of co-morbid conditions. A CT scan showed the presence of a massive right kidney tumor.
Due to his extremely poor general condition and other comorbid conditions he was a poor risk for surgery and hence spent a fortnight in the ward undecided as to what is to be done. Each day his condition deteriorating.
That’s when I had a long chat with his son and asked him if he was willing to consider surgery. The risks were high even to the extent of death on the table. But the way things were going he was never going to improve. If we did decide to consider surgery that I recommended we do a PET CT scan and if that suggested that the disease was restricted to the kidney then alone would we would proceed.
He agreed and we went ahead with the radical nephrectomy.
It was the largest kidney I have ever removed. Over 6 kg in weight and as you can see it overshadows the scale being held along side while taking the image.
This patient made a dramatic recovery without so much as a stitch abscess. A week later he was discharged. This is an image of him a fortnight later.
A far cry from the moribund patient that was lying listlessly in the ward. And though it is still early days at the very least his quality of life has dramatically improved.
At times like these we surgeons tend to strut around the wards patting ourselves on the back, and when our hand tire we encourage others to take over.
However those of us who have been around long enough know that there are other factors that are always involved in the eventual result. Factors far more powerful. Non believers would put it down to luck. Or tumor biology. Or coincidence.
But, for those of us who believe there is another term.
Over the years I’ve seen a number of cases where the sequence of events and the final result defied logical thinking or scientific explaination.
My final two cases for this evening are a couple of such incidents.
The first is of a middle aged lady who came to me with a diagnosis of cancer of the rectum.
In the 70’s the standard of care for cancer of the rectum was a surgery called Abdomino-Perineal Resection of the rectum, or APR for short. Here the entire rectum anal canal and the anus are resected and the patient passes stools via a permanent colostomy placed in the lower left quadrant of the abdominal wall.
Then in the 80s, with better understanding of the biology of this disease along with the availability of special staplers that allow a very low colonic anasomosis, it became possible simply resect the cancer and use the stapler to reestablish intestinal continuity. A permanent colostomy was no longer mandatory in the majority of these cases.
This lady first sought the opinion of a senior surgeon who happened to be a professor of mine when I was a post graduate student in Sion hospital. After his intial evaluation he informed her that there was 90% chance that he will need to perform an APR with a permanent colostomy and less than a 10% chance that he would save normal rectal function.
She decided to take a second opinion and that’s how she came to me. I had just come out of the Tata Memorial Cancer hospital where I had been trained in the technique of sphincter saving surgery. So, with the super confidence of youth, I told her that there was a 90% chance I’d save rectal function and only a 10% possiblilly that she would need a permamant colostomy.
Needless to say she opted to have the surgery done by the over-confident young buck.
The surgery went smoothly and in the immediate post operative period I was a rooster swaggering arould the hospital. This was after all the first time this surgery was performed at the Holy Family Hosptial.
Then on the 5th post operative day there followed a sequence of events that taught me my very first lesson in humility in private practice.
After our evening consultations most of us consultants would take a quick round of our in patients before heading home to dinner and bed.
Around 8.30pm I took the patient to the treatment room to change her dressing. She fainted.
She recovered in a few moments and assuming it was a vaso vagal attack I continued to do the dressing and had her taken back to her bed.
From there I went to my car where I bumped into a cardiologist friend with whom I stopped to chat.
It so happened that the anasthetist who had give anesthesia for the case was called in for an emergency and he had just driven in.
We exchanged a few words before he proceeded to the operation theatre.
On the way there he did something that he normally never did. He popped in to see the patient. Most anasthetists rarely see ward patients unless there is a specific reason to do so.
That’s when he fould the patient unconsious with no recordable blood pressure and a rapid, thready pulse.
Fortunately he had met me in the car part and what was even more fortunate was the fact that I was with a cardiologist. He immediately sent a ward boy to rush and fetch us.
Remember this was the early 90s and there were no cell phones.
When we arrived the patient had been shifted to the ICCU. By now she was completely unconscious and placed on the ventilator. Her pulse and blood pressure were unrecordable.
She had had a massive pulmonary embolism.
The cardiologist suggested we shoot her with Urokinase to try and dissolve the embolus but emphasized that it was simply a shot in the dark and was not at all optimistic about how successful it would be.
I went home that night totally shaken by the rapid turn of events.
The next morning with a sinking feeling in my gut I visited the ICCU. As long as I live I will never forget the sight that greeted me. She was sitting up in bed looking at me with big broad smile on her face. She was off the ventilator, fully recovered pleading to be shifted back to the ward.
It’s been about 25 years and a few months ago I bumped into her daughter. She was doing well except for a few minor ailments that were unrelated to her original malignancy.
And finally there is the case of this elderly priest who also was a case of cancer of the rectum.
In his case the cancer was locally advanced and we were forced to perform an abdomino-perineal resection or the rectum and give him a permanent colostomy and even then there was gross residual disease as in the region of the prostate gland.
Besides the surgery he also underwent adjuvant radiotherapy and chemotherapy.
A month after his treatment was completed he went into intestinal obstruction for which he needed to undergo surgery again. Thanks to the radiotherapy his small intestine was grossly inflamed and of almost lead pipe rigidity making it near impossible to satisfactorily relieve the obstruction. We did the best we could and performed a defunctioning ileostomy.
A day later he developed a fecal fistula and stools began pouring out his main abdominal wound.
He then went in to septicaemia and was put on the ventilator on which he remained for several weeks his condition steadily deteriorating despite all our efforts to control the infection.
Then on one Saturday night at 2 am I received a call. This is the ICCU resident speaking it said. Your patient just expired. It is a call that most physicians dread. But in this case, honestly, it came as a relief. This poor man had suffered tremendously and was finally put out of his misery. And with that thought I went back to sleep.
Early next morning I get a call from a young priest that was attending to our patient right from the time he was first diagnosed.
How is Father he asked me. Surprised at the question, I informed him that Father has passed away in the night.
What, he said, no one informed me! His explosive reaction told me that something was wrong somewhere!
I decided to check back with the ICU. It so happened that another terminally ill patient was admitted to the ICU of another hospital at night. As he was gasping and on death’s bed I was not informed on his admission but when he eventually passed away at 2 am they decided to tell me. As far as I was concerned I had only 1 ICU patient.
I can see the comic side of the situation now but, believe me, at that time I was embarrassed as hell!
From that day on Father made a dramatic recovery. Within days, his fecal fistula healed spontaneously as did his ileostomy and he began passing stools through his colostomy. He went off the ventilator and in a week he was back in the wards.
Even more miraculously, despite having gross residual disease on surgery, he is at present, 8 years after treatment, cancer free and living a normal life.
So coming back to our Christmas eve cases.
The elderly priest with the advanced incurable cancer of the rectum had symptoms of intestinal obstruction. We decided to operate in the hope that, if all went well he would be able to spend the last few months of his life relatively free of symptoms. Though the surgery went smoothly, the patient succumbed on the 5th post operative day. Not really the result we were hoping for
On the other hand, despite the adhesions and the retrosternal extension the lady with thyroid goitre did well. We successfully identified and preserved the recurrent laryngeal nerves and the parathyroids. And she was completely relieved of her stridor.
Two complicated cases. Where decisions had to be made. And though surgery in both were uneventful one did well while the other did not.
2016 is a landmark year for me. It marks 30 years since I first joined the Tata Memorial Cancer Hospital way back in 1986 to begin my career in Surgical Oncology.
And over these past three decades I have had my fair share of both successes as well as cases that did not go as planned.
I will also be the first to admit that some of my successes may have been in spite of rather than because of me, and on the other hand in many of my patients who did not do well I honestly can’t think of anything more or different that I could have done to alter the course of their disease.
There are so many factors that contribute to the success or failure of a particular case. Many of them not really in our control. And I realize now that what is important is not how successful one has been over one’s career or the number of times one has failed. that Instead there are a bunch of other checkboxes that need to be ticked.
For instance, did we practice evidence based medicine consistently through out our career.
Or, in those grey areas where the guidelines of evidenced based medicine were blurred and vague and we were faced with the responsibility of deciding on a particular course of therapy then were the decisions we made based purely in the interest of the patient and not influenced by other factors like monetary gain or personal ego?
Were we sensitive to the fact that patients are human beings with emotions and feelings and not some random statistic to be treated as mathematical equations, only to be relegated to hospital databases.
And finally. You know it’s very easy when a particular case does not do well to conveniently put it on God. I tried my best but at the end of the day it was God’s will. However how often do we have the humility to recognize and acknowledge His role in our successes as well.
2016 is also the year that I turn 60. And these are the questions that I will be asking myself as I wait for a sign telling me I can now move on and begin to explore all my other interests in life.