We, the trainees at the Tata Memorial Hospital (TMH), Mumbai, known for its sheer volume of patients with cancer treated east of the Atlantic, always feel pride in providing care to our patients. All of the residents, fellows, nurses and even the ward boys have a deeply ingrained sense of empathy toward the patients, and we consider our work sacrosanct. We call it “service” which in ordinary metropolis lingo translates to just a job. Not so at TMH. Needless to say, “Service, Education and Research” are the three pillars that guide this 82-year-old legendary institution.
This culture of service makes young doctors like me ever eager to help, be it in the spheres of prevention, treatment, or palliation. We feel that we can make a difference and enthusiastically exhort all our contacts to send patients with cancer to TMH. I would like to share one such incident.
Oral cancer is the most common cancer amongst men in India, and with the numerous awareness programs screened on television and in the movie theater's pre-showtime clips, most tobacco users are now aware of the implications of a non-healing oral ulcer but afraid of the mutilating surgery and the treatment that follow, resulting in referral delays and ultimately advanced presentations. More than 50% of the population of Mumbai lives in the slums, either the traditional variety or the redeveloped vertical ones. The neighbor of my mother's household help, a 34-year-old man named Mohammed Sadiq*, a local shack owner, was one such inhabitant. My mother referred him to me for evaluation of a cheek swelling. The initial reports were sent via WhatsApp, and then a few calls to me ensued. My mother set up an informal appointment when I was traveling home for the weekend. My spot diagnosis was a right buccal mucosa cancer with right sided neck nodes. For the uninitiated, it was an advanced stage oral cancer with a dismal survival outcome. We asked him to register at TMH and make a case file the next day and guided him and his relatives step by step on how to get things done at the mammoth hospital. In addition, like a typical angry doctor, I expressed displeasure with his gutka chewing habit and also berated him gently as he happened to sell the smokeless tobacco at his shack. Despite my harsh words, like all young trainees, I helped him to quickly complete all the work-up. His disease seemed potentially curable as the primary tumor appeared fairly operable and the neck nodes were not encircling the carotids beyond the doable (we surgeons like bragging about the angle of encasement and our powers to save the carotids). Prioritizing him on the surgery waiting list, we were able to get this father-of-four-daughters on the operating table within three weeks. In the operating theater, the senior-most surgeon in our unit was called to perform the nodal dissection but unfortunately, we were not able to clear the node without leaving behind a sliver of disease on the holy internal carotid artery; this was enough for us to close him back up, abandoning the surgery. Such inoperability is rare in head and neck cancers as compared to other visceral cancers which more often present with such humbling surprises. Nevertheless, feeling defeated, we counseled him and his family about the options that we could offer for palliative treatment; considering his age, we immediately planned palliative chemotherapy with radiation, which theoretically would provide the best form of palliation. As he was young, we took personal interest in pushing for and getting all the expert opinions available for him.
And though we all take pride in doing our best for our patients with the best of intentions and expertise, sometimes interventions just do not work and we fail when faced with the might of the disease. The effect of palliative treatment in this case was limited, and the disease hardly responded. Mr Md (as the countless Mohammed prefixes of Muslim names in India are shortened to) Sadiq, was then planned for best supportive care and advised home care. Although he and his relatives never complained, they were naturally disillusioned by the treatment outcome, and I could sense an awkwardness in our infrequent communications that ensued.
The success rates we often boast of go so much to our heads that we become less compassionate towards individuals who do not make it to that figure. In almost every multidisciplinary joint clinic, more than 60 percent of the patients with oral cancer are deemed inoperable and referred for palliative intent therapy, and we have become so numb to mechanically granting this death visa that we disregard the haunting deep blankness in the eyes of each of these patients. I hardly ever telephoned his relatives but was updated about his worsening health by the occasional visits his brother made to procure oral morphine. After about three months or so, when it was one of the big nights of Ramadan, I visited home and attended the prayer service at the local mosque but had to rush back to the hospital for an emergency call. Thanks to the COVID-19 lockdown, I had to walk a mile to get to the expressway where I saw a small silent group carrying a Janaza (funeral journey of the dead). I was a bit reluctant to join, fully aware of the ongoing COVID-19 situation, but ended up joining in and lending a shoulder for a few steps, an act that is considered extremely rewarding amongst practicing Muslims. Quickly parting from the group, I started to cross the road when I felt a tap on my arm. I turned and saw the same person who used to come for the morphine tablets for Mr Md Sadiq. Indeed, his eyes informed me that the dead person I had just carried was none other than our besieged patient with oral cancer. With a lump in my throat, I could hardly offer consolation and I silently departed.
A few days later en route home, taking a shortcut through the slums, I happened to see a shack in which gutka and tobacco were being sold. I frowned and clenched my jaw in frustration, but immediately rearranged my displeased expression to an accepting smile when I saw that it was Md Sadiq's brother manning that shack. He smiled back and I had nothing to say!
We all desire a utopian world, but the reality is that for it to prevail, we need to accept the human disparities of our ecosystem and stop being so self-righteous: we are mere mortals and cannot be the moral compass for others.
*The name of the patient has been changed to protect the identity.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
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1. Shetty R, Mathew RT, Vijayakumar M. Incidence and pattern of distribution of cancer in India: A secondary data analysis from six population-based cancer registries Cancer Res Stat Treat. 2020;3:678–82
2. Singla A, Goel AK, Oberoi S, Jain S, Singh D, Kapoor R. Impact of demographic factors on delayed presentation of oral cancers: A questionnaire-based cross-sectional study from a rural cancer center Cancer Res Stat Treat. 2022;5:45–51