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Excerpt from Dr Umanath Nayak’s book ‘Enduring Cancer – Stories of Hope’. Dr Nayak is a Head and Neck Cancer surgeon, Apollo Cancer Hospitals, Hyderabad. His book may be purchased online through Flipkart and can also be downloaded on Amazon Kindle. Also Read - Akshay Kumar, Piyush Mishra, Sonam Kapoor and more Bollywood celebs who opened up on facing sexual abuse in childhood

The chemotherapy was taking its toll. With stage IV metastatic breast cancer and with bones and liver riddled with secondaries, Dr Sabitha had just a few more months to live. Till recently, this had not stopped her from continuing her practice as a full-time gynaecologist at the Apollo Hospitals. She would take her shot of the weekly chemotherapy and, within the next few hours, would be seen in the operation theatre, performing a hysterectomy or an emergency C-section. Her anaesthetist would just look on in wonder and click his tongue at her indomitable spirit. It was probably her way of cocking a snook at the cancer that was slowly destroying her. The chemotherapy was gradually compromising her immunity and it was no wonder that in trying to save a woman with a bad lung infection in obstructed labour, she contracted the same infection herself. Also Read - This therapy boosts confidence in patients battling cancer post-chemotherapy

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Dr Sabitha was in the ICU on a ventilator for a month with full-blown pneumonia and in septic shock. The ENT surgeon had to perform a tracheostomy, a procedure for opening the windpipe, to facilitate her ICU care. She recovered finally and was taken off the ventilator. For a long time, the tracheostomy opening kept bothering her by refusing to close spontaneously, creating a nuisance during respiration and speaking. For some reason, she asked for my help in getting it closed. I was only too happy to do whatever little I could to help her, though I did wish that circumstances had been better.

Dr Sabitha was diagnosed with stage II breast cancer in 1997. Hardly 38 years old then, she had detected a lump in her right breast in the course of a routine self-examination. A mammogram strongly suggested the possibility of cancer. She and her husband, Dr Rath, a senior cardiologist with the Apollo Hospitals, immediately decided to go to Mumbai for the rest of the work-up and treatment in order to avoid the embarrassment of the entire hospital being aware of her condition.

(Read: Working women likelier to get breast cancer!)

Both of them had been with the Apollo Hospitals since the early 1990s and had well-established practices. Dr Rath used his connections with cardiologists in Mumbai and got her admitted and operated by a leading surgical oncologist at the Breach Candy hospital.

After the diagnosis of cancer was confirmed, a total mastectomy and removal of the lymph nodes of the armpit (axillary dissection) was performed. Since the cancer had not spread to the nodes in the armpit, as revealed in the histopathology report, the surgeon felt that no further treatment was necessary at that time. But the medical oncologist, who saw her subsequently, strongly recommended chemotherapy, as there were some other negative prognostic factors in her histopathology specimen.

The past few decades have seen considerable developments and a paradigm shift in the management

of breast cancer. This has mainly to do with the present understanding that breast cancer is not a disease localized to the breast, but a systemic (or generalized) disease from the very beginning, with a high propensity to spread to other parts of the body.

Overtly aggressive surgical removal of the breast and its surrounding structures, as was practised before the 1970s (Halsted radical mastectomy), is no longer in vogue. Less aggressive procedures, such as modified radical mastectomy and lumpectomy (removal of the lump alone), are standard procedures today for local treatment, along with axillary node sampling. This approach has, to some extent, reduced the psychological impact of mutilating surgery on the breast. In addition, the routine use of chemotherapy even in early breast cancer to eliminate possible metastasis has improved cure rates significantly.

(Read: Chemotherapy, carcinoma, complete remission and other such cancer terms explained)

In view of the difference of opinion between the surgeon and the medical oncologist regarding the use of chemotherapy, Dr Rath decided to take his wife to the USA for a second opinion. The doctors at the Memorial Sloan-Kettering cancer centre in New York, after re-evaluating her pathology specimen, were in concurrence that Sabitha should indeed receive chemotherapy as studies showed that she would not be responsive to hormonal therapy. In addition to regular chemotherapy, they also recommended the use of another drug, Herceptin, which had just then been introduced in the USA. Breast cancer is one of those cancers (the others being ovarian and endometrial in women, and prostate and testicular in men) in which the body’s naturally produced hormones play a major role in the initiation and progression of the cancer. Manipulation of these hormones, i.e. reducing their effects through drugs and other means, retards the progress of the cancer and can even help in cure. The hormones that are important in breast cancer are oestrogen and progesterone. It has been found that approximately 60% of breast cancers express receptors to these hormones in their tumour tissue. These cancers are termed ER (oestrogen receptor), PR (progesterone receptor)-positive. ER, PR-positive patients benefit from using drugs such as tamoxifen, which block these receptors and thus prevent the naturally occurring hormones produced by the patient from stimulating the growth of the cancer. The remaining 30%–40% of tumours do not express these receptors and are termed ER, PR-negative. These patients do not benefit from hormonal manipulation and overall, their prognosis is worse than that of ER, PR-positive patients. For such patients, chemotherapy is recommended even in the early stages. In addition, since the late 1990s, yet another receptor, the HER-2 receptor, has been studied in breast cancer tissues. It has been found that patients who have these receptors fare worse than those who do not have them. At the same time, they benefit from the use of Herceptin, which blocks these receptors. Today, this drug has become a standard part of the treatment of HER-2-positive breast cancer.

Sabitha’s cancer was ER, PR-negative and HER-2- positive. All the features of a bad cancer! Sabitha and Dr Rath returned to India and went to Breach Candy for chemotherapy. She received six cycles of chemotherapy, in addition to Herceptin. The Herceptin had to be imported from the USA at a great cost, as it was not yet available in India. Dr Rath took up a suite for his wife at Breach Candy, overlooking the sea. He would shuttle between Hyderabad and Mumbai every week, practising at Apollo from Monday to Friday and flying to Mumbai on Friday evening to spend the weekend with his wife. They kept the news of her cancer and the treatment secret and no one in Hyderabad, including their family, was aware of what was going on. They did not want to upset their children as far as possible.

When Sabitha returned to Apollo after an absence of four months, the initial curiosity about her long absence and her new hairstyle (she had lost all her hair due to the chemo and was wearing a wig) soon faded and she immersed herself in her practice. This kept her mind off the unpleasant thoughts and worries that plagued her and her husband about a possible recurrence of the cancer. She continued Herceptin for one full year.

Two years after the completion of her treatment, without any warning, Sabitha developed metastasis in her bones. Once again, they visited the Memorial Sloan- Kettering hospital in New York to explore the options. The medical oncologist later called Dr Rath privately to his chamber and told him that it was time that the rest of the family was taken into confidence regarding her condition. The cancer was incurable and she only had one or two years to live. Palliative second-line chemotherapy was suggested to prolong her survival.

Read more about causes, symptoms, diagnosis and treatment of breast cancer.

The burden of informing Sabitha’s parents and other family members fell on Dr Rath. The most difficult part was breaking the news to their children. His daughter, then 12 years old, took the news quite calmly and the maturity she displayed was far beyond her years. Their 8-year-old son was not fully able to comprehend the gravity of the matter, though he was aware that something was seriously wrong.

Sabitha continued her chemotherapy and her practice side by side. In the words of her husband, ‘She was a brave woman who refused to succumb to the cancer. It just took her away!’

As Sabitha’s condition gradually deteriorated, her mother came to live with them and remained by her side day and night. On 3 March 2003, Dr Sabitha breathed her last. The entire hospital mourned the passing away of a courageous doctor who fought her disease till the very end on her own terms.

(Also read by Dr Nayak: How to cope with incurable cancer)

Dr Umanath Nayak’s book may be purchased online through Flipkart and can also be downloaded on Amazon Kindle.

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Published : August 16, 2013 12:25 pm | Updated:June 2, 2014 4:32 pm

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