The surgical valour

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I did not know I was going to meet someone like her. She was all of 32 years old and sat in front of me with the poise of someone who had completed finishing school. Her white top enhanced her wheatish complexion. She crossed her legs one over the other with such elegance that even her linen pants did not wrinkle. Her ageing father watched her as she responsibly arranged all her files and papers on the table in front of us - the metaphysical barrier that allows a physician to maintain an emotional distance from their patient.

She had black wavy hair with streaks of silver. Her eyes seemed to have the accrued wisdom of several previous generations. Her face had the serenity of the Buddha and adorned a gentle compassionate smile. But the first words that came out of her mouth were earth-shattering to me. "I have breast cancer," she said with a composure I have never seen. From the corner of my eye, I could see tears rolling down from her fathers' face. "In both my breasts," she added stoically. "I'm so sorry to hear that," I emphasised, "but what brings you to me?" the neurosurgeon in me enquired. "My oncologist got a PET scan done to plan the course of treatment and they found a tumour in the brain as well. That's why he sent me to you," she said. "We also got an MRI dedicated to the brain to ascertain what tumour it is," she continued, as she pulled out the films to show me.

"Aren't you scared of all this?" I asked her, curious to know what was going on beneath that unflappable exterior. "I have loved the stars too fondly to be fearful of the night," she smiled, impressing me with some Sarah Williams poetry. Literature is a great coping mechanism.

What was delivered to her was so unfair, I thought to myself as I plugged in the films one by one to analyse the scans. She didn't have the slightest headache or, for that matter, any other symptom of the 6 cm ghoulish brain tumour nestled within her, between the frontal and temporal lobes in a region of the brain called the insula. After careful thought, I announced that this wasn't a spread from the breast, but a separate primary tumour of the brain. "This is a probably a low-grade glioma, a tumour that arises from the glial cells of the brain," I decreed. "So, can we just leave it alone?" she asked with the curiosity of a child. "Can I proceed with the chemo and then go ahead with my mastectomy as planned by my doctor?" She told me she was eager to get back to flying as a pilot, and that she'd been granted leave only for three months. I didn't have the heart to tell her that she might have to resort to a ground job in aviation.

Sometimes, there is no right answer. I thought for a while and explained that we would have to get rid of both tumours, and that we'd have to do them in quick succession. "We could do either of them first," her oncologist told me over a phone call, "but if the brain tumour can wait, we'd rather do the breast," he concluded.

I asked her what she would like to do. I remember my mentor, when faced with several options to choose from, always chose to tell his patients, "Whatever decision you make will be the right one." I have religiously followed that practice over a decade. Except, I end up saying it more to my wife than to my patients.

"Let me get done with the breast and then we'll proceed with the brain," she decided together with me. I sat there in awe of her fortitude to take life-altering decisions with such surety, although I was sure that a deluge of emotions might be erupting within. I find it tumultuous to deal with a flu, and yet, I see myself giving hope and strength to patients with brain and spine tumours on a daily basis. We bid adieu with a plan to operate on her head once she had gone through a mastectomy and breast reconstruction. Chemotherapy was to start in a week. Often-times in the treatment of cancer we need to administer chemotherapy to shrink the tumour before we operate on it.

Two months later, her father called frantically saying that she had had a seizure. She was unconscious at home. They took her to the ER of the closest hospital, which managed to salvage the situation. The day of the seizure was the day she had completed her chemo, and she was scheduled to undergo breast surgery a few days later. However, a repeat MRI of the brain showed that the brain tumour had grown marginally. We had a muti-disciplinary tumour board meeting and decided to go ahead with the brain surgery first. A couple of days later, we opened up the head to enter an area that was once known as "no man's land"; such was the danger that surgeons used to avoid going there. It was like the Kashmir of the brain: difficult to access, but once there, it enraptured you. We strode in bravely and could remove the entire tumour as it was, straddling the areas of cognition, motivation, fear, anxiety, and happiness. She woke up smiling broadly - a rarity after brain surgery. We discharged her in a few days, fit enough to have her second operation. Weeks later, she called to tell me that recovery from her brain surgery was a walk in the park compared to a double mastectomy with breast reconstruction.

"We only dug a hole; they resurrected a whole new structure," I facetiously justified the hard work of my colleagues.

The Financial Times recently published an article on the unexplained rise of cancer among millennials. It mentioned that the past 30 years have seen an upsurge in cases of so-called "early onset" cancers in the under 50s. So marked is the increase that leading epidemiologists have suggested it should be called an epidemic. Scientists are not sure why, but changes to nutrition and ways of living hold at least part of the key to the puzzle. The consumption of food high in saturated fat and sugar is believed to alter the composition of the protective gut microbiome in ways that can harm an individual's health.

Excess usage of antibiotics and other medication may also be responsible for altering the gut. Whether it will happen to one of us, only time will tell; now, it is also possible for us to do a whole genome sequence analysis to check if we could be at risk. "Our graces don't stand to reason any more than our sins do," I read on someone's Twitter handle.

She returned three months after having valorously completed both her surgeries. Her long hair had transformed into a small frizzy bun, gracefully sprouting again after being jettisoned by the chemo. There was no tumour in the brain and the breasts were brand new. She beamed with confidence, hugging me tightly.

"When can I start flying?" she asked like a little child eager to return to her playground. Knowing that this was a permission I couldn't grant as yet, I replied, "You're already soaring way above everyone else."

The writer is a practising neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.