Interview with Dr Rajay Kumar (Surgical Oncologist)

Dr Rajay Kumar is a surgical oncologist specialised in liver transplant, hepatobiliary cancer, and laparoscopic Surgery. He has completed his GI and HPB fellowship from Tata Memorial Hospital and HPB liver transplant fellowship from South Korea. He has over 12 years of proven experience in cancer treatment, treating thousands of patients to recovery.

Most of your surgeries have been specialised in liver, pancreas, and digestive system. So could you please share your insights on that?

Cancer in the liver is mostly due to Alcohol and bad diet. High consumption of Alcohol leads to cirrhosis and then Liver Cancer. Similarly, an unhealthy diet high in fat leads to the fatty liver, which contributes to Liver Cancer. Also, hepatitis injection for a long time of around 15 years can damage the liver and can further lead to Liver Cancer. The pancreas is also more or less the same. There is no particular agent for pancreatic cancer, but repeated pancreatitis infection can lead to cancer, even though that's not the primary cause. Gall bladder cancer is found mostly in people from the Northern regions of the country, but we have not yet been able to find out the cause of that. Cancer in gall bladder is found mostly in people from Northern India, but we are yet to find the cause.

How does Cancer Treatment differ from first stage cancer to advanced-stage cancer? What are your insights on Palliative care?

When the cancer is in the first or second stage, you go for Surgery. But when it's stage three or stage four, then there is no standard rule of Surgery for cancer treatment; patients generally go with Chemotherapy. In earlier stages, it's more amenable to do surgery, but in advanced stages, it is not opted for. For advanced-stage patients, Cancer Treatment includes chemotherapy, Radiotherapy and mainly palliative care, where the purpose is to improve the quality of life rather than to cure the disease completely. The main aim of Palliative care is to improve the quality of life. If the patient decides against taking Chemotherapy or radiation, then it's just taking care of their nutrition. If they have specific symptoms, like Pain or vomiting, we give specific medications to relieve them of the problem. So basically, medication for specific conditions is what palliative care is all about.

When should a patient decide to go ahead with the Surgery and when should they not do so?

It needs lots of investigation like figuring out the stage of the disease, the area affected and so on. After figuring out the stage of cancer, we plan our Cancer Treatment accordingly. If it is the first or second stage, we go ahead with Surgery most of the time. And the other important thing is that we don't look at age but performance status. Various modalities like blood pressure, diabetes, heart disease and how the patient is overall, are considered to decide whether to go for Surgery or not. Doesn't matter if you are 90, if your vitals are good, we go ahead with Surgery.

Have you come across a rare case which was very challenging for you?

One of my most challenging cases was 10-12 years back during my training. There was a tumour in the uterus of a 28 years young lady that was extending all the way from the uterus into the heart. The tumour was coming from the uterus and going into the blood vessels in the abdomen, then it went into the chest and then into the heart, all in one piece. We had a team; there was a cardiac surgeon; we put the lady on the bypass machine, then we took it out from the heart and then from below. It was a very long and complicated surgery, but she is fine now.

What is the best nutrition plan for a cancer patient? Also, how does a patient cope with the side effects of cancer treatment?

Once the patient is diagnosed, there is not much time between Surgery or other cancer treatments to implement a good nutrition plan. It may be only around one week for surgery, within which time, nothing much can change. Nevertheless, we can guide them before Surgery to have a healthy, high protein diet. You can optimise them for one week before Surgery to improve their overall condition, but the main changes can be implemented post-surgery. After the surgery, you can advise them to have less fatty food, more vegetables, and a high protein diet.

Avoid oily food, red meat, have more vegetables, proteins, or you can add some vitamin tablets or protein powder to increase the protein intake of the body. Drastic changes won't be prescribed since the patients find it hard to stop eating something very suddenly. There are side effects like nausea, diarrhoea, vomiting, loss of taste, loss of hair, dryness in the mouth, all of which are side effects of chemotherapy, and doctors give medications for that. Post-surgery also, there will be certain effects like weakness; the patient won't be able to get out of bed, loss of appetite, constipation and such. Most of these side effects are expected, and thus medications will be provided.

What do you suggest to people who have terminal malignancy, on their nutrition intake? Additionally, after the transplant, how do you bring the person back to normal?

People with terminal malignancy may have a loss of appetite, so even if you tell them to have a balanced diet, they would not be able to go by that. Whatever they feel comfortable with, they can have that. We don't force them with diet or medicines. For terminal patients, the main thing that we try to ensure is their quality of life.

They can have solid food, juices, or protein powder mixed in milk or water and such things that can be easily digested. A body that has gone through the Stress of Surgery takes a couple of weeks to come back to normal life. The removal of an organ doesn't affect the body as such, as the body compensates, and it starts functioning the way it is supposed to. A body can function with half a liver or one kidney. Even in cases where parts of the intestine have to be removed, a stoma is fixed, through which stool can be passed. Even then, it is a more a mental problem of getting used to it than a physical one.

What is the difference between a general surgeon and a surgical oncologist?

When you are doing oncology, you need qualification, just like a cardiac surgeon needs to be trained in cardiac Surgery. We all start-up as a general surgeon, and then certain guys go on to do cardiac surgery, neurosurgery, or onco Surgery. Earlier, there were no degrees, the general surgeons used to work with prominent onco institutes, get training, and used to become onco surgeons for Cancer Treatment. The problem we face now is that a lot of surgeons, who don't have much practice, feel that they can tackle it because of their degree.

So, the patients should do extensive research on the doctor. They can get information from Google, like how experienced he is, how many years he has practiced oncology, which centre he worked in, etc. The problem is that you only have one shot, so if a general surgeon does something wrong, then it becomes difficult to fix it. Therefore, do proper research and take a second opinion too before going in for Surgery. You may have only one shot for surgery, so do proper research. Always get extensive information about the doctor before going in for Surgery We now have lot of surgeons, but without enough practice. So do your research well Always do proper research to get the best possible doctor. Even private hospitals now provide free surgeries for the needy/ underprivileged.

Also, when should a patient choose debulking, palliative, and reconstructive surgery?

Debulking is generally used in ovarian cancer, where we try to remove the tumour as much as possible. We might not be able to remove the entire thing. Still, we try to reduce the bulk, so that when a patient goes for Chemotherapy or any other cancer treatments, the volume of disease inside the body would be significantly less. Reconstructive Surgery is the surgery used to reconstruct. If it's a big tumour, you need a plastic reconstruction.

Suppose your jaw is removed along with the skin, then there are various plastic surgeries; you take muscles from the chest and put it on the face to cover the defect. You take bone from the leg and put on a face to reconstruct the jaw. Palliative Surgery is done significantly less now. If a patient has jaundice, then we do Surgery to release jaundice, but at the same time, if other options are also available, we try to look for alternative methods of Cancer Treatment. It depends on the patient's overall health; that is, whether he/she can withstand the Surgery. Similarly, if Breast Cancer tumour is big and is bleeding, the tumour will be removed even though it is not usually done.

Could you enlighten some points on Head and Neck Cancer as they are on the rise now? Similarly, what is the reason for the stomach or colon cancer?

Head and neck cancer is common in India because of the high smoking and Tobacco use among the people. People chew Tobacco and keep it inside their mouth, due to which oral and throat cancer are very common nowadays. Mouth, tongue, throat, and larynx cancer is basically due to the use of tobacco, smoking, and eating betel Nuts. Awareness programs are going on, but people still do not let go of their habits, feeling that they won't get affected by cancer. Awareness has increased compared to what it was earlier, but unless the habit goes, the rise in cancer cases won't come down. Most of these cases of stomach and colon cancers are due to genetic mutations. The diet does have an impact on stomach and colon cancer, but you can't say that it is only because of that. Reports say smoked fish, red meat, or very deep-fried stuff that have crumbs, have carcinogens that can cause Stomach Cancer. Once these things go into the body, the acid in the body can convert them into carcinogens, which can cause stomach and Colon Cancer. Moderate consumption is acceptable, but adding it in the daily diet can become troublesome.

Could you through some light on social stigmas attached to cancer and cancer treatment?

Some people still try to cover up their difficulties without heeding much notice to it. Why do you think it is so? Nowadays, people are aware of cancer, but still, certain families don't discuss or disclose the news. Compared to 5-10 years ago, people are a little bit more open about it now, but the stigma is still prevalent, it is not something which goes away that easily. A lot of the times, when you have something inside the abdomen, you generally tend to brush it off. We feel that it might just be a stomach ache, or sometimes you might feel the heaviness. So, you don't immediately go for a scan just because of mild pain; you tend to ignore it. And in that period, it grows so fast, and the space in the abdomen is so that it will go anywhere, and you won't even realise it. People need to be more aware and vocal about it.

What are the most common types of hereditary cancer? Should every member of a family get themselves checked if any member gets diagnosed with cancer?

Breast cancer is one of the most common types of Hereditary cancer. There are other cancers like colon cancer, but the most common is Breast Cancer. These cancers affect a person irrespective of the lifestyle that they followed. Suppose if you have a family history, there are specific tests that can help you figure out whether it's genetic or not. You can take precautions such as getting yourself checked regularly, going for mammograms, getting your pap scan done and the like. Don't ignore symptoms if you have a family history; do go for check-ups at least once in a year.

What is a healthy life protocol?

There is no set protocol; Generally stay away from fatty food, smoking, chewing tobacco, red meat, deep-fried stuff, and the like. You should have a balanced and healthy diet. Avoid excess of anything and keep everything in moderation. There are chances that you can still end up with malignancy, but it is better to follow a healthy lifestyle to reduce the chances.