The Proof of the Pudding Principle in Oncology

The Proof of the Pudding Principle in Oncology

International Perspectives

Aug 08, 2018

Dr. Raj MohanBy Raj Mohan, MS, DNB, Mch

As a surgical oncologist, sometimes it is really disheartening to see the patient for whom one did a painstakingly long Whipple’s operation present only months later with multiple liver metastases. Every other day we are reminded of the famous quote by Professor Blake Cady, who said that in surgical oncology, biology of the tumor is the king.

After finishing a major surgery, many of us are on top of the world. Sometimes the combined oncology rounds are an opportunity for the surgeon to drumbeat to the medical and radiation oncologist as to how close we were to the major vessels, how we did a limb salvage, or how daringly we did this particular tumor resection and so on. Only later with a bad tumor recurrence do we realize that the proof of the pudding in oncology lies in survival, lack of tumor recurrence, good quality of life—not in brilliance or heroic surgeries. The end result is that which matters.

However, it takes time for each of us to realize this big truth and it is indeed a very grounding and humbling lesson when we do learn it. I like to call this the “proof of the pudding principle” and it applies to all branches of oncology, although it may be a little more apt for the surgeons. Sometimes resections which are margin-free recur locally and margin-positive or close ones don’t. Of course that doesn’t mean one becomes detached and settles for a mediocre surgery. What I mean is to remain humble and wait patiently for the outcomes with the patient’s interest at the top, and not the surgeon’s achievement as the center of everything.

It is a commonly accepted truth that while a surgeon has been celebrating their success, their patient has gone to see another physician because their tumor has had a recurrence, so the surgeon is living in a false world. Let’s accept that, finally, tumor biology is the king and that celebrating success in oncology may take time and requires patience and maturity. It requires of us to travel with the patient and the disease to its long-term outcomes after the initial recovery, and is definitely taxing at times.

Just like the pudding, the real satisfaction should come not from doing the procedure but from the outcomes both short- and long-term.

Dr. Mohan is a surgical oncologist with the Indian Air Force in Bangalore, India. He is a 2017 recipient of ASCO and Conquer Cancer’s International Development and Education Award.


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