SURGEON’S  DIARY: Patient faced with mastectomy or losing only pregnancy in her life

“In conferring the fellowship of this College, we are merely taking your L plate off and granting you a qualification to practice surgery,” Mr Dickson Wright, the head-examiner said to the batch of candidates, including me, who had passed their oral examination on the 15th of May, 1958. The solemn ceremony was held, over a glass of sherry in the Fellows’ Room at the Royal College of Surgeons of England, in Lincoln’s Inn Fields, London. We had finished our oral examination at about 4pm, after a gruelling day, when we were mauled by 16 examiners, four in clinical surgery, four in operative surgery, four in surgical pathology and four in viva-voce, where any surgical topic under the sun was fair game for a question and answer session, which lasted until the bell rang to signify that the time was up or the candidate had run out of answers.

The marks were collated by 6pm, when the Registrar carrying the college mace, announced the results and the successful candidates, were led in the Fellows’ Room, where the same sixteen stern faces from top hospitals in England, who we had met during the day bowed as they granted us an entrance into this exclusive Fellowship. Waving his finger in the air, Mr Wright warned: “Inserting FRCS after your surname does not make you a good surgeon.  That comes after long experience and keeping up with progress in surgery. During your time, you will see some breath-taking advances in your chosen profession.” How true! 

Similarly, when I joined the missionary medical school in Miraj, South India, the Dean, Dr Carruthers, a Canadian doctor, working in rural India, following the example of Albert Schweitzer, who toiled in the jungles of Equatorial Africa, welcomed us in these words. “Medicine is progressing so fast that what we teach you today will be obsolete by the time you leave us. To keep up with progress in your specialty, you will have to continue your medical education.” 

The term CME, Continuing Medical Education was not coined yet but that is what he meant, which over the years, has become an essential element of “Centres of Excellence” all over the world.

 These two oracles, who seeded me with the concept of lifelong learning, one when I was on the threshold of my career, and the other who gave the farewell message at the peak of my academic goal have illuminated my career path. I have seen progress in surgery travelling faster and nowhere is it more notable than in my specialty of breast surgery. The tale I am going to tell, illustrates the point.

It started when Mary Mumbi, a 35 year old hair-dresser came to see me for a lump in her breast. I was merrily taking her medical history until I came to my question. “When was your last period?”

“Four months back.” Mumbi replied.

I jerked up and raised my head. “Are you pregnant?”

“Yes and that is why I am here,” she replied and added “I am four months pregnant and have cancerous lump in my right breast.”

“Both proven?” I asked.

“Yes,” replied Mumbi.

“So, why are you here?” I asked, trying not to sound brash. “Are you here for a second opinion?”

“Not for a second opinion.  In fact, you are the fifth.”

 “Why so many opinions?”

“Surgeons who I consulted said that I need chemotherapy to shrink my tumour, so that I can undergo a safe mastectomy. But I can’t have chemotherapy because I am pregnant. So unless I consent to an abortion, my treatment can’t start. As one of your colleagues put it, I have to choose between my life and that of my baby,” Mumbi explained.

I looked at her more intently because she seemed to have a good grip on the dilemma, constantly faced by us and said. “You still haven’t explained why you have come to see me.”

“Yes, I will tell you. A friend told me that you are the most senior breast surgeon in Kenya and might suggest a way out of this tight spot. I am ready to lose my breast but am not prepared to lose my baby.”

As I saw the determined look on her face, she went on. “My unborn baby is precious because I conceived it after trying for six years, for which my gynaecologist could not find any reason despite carrying out numerous investigations on my husband and me.”

Deeply touched by what she said, I decided to examine her. As I did so and silently agreeing with the findings and opinions of four professional colleagues, I remembered an article I had seen recently in “Recent Advances in Breast Surgery.”  After completing the physical examination, I said to Mumbi, “You are the fifth bosom, I am examining this morning,” I stretched my arm to a low table below my examination couch to retrieve the journal and added. “I remember reading a research paper, describing a new chemotherapy drug, safe in pregnancy.”

As I saw tears of relief welling in her eyes, Mumbi asked, “Are you sure that the new drug won’t hurt my baby?”

I nodded and added.”This new drug can’t cross the placental barrier and therefore can’t reach the foetal circulation to cause any damage.” To re-assure her, I added “We can do periodical ultra-sound scans to monitor the baby.”

After re-reading the article in the presence of Mumbi, I rang my chemotherapist colleague and found that she had read the paper.  It was an important article and she agreed to try it. “Is the drug available in our pharmacy?” I asked.

“I am sure it is but if it is not, I can ring the Royal Marsden Hospital, where the therapeutic trial was held and they will fly it to us here,” she assured me.

We were in luck because our hospital pharmacy had the medication in stock and we injected the first intravenous dose. Mumbi felt very sick and lost all her thick curly hair but her intense desire to preserve her pregnancy and shield her baby, kept her going against all odds. When she had a few wisps of hair on the crown of her head, she remarked, “This is ironical for somebody who makes a living as a hairdresser! I am going to tell my colleague to shave the shrub off. I will invest in a few wigs.” As I smiled at this intrepid statement, she added. “When I gave this advice to my customers, I never knew that one day I myself would have to take a dose of my own medicine!”

All the time we were administering the new medication to Mumbi, I was in constant communication with the lead research doctor who was working on this innovative project to make sure that we were on the right trajectory and at 28 weeks of Mumbi’s pregnancy, he advised. “As soon as the baby is viable, please ask your obstetrician to do a Caesarean Section on your patient, so that you can put her on the time-tested drug, because the medication, she is on is only to be used while the foetus is in the uterus. This remains our policy until wider trials are completed on the new drug.”

Accordingly, I got in touch with Mumbi’s obstetrician and with the consent of Mumbi and Mark, she did a C-Section and delivered a healthy baby boy, who went under the care of our neonatologist, who looks after normal but premature babies, until they are one year old.

By sheer coincidence, the date of the C-Section fell on Christmas Eve and I will never forget the delight on the mother’s face, as she held her precious son before he was taken to the ‘Prem. Unit’. “It is the best Christmas gift, I could have wished for,” Mumbi said when I put the baby on her lap, after her surgery.

Two days later, I told her another reason for her C-Section. “As you know, we can’t do X-rays on pregnant women and so another reason to deliver your baby by a C- Section is that once the baby is out of your womb, we can do X-rays of your bones and lungs, scans of your brain and liver to see that the tumour has not spread to any of these organs.”

“And if it has?” asked Mumbi and then replied pessimistically. “We have done all this in vain.” 

“It is a question of describing glass as half full or half empty.” I replied. “Even if we find metastasis, we have drugs to cure them provided we catch them early.”

Luckily the glass was half full and there was no spread anywhere. Not to leave my readers hanging in the air, I wish to add that baby and mother are doing very well, two years on. Mumbi was not allowed to breast-feed, while she was on chemotherapy, a course, she finished a year back. I followed it with a mastectomy, because chemotherapy made the breast operable.  She is now on hormonal treatment - tablets - to suppress her ovaries from producing oestrogen, which is directly related to development of breast cancer. It gave her premature menopause with all its trials and tribulations. When I told Mumbi that she would not conceive after the hormonal treatment, her reply was. “One perfect baby which you have enabled me to have is enough!”