The Time Is Now for the Worldwide Cancer Community to Be Proactive

A Conversation With Chandrakanth Are, MBBS, MBA, FRCS, FACS

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Although it is good for us in wealthy industrialized nations to advance cancer research and treatment, we as oncologists also have an obligation to help care for the multitudes of cancer patients living in poverty across the world.

Chandrakanth Are, MBBS, MBA, FRCS, FACS

The ASCO Post recently spoke with nationally recognized surgical oncologist Chandrakanth Are, MBBS, MBA, FRCS, FACS, Jerald L & Carolynn J. Varner Professor of Surgical Oncology & Global Health; Vice Chair of Education; and Program Director, General Surgery Residency, University of Nebraska Medical Center, Omaha. Along with his clinical and research endeavors at the University of Nebraska, Dr. Are is interested in the socioeconomics of global cancer, especially in the developing world. In fact, Dr. Are currently serves as the Guest Editor for the Global Cancer Burden feature in The ASCO Post.

Background and Early Influences

Could you tell the readers a bit about your background.

I was born in India and reared in Hyderabad, the capital of the erstwhile state of Andhra Pradesh and now the capital of the bifurcated state of Telangana. My parents were from and lived in a small town but placed me in a boarding school in Hyderabad to give me a better educational opportunity.

Were there any early influences that helped shape your decision to become a physician?

Yes. The primary reason I became a physician and specialized in surgery was the influence of my father, who was a general surgeon in a small town. He was my role model, and even 2 decades after his demise, he continues to inspire me. India obtained its independence from Great Britain in 1947, and my father went to medical school during the early postcolonial period. He then completed his general surgery residency and for some reason relocated to a small town called Jagitial of Andhra Pradesh. This town around 50 years ago did not have a formally trained surgeon nor did it have a trained anesthesiologist. For surgical procedures, my father would administer anesthesia first, scrub out and re-scrub to perform the procedure.

My mother would send me to observe my father in the operating room from a very young age, around 5 or 6 years old. His operating room was simply a small room with a table of fixed height and the most basic surgical instruments. He performed operations ranging from hernia repair to peptic ulcer surgery, cesarean section, urological, and pediatric procedures. There was no electrocautery, different types of sutures, or any other instruments of sophistication. He used cotton and silk suture for almost everything. Resources were scarce to the point that even our gloves would be re-sterilized several times over. I would sit on a stool and watch my father operate. Even to this day I wonder how he operated in such acutely austere circumstances when we here complain even when surrounded by such abundant resources and technology.

We lived on the floor above the hospital and clinic. The ground floor hospital had around 10 to 15 in-patient beds. My father used to complete his morning postoperative rounds around 6:00–7:00 AM and start his outpatient clinic from approximately 8 AM or so. I still recall watching from the first floor the vast numbers of patients in his clinic, which he usually closed for a break around 4:00 PM. He would come up for lunch, rest for a while and return to clinic around 5:00–6:00 PM. His operative list started around 7:00–8:00 PM and would continue until midnight or longer depending on the number of cases. He did this to accommodate the number of outpatients during the day time. This was his grueling routine almost day after day for nearly 2½ decades until the day of his demise.

Several events come to my mind when thinking of his influence. Power outages were very common in those days, especially in small towns during the middle of searing hot tropical Indian summers. Without power the only fan did not work and it did get very hot in the small operating room. And without the only light, an assistant would hold a kerosene lantern over the patient while my father operated. During his government service days, my father was also responsible for conducting autopsies for the state. I would accompany my father on these trips to even smaller towns which sometimes were so remote that we could only reach them by foot. Those medical adventures were very exciting for me a child and had a huge influence on my career.

During tenth grade in boarding school, I still vividly remember this incident. My father came to the city to visit and he told me that he had a patient with gastric cancer, but he was not a candidate for surgery. He was poor and could not afford chemotherapy, which was very expensive even then. My father asked if I thought we should buy it for him. Of course I said yes, and we purchased a vial of fluorouracil. It was during 1989 and in India, the cost of a vial of fluorouracil was about the same as the monthly or yearly salary of many. I’m not sure what a few vials of fluorouracil did to that patient, but incidents such as those leave indelible imprints on a child’s mind.

I knew that my father did a lot of good as a doctor. He had a passion for his profession, always thought about his patients first and scores of patients recall how he dispensed care for free if the patients could not afford it. When he died, thousands of patients showed up to pay their respects. Once I saw that, there was simply nothing else I wanted to with my life other than become a surgeon.

A Growing Interest in Oncology

What influenced your decision to enter the field of oncology?

I obtained my medical degree from Osmania Medical College in Hyderabad, India. It was a very old school, established in the mid-19th century. While in medical school, I had a wonderful professor in orthopedics who had an interest in oncology. He piqued my interest in oncology, and I initially thought about orthopedic oncology, but colleagues of mine stressed that bone tumors were quite rare, and I’d be better off in general oncologic surgery.

After my internship, I went to the United Kingdom and from there on to the Republic of Ireland where I completed my general surgery training to become a fellow of the Royal College of Surgeons. I was in Ireland for a few years before moving to the United States. I completed my general surgery residency at the Johns Hopkins Hospital, Baltimore, Maryland, and did my surgical oncology fellowship at Memorial Sloan Kettering Cancer Center, New York.

The Human Side of Medicine

Please describe your current position at the University of Nebraska Medical Center.

I am the Jerald L & Carolynn J Varner Professor in Surgical Oncology & Global Health. I’m also the Vice Chair of Education and the Program Director for General Surgery residency. Along with my teaching, administrative, and clinial duties, I am passionate and also involved in global health and clinical outcomes research. I used to have a basic science lab but gave that up once I became the program director. There just wasn’t enough time in the day.

I have a strong interest in the human side of medicine, humanistic approach to patient care which is the core purpose of our profession. On the global perspective, cancer is set to become the leading cause of death, overtaking cardiovascular disease. We are facing a worldwide epidemic. On the positive side, because of the nature of the disease, we have time to act, so it is imperative for the international cancer community to be proactive in tackling the rising global cancer burden.

The urgency is driven by a demographic reality. In another 15 or 20 years, 50% to 60% of the newly diagnosed cancer cases and about 65% of all cancer-related deaths are going to occur in low- to middle-income countries in the developing world. Not all of these areas have the resources to cope with this impending crisis. In the United States, we can order a positron emission tomography scan or expensive chemotherapy for our patients. However, 80% of the world’s population lives on less than $10.00 a day, and 2 billion people live on less than $2.00 a day.

So although it is good for us in wealthy industrialized nations to advance cancer research and treatment, we as oncologists also have an obligation to help care for the multitudes of cancer patients living in poverty across the world.

Closing Comments

Any last thoughts you would like to share?

I always say that for most of us we won the genetic lottery by birth. We could have very easily been born in the 80% of the world’s population that lives in poverty. We won the educational lottery by getting into medical school. We won the employment lottery by securing one of the most stable and satisfying jobs. I tell every physician that our profession has been very kind to us. So it is time for us to roll our sleeves and do what we can to return our favor to the profession and thereby alleviate the suffering of cancer patients worldwide. ■