Medical Lessons from the Death of Revathy Gopal

This is an article that Revathy's husband, Gopal, wrote recently. The article appeared in HT Cafe on 10 April, and also in Chowk.

Revathy passed away on the 7th of March.

The article is not going to bring Revathy back; people might not learn from their experience (people usually never do, from others' lives); but it puts the matter out in the open and that is important.

No matter how educated we are, (or how much we think education has to do with avoiding such catastrophes) when illness comes, we see doctors as shamans and we put our faith in them in an old-fashioned way. Any clarity we have about their fallibility is only in hindsight.

Someone somewhere might read an article like this one and ask for a second opinion; might insist on a full body scan; might ask more questions about injections of monoclonal antibodies; might talk to other patients and see how their experiences might help. At least, I hope so.

MEDICAL LESSONS FROM THE DEATH OF A POET- REVATHY GOPAL

by V.S.Gopalakrishnan

That Revathy Gopal, Bombay-based poet, writer and columnist, passed away on 7 March 2007, after a brave battle with cancer, has already been covered in tribute-rendering reports and articles in print and elsewhere. She was my wife and life partner for 38 years, and died untimely at 59 years of age. The story of her illness has lessons for everybody who values his or her own life and others' lives, by spreading awareness in the matter.

She was imbued with very good health at all times that lent strength to her beautiful and attractive appearance. Like any widely read person, she was attentive about health and nutrition and was familiar with modern-day diseases and afflictions and preventive practices.

It was in April 2006 that she, during self-examination, suspected a lump on her left breast. She quickly underwent a mammography which confirmed her suspicions. One of the prominent hospitals in Bombay was immediately contacted. A top breast surgeon - let us call him Dr.X - came on the scene and within a week the small cancerous lump was removed. The lump was less than a centimetre in dimension. An
adjoining lymph node, under the arm-pit, was also removed as a precautionary step. The breast-surgeon assured us that that was all and there was nothing more to worry. Some radiation was prescribed. A tablet was to be taken daily that would prevent oestrogen formation in the body. So far so good.

Later in May 2006, Revathy underwent an ultrasound procedure for abdomen and pelvis as she was 'spotting'. This was at another hospital and the report showed unusual endometrial thickness of the uterus. Armed with this report, we met the breast-surgeon who did the lumpectomy, as a first step. The mortal mistake he made was that he did not refer the matter to a gynaec-surgeon in the next cabin. On the otherhand he assured Revathy that the unusual endometrial thickness must be due to oestrogen deposit and could vanish soon due to the post-lumpectomy non-oestrogen forming pill prescribed and being taken by her already.

That was a welcome assurance for Revathy. She had planned a trip to England in July to see her son, over three weeks. Could she go, she asked the said Doctor X, in keen anticipation. Yes, indeed, was what the doctor said. This pleased Revathy immensely. The doctor said that after her return from England she could have another look at her uterus. He further said that even if something wrong turned out with the uterus, that would not be life threatening.

Imagine a breast-surgeon of great eminence assuming the mantle of a gynaec-surgeon! Sure enough my wife Revathy went to England, had a great time, and returned by mid-August by which time spotting had turned into bleeding. A fresh ultra-sound was done from a nearby place and the report showed that the condition of the uterus was much worse. The original unusual thickness f the endometrium detected in May had doubled in thickness by mid-August.

So, we again, as a first step, rushed to Dr.X, the eminent breast specialist. Seeing this report he got a real shock. He led Revathy at once to a gynaec-surgeon in the next cabin for the first time for further procedures. We had lost two precious months in this process!

After a Dilatation and Curettage procedure, it was revealed in the biopsy that there was carcinoma of the uterus. Post-procedure, Revathy was prescribed anti-biotics and pain-killer for five days. The pain-killer cum anti-inflammatory was 'combiflam', taken three times a day. After the fourth day, Revathy developed severe drug-induced gastritis said to be thanks to combiflam, that lasted a month during which time she could hardly eat. So, my wife lost one more month before she could undergo a CT scan of the abdomen and pelvis.

The CT scan (in the latter part of September) revealed extensive metastasis (secondary disease of cancer) in the abdomen, pelvis and thorax areas. There was now no point in removing the uterus. The whole system had to be treated. Hence, chemotherapy treatment to be done intravenously in six cycles, was immediately commenced by a very competent oncologist. The sixth cycle ended in mid-January of 2007. Revathy had hardly any side- effects barring loss of hair and some loss of weight. We thought that she had survived and the worst was over.

That was not to be. She developed some pain on the back. An MRI of the spine was then done. (Could it not have been done long ago as a part of a thorough diagnostic assessment?) It was found that four vertebrae showed lesions. Then followed radiation of the vertebrae. A little later Revathy suddenly found her left leg going limp. Then followed an MRI scan of the brain. That showed two secondaries in the right section of the brain. (When the world-famous cycling champion Lance Armstrong was detected with testicular cancer in the USA, every part of his body was scanned at once including the brain which showed two secondaries that were surgically removed right away and as luck would have it, they were found to be necrotic, meaning already dead !). Revathy's MRI scan showed two secondaries in the right lobe. Then further complications followed in her case and she passed away peacefully and painlessly in that famous hospital on 7 March 2007.

Another interesting part of this tragedy is that the oncologist at no time suggested to me on his own the use of monoclonal antibodies (MAB) which are part of the recent medical developments and which attack the cancerous cells only and do not harm the normal cells. MAB is very expensive with one injection priced at a lakh of rupees. The oncologist perhaps presumes that if you are not an Ambani, you cannot afford a course of four MAB injections. Due to my extensive readings, it was I who suggested to him sometime in January 2007 or so about the administration of MAB to Revathy. It was ultimately done on 3 March, just four days before she passed away!

I do not intend to point my fingers now at any of these eminent doctors. I am just raising some issues so that the readers are enlightened and could save their lives and others' lives. The issues that arise from Revathy's case are as follows:

1. Can a breast specialist, however eminent, take over the role of a gynaec specialist? Revathy may not have had the secondaries if those two months had not been lost. I would now recommend to the readers the importance of a second opinion.

2. Are drugs like combiflam which many people do not tolerate require to be prescribed for our patients? Revathy lost a month before her CT scan due to drug-induced severe gastritis.

3. Why do our doctors go for scanning piece-meal depending on any symptoms of the patients which can occur possibly very late? In the USA they do scanning head to foot at one go right at the beginning.

4. Why did not the oncologist suggest treatment with monoclonal antibodies (possibly together with chemos) at the beginning of the treatment? This could have been a surer way of saving a life.

Finally I have taken consolation in the theory of karma. The only thing is that the erring doctors' karma apparently sealed Revathy's fate.