Two Distinct States of Mind

As a young medical student, I saw a person dying. Fluid was filling his lungs as a heart valve had ruptured from a massive heart attack a few days earlier. I did not have the ability to save his life where I was working — no immediate ICU or surgical care was available. It struck me later that I had the choice of disclosure. Should I have told him and his wife that he was dying? Would there have been a few minutes of “I love yous” and goodbyes? Or, would ensuing panic be all that remained etched as the last few memories?

Working in the developing world, non-disclosure to the patient, and their right to not know all about their healthcare is the default. Patients entrust decision making and autonomy to their family members, and many times, they are implicitly aware that they are not fully in the loop. Families also do not want diagnoses of terminal illness disclosed to patients. The enduring belief is that this will shorten their life and remove potential for happiness. In cultures accustomed to death at any age, dying is seldom discussed. It often happens, at home, with family, silently, without much accompanying discussion.

It has always struck a chord with me that the dying are aware that they are passing away. The ebb of the body’s energy is not mistaken at the end of times for something else. Spoken or not, it is implicit in every interaction.

In cultures accustomed to death at any age, dying is seldom discussed.

Yet, friends often describe a loved one’s passing from cancer as “sudden” or “unexpected”. “He was doing fine”- in the house in bed, or in the hospital ward, until he fell sick and passed in a matter of days. Despite a terminal diagnosis of advanced refractory cancer, the story that is told is one of death arriving without a warning.

I believe that there are two distinct states of mind— one of caregiving, and the other of grieving. These cannot coexist easily. The caregiver, even the self, nurtures the past and hopes for the future, since the present is intolerable. The grieved, instead lives solely in the past, and rewrites history to make sense of the powerlessness to change the future.

Physicians struggle with this. As a patient transitions from curative to comfort driven measures, they raise the specter of disclosure, of poor prognosis and impending death, as a way to absolve themselves of any guilt, any way to impact the future. Rarely, this is needed in the developing world. As a gross generalization, bucket lists are the privilege of the healthy and wealthy. Otherwise, many families are already together, at home, with their loved ones, in the non-medicalized ritual of dying that is as ancient as our cultures.

What is forgotten is that no one knows the future. We play with probabilities and pretend that they are certainties. The removal of hope for families and self leaves very little to get through the everyday with. Much has been written about living a pain free day, the taste of something special, or watching a grandchild at play. But there is also the balm of improbable hope, balanced with measured, comfort providing interventions, that allow family and patient to weather the present.

There will always be time for grieving. I am now beginning to see the wisdom of not starting that process while our loved ones are still with us.

-Dr. Naresh Ramarajan


Online Expert Opinion: www.Navya.Care

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Tata Memorial Centre (TMC) National Cancer Grid (NCG) Online – Navya Expert Opinion Service: Empowering cancer patients with expertise and information on their treatment options

Navya Press Release img1

TMC NCG Online – Navya Expert Opinion Service empowers patients with critical information within 24 hours enabling families to make robust decisions in cancer care with adequate inputs from oncologists at Tata Memorial Centre and National Cancer Grid . This service, available at, allows patients to upload their reports and get a response from world renowned experts.

While diagnosing the presence of cancer can be relatively straightforward, treatment is highly specialized and the number of experts experienced in managing complex cases is very few. Many cancers are curable or can be managed for a number of years if diagnosed early and treated appropriately. Choosing the right therapy can be the difference between the best possible outcome and failed treatment. Patients are able to receive the best possible treatment opinion which includes what therapy to choose (surgery, chemotherapy, radiotherapy or immunotherapy) as well as dosage, duration, side effects and other details pertinent to the treatment. The detailed report, that answers all questions asked by the patient in language that is simple to understand, can then be shared with the local oncologist to proceed with the treatment locally.

Since 2015, over 12,000 patients from 22 developing countries have reached out to Navya to get expert opinions. Abdul Rahman, who lives in Erbil, in the Kurdish region of Iraq, had previously undergone surgery for pancreatic cancer. Five year later, he started experiencing acute pain in his abdomen and a subsequent CT scan showed a tumor on his liver that had metastasized to his lungs. The local physician asked his family to take him to a tertiary care center that could adequately advise a treatment plan and recommended Tata Memorial Center in Mumbai, India.

Abdul’s brother in law, Haseeb, started evaluating the logistics of traveling to Mumbai and found that the travel and lodging expenses for a trip for him and Abdul would be upwards of $5000. Further, the procedure of getting a medical visa would take at least a few weeks. They would also need to travel with no visibility on how long they would need to stay in Mumbai as they did not know what treatment would be recommended.

Haseeb started finding out more about Tata Memorial Center by going online when he came across the TMC NCG Navya expert opinion service. He was initially skeptical about the veracity and thoroughness of the service as he did not know if it would be comparable to making a trip to Mumbai. He decided to register at and explore the service further.

On registering, Haseeb received an email that explained the complete process that the expert opinion service followed. He would need to upload Abdul’s reports, which would then be summarized and sent to relevant experts at Tata Memorial Center who would provide a treatment plan that would be detailed in a patient report. This patient report could then be shared with the local physician in Erbil and he could be treated there. “The expert opinion service was a boon to us as this was more convenient and cost effective than traveling to Mumbai and Abdul could get treated locally”, said Haseeb Mohammad.

The necessary reports were uploaded following which a patient advocate spoke to Haseeb to understand the case in detail. Some additional reports were sought which the family had but didn’t know were relevant. “I found the person who spoke to me to be very empathetic and thorough in understanding the history of the case. This gave us comfort that the case was being comprehensively analysed.” He was immediately able to upload the additional reports that had been requested.

The case was summarized and sent to a gastrointestinal expert who had trained at National Cancer Institute designated cancer centers such as Harvard, Stanford and UCLA affiliated cancer centers. The expert’s recommendation was detailed in a patient report and the treatment plan included chemotherapy that could be administered in the local hospital. The report was shared with the local physician who started the treatment immediately.

Mr Haseeb said: “Our experience with the online expert opinion service was all that we had hoped for and more. In addition to it being cost effective and quick, we were able to get a treatment plan from an expert without the patient having to travel long distances. The patient advocate was thorough, the process was efficient and the report that we received was detailed and the treatment plan followed international guidelines. Our doctor in Erbil felt that we had made the right choice in approaching TMC NCG Navya online to get an expert opinion.”

Families seek to vet treatment plans with experts but often access to experts is limited. Balancing the need to act quickly while ensuring the decision is made with all relevant inputs is when Navya’s Online Expert Opinion Service becomes a powerful ally. The timely response from experts through Navya has meant that the treatment followed standards accepted globally and may have been the difference between a failed treatment and the best possible outcome.

Data Driven Doc: Staying Informed on the Diagnosis (Part 2 of 2)


(Continued from previous post here)

We struggled with how to let my dad know about this upstaging. I intensely felt the need to protect him from bad news and at the same time the need for disclosure to move ahead. But I couldn’t move past the diagnosis and into treatment planning until he knew. We waited for his appointment that evening and then broke the news to him.

Perhaps overwhelmed by this unforeseen information, I dropped my guard. The urologist recommended surveillance to see if the cancer cells at the positive margins would grow. We did not start any anti cancer therapies. We were not even referred to see a radiation oncologist.

For a high-grade tumor that was outside the capsule of the prostate already, this approach should not have passed the smell test. But all the energy I had put into researching my options were now focused on helping dad recover from the surgery. We simply took the urologist at his word and waited. I didn’t even lookup my online medical references.

No surprise to anyone but us, the tumor markers quickly started inching up and doubling. Imaging showed that the recurrence was not spread in the body, and was still local. Alarmed, I went back to my information-first mode, and read every study on local salvage therapies. I was surprised to find out that early salvage radiation and hormones immediately after surgery were already becoming standard.

I discovered that in most other locally advanced tumors with a high grade, positive margins aren’t simply ignored, rather are treated with repeat surgery or adjuvant therapies!

Although reeling for lost time, I was also exceptionally thorough this time. We went through every possible radiation and hormone therapy option – to radiate the pelvic nodes or not, use protons or photons, what dose, to use short course or long course hormones or no hormones.

I read every study and guideline that was applicable. I spoke with every expert in the area I knew at UCLA, Stanford and nationally. I wanted to be certain that I was making a decision with the best information at hand.

After extensive discussions with my father on his preferences, and discussions with his radiation oncologist, we embarked on round two of beating his prostate tumor. My dad was fully aware of his diagnosis, his options, and his choice of therapy. The clarity of that knowledge and reassurance that we were doing everything possible gave us so much strength. Instead of being victims to the process and the disease, and have something to hide from and be protected from, we were open, clear, calm and as much in control as we could be.

That was almost 5 years ago. Luckily, my dad continues to have his 3 month check-ups that are coming back clear. He is not out of the window of recurrence just yet, but it is safe to say we are getting there.

Not all stories have happy endings. Despite being treated at the best cancer center in America, my aunt succumbed to inflammatory breast cancer in 2009. She was diagnosed the same year as my father, and we went through the same exhaustive search for therapies and options that we did with my father. When she went on hospice, she knew she had exhausted every option medical science could offer us at the time. I still carry that little piece of reassurance inside me today.

While my physicians have my best interests in mind, they are limited in ferocity as this is not their battle to fight. It is mine.

I see a diagnosis of cancer for what it is now. Without knowing the name of my enemy, I cede power of fighting to others. While my physicians have my best interests in mind, they are limited in ferocity as this is not their battle to fight. It is mine. Staying informed on the diagnosis, science behind the options, and the experience of true experts in the field is the only reassurance I can have that the best possible decision has been made.

-Dr. Naresh Ramarajan

Online Expert Opinion: www.Navya.Care
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Data Driven Doc: Staying Informed on the Diagnosis (Part 1 of 2)


I’ve been told the events of the first time so many times, that I have a vivid memory of it now. My fathers mother, Bhuma, succumbed to a recurrent brain tumor that kept growing in the small confinement of her skull. When she was first admitted to a small hospital in Massachusetts, confused after a fall, my father was not at her side. My aunt had driven her to the hospital, and first received the news of impending brain surgery. But without my father around, my aunt couldn’t let my grandmother know. Bhuma was a woman who was in exquisite control of her world and those around her. To know that she was losing that control in a strange land would unravel her deeply, thought my aunt. Could she undergo surgery without knowing why?

Although common in South Asia and other parts of the world, this idea of keeping a diagnosis secret from the patient, especially one who needed a surgery, was foreign to the surgeon. As the story goes, my aunt stood between the surgeon and my grandma, and refused to translate a word of his English into her Tamil. The standoff continued until my father got there the next day.

Once my father arrived, my aunt gave up her shield to him. The energy of my family was spent in understanding the prognosis and explaining it to my grandmother. It did not occur to them to explore what treatments to do and in which sequence. It was 1989, and the trust in the surgeon was much higher than the trust in the patient.

After much reassurance from the surgeon, and not much understanding, my family consented to neurosurgery. The tumor was incompletely removed, and treated almost too conservatively. It came back again and again until there was no radiation or surgery that would stay it’s course.

I often wonder what Bhuma thought of all the medical decisions she relegated to her surgeon alone, and what sense of acceptance and calm allowed her to continue through the storm of medical care that pursued her the rest of her life. For a woman who consistently went out of her way to ensure that even her neighbors had their lives in order, the loss of autonomy and empowerment might have been frightening.

I often wonder what Bhuma thought of all the medical decisions she relegated to her surgeon alone.

Many years later, cancer found my family again. Freshly graduated from Stanford Medical School and an intern at UCLA, I felt ready to assume decision making for my father. When we were initially debating surgery vs radiation for early prostate cancer, I did exhaustive searches of the published research and expert reviews. I understood the side effects and the tradeoffs extremely well. My father became integral to the decision making. We made a calculated choice to go for surgery. My father strongly preferred to have the cancer out, and to have radiation available as a salvage option. The evidence and guidelines supported either choice, although each expert still had their preference in the matter. We were confident we had made the right choice.

So when my mother called me with her early online access to dad’s pathology report – I was saddened and grateful at the same time. The tumor was more aggressive than we thought, a Gleason score 9 instead of a 6, was not early and limited to the prostate but had invaded the surrounding tissues, and the margins were positive. There was still some of that cancer left behind.

We certainly would not have known this information without a surgery. My dad was in the small percentage of patients where the preoperative imaging and biopsies had not picked up the full extent of the disease. It was a lucky alignment of our decision and hindsight.

-Dr. Naresh Ramarajan

Online Expert Opinion: www.Navya.Care
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Data Driven Doc: Empower in The Process


A friend of mine reached out to me to check in on what to do after a mastectomy. She is in her early twenties, and just prior to graduating from college had been struck with invasive breast cancer without a predisposing family history.

What is the benefit of increasing survival over 10 years by 4%?  Navya’s risk estimates projected a 3-8% chance of reducing mortality in 10 years by adding chemotherapy to hormones. But adding chemo came with real risks – infertility, premature ovarian failure, and a small but real risk of infections and major side effects.

How does one make these real-life trade offs?

Data. Expertise. Personal values. These drive every decision that Navya informs.

Ultimately, we start with good data. We don’t skip any steps. We get individualized risk models from the evidence to generate a range of probabilities that assign realistic numbers to various events. Navya’s evidence engine allows us to generate these estimates in real time with the best available data. We then piece it together with what the patient wants given this playing field. We think this is the strongest predictor of whether a person will ultimately be happy with their decision or not. Finally, we ask several experts in the field – to get the best eyes possible to review the facts and the decisions in real time.

Ultimately 4% over 10 years was still enough for someone in their early 20s. The long tail of Breast Cancer recurrences that happen late were enough to move her to brace for chemotherapy.

Data. Expertise. Personal values. These drive every decision that Navya informs. It’s eye opening no matter how many times or how many people we empower in the process.

-Dr. Naresh Ramarajan

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The Convenience of Access

Convenience matters, as does commitment to access.  Access to expert cancer care.


Three things compelled me to write this today.  One, each time I think of decision making in cancer care, be it for a cancer patient or his or her family, or an oncologist, I fall back to the basics of evidence (applicable clinical trials), experience (treating thousands of complex or rare cases), and experts (true experts, of which there are only a handful, do not be fooled).  Boil this down further, and you are left to the ability to identify and use the few really applicable high quality clinical trials (evidence) and consult the experts at tertiary care cancer centers (true experts), especially for nuanced decision making (experience treating the uncommon).  Why then is there the talk of digesting millions of records when only a few trials are high quality and it is the applicability that matters, not the large volumes of any and all data?  (I don’t understand, and hence I write…) When there are only a handful of true experts and only their experience matters, then why are we spinning our wheels on doing anything but increasing access to their expertise?  (Beats me, when there’s blatant publicity on hospitals without any bearings to whether it’s a peer-recognized world class institute…)

This brings me to my point #2.  I’ve been helping a friend of a friend get a pathology review from a leading hospital, for her sister’s rare tumor.  I am a sister.  I know her fight and will fight with her.  Despite my fantastic everything, this person was stuck in the logistics of figuring out how to send a sample, to whom, how, packaging difficulties, courier challenges, unclear billing instructions, completing online forms, invoking treating doctors for telecommunications, and most importantly finding a person on the other end to just talk to and make this work!  Wait, wait, wait — is what she got at each instance, and if you’ve ever waited for a month to just send a sample and expect to wait a month to receive a report, you know what I mean (especially if the cancer-word is in play).

Why are we spinning our wheels on doing anything but increasing access to their expertise?

So, my third point:  operations matters.  A one day turnaround that my analysts strive to deliver, using simple and powerful tools to expedite the opinion of true experts (handful in the world, in India, in the US, in the world…), really matters.   Leveraging only the applicable clinical trials and the nuanced machine learning from expert opinions on complex cases, is all that is needed to make intelligent decisions.  The commitment to make this available to you – really matters.

We offer that, because we want to, because we know what it feels like to want it and not have it – but need it; and because we have worked really hard to use teamwork, clinical informatics and machine learning, and relevant high quality data, to deliver it.  When we work with only the true experts, we know that no other service can do what we do, and it is our duty to bring true expertise to everyone, conveniently and quickly.   And hence, I confidently ask that everyone in need of an expert opinion, an expert treatment decision in cancer care, please reach out to Navya online.  8,000 patients from 42 countries, are testimony to our commitment to convenience and access to expert cancer care.

-Gitika Srivastava

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