Dr Narayana Subramaniam: Converting Oncological Impossibilities into Possibilities

Dr Narayana Subramaniam
Narayana Subramaniam -Senior Consultant and Head of Department, Head and Neck Surgical Oncology

A constantly innovating mind can invent possibilities in the darkest realms of impossibilities. When it comes to saving lives through their highest risk-taking surgeries, Oncologists are continuously breaching the barriers of what is possible.

Dr Narayana Subramaniam has performed such breathtaking magic not only once, twice, or thrice but a thousand times. A Senior Consultant and Head of Department, Head and Neck Surgical Oncology at Sri Shankara Cancer Hospital and Research Centre, Dr Subramaniam led the team that performed the world’s first bilateral ZIP flapwhere the entire upper jaw was removed for cancer and restored with a full set of teeth in a single surgery in a young lady, which was a significant improvement on an existing surgical technique. This technique has received awards and acclaim. Additionally, Dr Subramaniam and his team have combined patient-specific titanium implants with microvascular free tissue transfer for facial tumours to restore form function and teeth; “To our knowledge, these are the first two cases described in the world,” he shares.

Through dedicated protocols and postoperative techniques, surgical outcomes have been consistently improved, specifically in advanced tumours, already treated tumours that have recurred, and tumours in patients older than 75 years, three groups typically neglected in cancer treatment.

Dr Subramaniam adds, “I have operated successfully on rare and complex tumours, some of which have been described as having occurred in fewer than 30 patients in the world, as well as in children with head and neck cancer, which is also an extremely rare occurrence.”

It is then no wonder that Dr Subramaniam received several awards for research, which has been focused on key areas: oral cancer in young patients, better understanding outcomes in head and neck oral cancer, improving survival and improving existing staging in head and neck cancer. He also led national and international consortiums on oral cancer research with thousands of patients’ data to address this issue, resulting in multiple international publications. Their work in chewing tobacco-related oral cancer, which is predominantly an Indian phenomenon (the West has smoking-related oral cancer, which is fundamentally different), has shown novel changes in the tissue that may lead to novel treatments in this group. He has been invited to multiple international platforms to address this neglected area of cancer.

Through collaboration with GE Healthcare, he has worked with multiple cancer-related start-ups to improve patient acceptance, clinical validation of medical devices, and sustainability and affordability in innovation. Many of these start-ups have made an impact in the cancer space. He says, “I have multiple grant applications with GE Research that look at reducing cost and time taken for oral cancer detection in a rural setting, as well as remote patient monitoring for patients on cancer treatment.”

Dr Subramaniam spoke in an interview with CIOLOOK INDIA, the highlights of which are given ahead.

Please brief our audience about your clinic/hospital, its USPs, and how you are currently positioned as one of the renowned oncologists in India.

The Department of Head and Neck Oncology at Shankara Cancer Hospital Bengaluru has quickly evolved into a centre of excellence for the whole spectrum of treatment for head and neck cancer and its side effects. The department has emerged as a referral centre for complex head and neck surgery, especially for those requiring previous treatment and surgeries and those requiring complex jaw reconstruction.

It is a multidisciplinary team that comprises oncologists, reconstructive surgeons, ENT and oral and maxillofacial surgeons, a dental oncologist, a maxillofacial prosthodontist and a speech and swallowing therapist. This ensures holistic treatment of all patients with head and neck cancer, from those with early disease to advanced cancer requiring complex surgery and those with incurable cancers requiring palliative care. The focus of treatment is not only on survivorship but rehabilitation and quality of life.

In addition to providing the highest standard of care, our prime consideration remains providing affordable care; in head and neck cancer, many advanced treatments are unfortunately considered a luxury for patients who cannot afford them. The hospital remains committed to ensuring that through charitable donations and subsidies wherever possible, the highest quality of care is offered to even those who could otherwise not afford it.

Tell us more about your clinic/hospital’s offerings and what makes it stand out in the evolving oncology segment.

Our jaw reconstruction protocol is completely innovative and was developed in-house. We are currently the only centre in India that does single-stage jaw-in-a-day procedures for cancer, where the patient receives surgery for oral cancer where the tumour is removed, the jaw is reconstructed, and the patient gets a new set of teeth in a single-stage, the wake up after surgery with a full set of teeth. With conventional treatment protocols, patients can take months or even a year, from removing jaw cancer to having an entire set of teeth.

We have become a referral centre for complex and re-doing head and neck cancer surgery. Many of the patients we operate on have had previous surgery or radiotherapy, making any additional surgery very challenging. We can operate on these patients and give them excellent results after many are turned away from other hospitals as unsuitable for surgery. We treat head and neck cancer (mouth, throat, voice box, airway, thyroid and parathyroid, salivary glands, nasal passage and skin). We also perform a good volume of skull base surgery, which refers to surgery on tumours that affect the junction of the bone lying under the brain with the nose, eyes and sinuses. This is complex surgery due to the narrow space, complex anatomy and many critical structures that pass through them. We routinely perform skull base surgeries on rare tumours with good outcomes.

We have improved surgical outcomes and reduced complication rates through modified protocols, emphasising those undergoing complex surgery (elderly patients, re-do surgeries and in complex tumours). This has allowed us to keep complication rates extremely low, in some instances at a better than global standard (perioperative mortality <0.5% in all ages and 0% in the >75-year age group, and return to theatre <5%). We are looking at replicating this success in different centres by sharing these protocols for implementation.

Tell us about the immersive benefits of varied diagnoses and treatments your clinic/hospital offers to its clients.

Head and neck cancer is a complex group of diseases that is one of the most common cancers in India, but awareness is critically low. These cancers are intrinsically curable, especially when detected early. With early detection, cure rates are high, the amount of treatment is limited, and the cost of treatment incurred is less. With oral cancer, which includes cancerous and non-cancerous tumours of the mouth, there is often a need for extensive removal of important structures that affect speech, swallowing, appearance and social interaction to cure the disease. With a good quality of reconstruction, patients can now have a normal appearance and functioning and go on to live fulfilling, productive lives. The strides made in oncology and reconstructive surgery have been immense; it is important to be aware of all the options before treatment. We offer the full range of treatment to our patients, whether it is cancer surgery, reconstruction or rehabilitation, so that they can, as far as possible, return to a pre-cancer level of functioning.

As an experienced leader, share your opinion on how adopting modern technologies like AI, ML, Cloud, and Blockchain impacts modern healthcare and how your clinic/hospital is contributing to the change.

These newer technologies need to be embraced rather than feared. There is growing concern that more automation will result in the loss of jobs and redundancy. However, it is more likely that if you don’t understand these technologies, you will be replaced by someone who does. Artificial intelligence is excellent for repetitive tasks that result in a predictable outcome, reducing redundancy and human error while not suffering from fatigue. It is unlikely that doctors will be replaced by automation soon because of the highly unpredictable and dynamic nature of clinical practice and the following ethical dilemmas.

Data analytics is also a powerful and underutilized tool; good record-keeping and analyses, even at a department level, can give you valuable insight into improving treatment, how patients in your hospital react or respond to treatment and how to evolve your practice. I enjoy working with multiple start-ups in the health-technology space, which allows me to understand better and apply them to daily practice. Currently, we are using them investigationally through research projects, but hopefully, we will implement them in routine clinical practice soon.

Considering the current medical scenario, what challenges do you face, and how do you drive your clinic/hospital to overcome them?

As the quality of medical care progresses, major hurdles remain: affordability and access to care. Medical care costs are spiralling, and the number of patients covered by health insurance or schemes remains limited in our country. Very often, accessible medical care is not adequate or affordable, so patients must travel far distances for medical care. As a charitable hospital, the major challenge is keeping costs down. We do this by remaining efficient, innovating, performing a high volume of work to maintain an economy of scale and avoiding unnecessary expenditure.

We can also follow a cross-subsidy model where patients who can afford it undergo the complex surgeries we offer and pay a higher cost so that those who otherwise could not afford treatment benefit from a subsidy. Despite this, there are still patients who cannot afford even subsidized care; we work with NGOs and charitable institutions to try to arrange treatment funding for them. This never-ending challenge will only end with country-wide universal health insurance.

What would you advise budding medical professionals aspiring to enter the oncology segment?

Oncology is a fascinating line of work evolving at an incredible speed. For most cancers, the treatment offered to patients undergoes a complete overhaul every decade or so. In the surgical field, technology has also allowed us to do more complex procedures and reduce complications; these surgeries would not have been feasible a decade ago. It is a physically and mentally demanding field but also rewarding. Your relationship with your patients is unique and will last your lifetime.

It is important to innovate in this field; learning well and reproducing is probably not enough to reach excellence. Research and scholarship are also important components; the amount of research published on cancer every year is immense, and keeping up to date is needed to ensure that your treatment is of a high standard. It is an exciting field you should pursue if you have passion for the subject and a capacity for hard work; it is a field that one lifetime is not enough to master.

How do you envision scaling your clinic/hospital’s operations and offerings in the future?

The volume and complexity of work that we do has been steadily increasing. We have recently expanded the department to address the need. Additionally, we are looking at sharing our protocols in jaw reconstruction and enhanced patient recovery to try and replicate the success that we enjoy in other centres. This will ensure that we can scale up the volume of our work while maintaining high standards and quality.