Why don’t you publish this data?” asked Dr K. Pavithran, one of the most respected medical oncologists in the state, as we walked out of the auditorium. My presentation had just ended. The data we had shown was simple, yet unsettling in its clarity. For early-stage tongue cancer, surgery alone yielded a 90 to 95 per cent survival rate. This included selected stage III patients as well, who would not usually be considered early stage. No radiation. No chemotherapy. Just complete surgical removal, clear margins and careful follow-up.
From patients to patterns
We documented every patient carefully—not only to measure outcomes, but to preserve memory. At first, they were individual stories. Then, over time, stories became patterns. And patterns became data. The numbers helped us understand what we were doing right, what we could do better, and when doing less might actually be better for a patient. In oncology, doing less takes immense discipline. Because every reduction in treatment is also a decision to trust biology, surgery and follow-up. Radiation, after all, is not a neutral addition. It carries lifelong consequences—dry mouth, difficulty swallowing, altered taste, changes in speech and sometimes long-term discomfort. So when surgery alone gives a carefully selected patient a very high chance of cure, the real question becomes: does adding radiation meaningfully improve that outcome enough to justify the impact on quality of life?
Guidelines, data and uncertainty
In recent years, staging systems and evolving guidelines had led many centres and doctors to consider radiation more readily, even in patients whose tumours had been completely removed and who had no obvious high-risk features. But our own data suggested something more restrained. In carefully selected patients, adding radiation did not appear to provide a meaningful benefit. So we chose vigilance instead. We followed our patients closely and observed a pattern: most recurrences occurred within the first 11 months. That observation shaped our practice. During the first year, patients returned every month. It was not passive observation, but active surveillance—an attempt to detect recurrence early enough to still change its course.
I had told Dr Pavithran (who died this April) that I was in the process of publishing the data. But publishing data is easier than living with what the data means. Because behind every percentage is a patient who refuses to remain a statistic.
The young lady
She was 26. Tall, graceful and quietly confident. A small cancer on the side of her tongue. Her speech was barely affected. She asked precise, intelligent questions and wanted to understand every step before deciding. Her disease was early stage, confined to the tongue. We operated. The tumour was completely removed. Margins were clear. Lymph nodes were negative. No other high-risk features. Our multidisciplinary team—surgical, radiation and medical oncology—reviewed her case. The conclusion was straightforward. No radiation. Only careful follow-up. It was a decision supported by evidence, guidelines and consensus. We explained everything to her in detail. She understood. She agreed.
When recovery looks like certainty
For several months, everything went well. Each visit felt lighter than the previous one. Her speech improved. Her confidence returned. The light in her eyes seemed brighter each time, her smile more effortless. Month after month, she came for review. And month after month, there was nothing to suggest otherwise.
The first doubt
Six months later, she said quietly: “Doctor, there is a little discomfort here.” It could have been nothing. Most such complaints are. But experience teaches you something else entirely. When you have treated someone for cancer, you learn that even small doubts deserve attention. We did an ultrasound. It looked reassuring. Two days later, she returned. “Doctor, I still feel something,” she said. So we proceeded to an MRI. I reviewed the images with Dr Julio Chacko Kandathil, our experienced radiologist. He paused at a small area on the screen. “There is a change here,” he said. Another pause. “I’m not sure what it is, but it needs to be investigated.” We needed certainty. A biopsy was done. The report came back: suspicious for cancer. The 10 percent had found her.
The second battle
Before planning treatment, we did a PET scan. There was no distant spread. The disease was still confined. But it had returned. We planned surgery again. This time, the tumour behaved differently. More aggressive. More infiltrative. Closer to major vessels. Less defined than before. We carefully removed all the tumour we could identify till there was no obvious residual disease. But the conversation had changed. This time, radiation was recommended. Proton therapy had recently become available in India. Her family asked about it. They wanted the most advanced option available. We supported their decision. They travelled. She completed treatment. And we hoped.
The return
One month later, the disease returned. Aggressive. Unrelenting. Despite surgery and radiation, it progressed. The young woman who had once walked into the clinic with quiet confidence was now losing weight, strength and time. The light in her eyes had dimmed. The smile that once defined her follow-ups had disappeared. I knew then that my voice no longer carried the assurance she once drew strength from. Her brother stayed with her throughout. He came often. And eventually, he asked the question that arrives when medicine reaches its limits: “Doctor, is there anything else we can do?” Sometimes there is. Sometimes there isn’t. This was one of those times.
The question that lingers
Months passed. Life moved forward, as it always does. Then I heard from the referring doctor. She had met the brother. “He was grateful,” she said. Then she paused. “But he still wondered if something could have been done differently.” I understood, any oncologist would. Grief does not accept finality easily. It searches for alternatives. For missed paths. For different beginnings. What if we had given radiation from the start? It is a question that has no clean answer. Because we will never know whether earlier radiation would have changed her outcome. A treatment may show no meaningful benefit at the population level, and yet we can never be certain whether the individual in front of us was the exception. We had not made the decision lightly. We had considered her pathology, our data, the available evidence and the balance between benefit and harm. We had discussed it in a multidisciplinary forum. We had explained it to her family. We had made the best decision we could with the information available at that time. She had simply fallen into the small group that develops recurrence—an outcome that science still struggles to predict with precision. We could not identify her in advance from the much larger group who would remain disease-free. That is the space where oncology lives. Between certainty and uncertainty. Between population and person. We know probabilities. We do not know outcomes.
The burden of doing less
It is often easier to do more. More surgery. More radiation. More chemotherapy. Because if the disease returns, there is always a sentence ready: “We did everything.” But medicine is not measured by how much is done. Doing more and doing right need not be the same. Sometimes, restraint is the harder and more honest choice. Sometimes, doing less is the most difficult form of care. Because it requires accepting that even the best decision cannot protect every patient. There will always be the small group. The unexpected course. The exception that breaks the pattern or sets the pointer towards a pattern hitherto unearthed.
The problem with percentages
Oncology speaks in numbers. Ninety-five per cent survival. Five percent recurrence. Ninety per cent cure. Ten per cent failure. These numbers are essential. They guide research, shape guidelines and move medicine forward. But patients do not live inside percentages. A small percentage in a dataset is an entire world to a family. A life that cannot be reduced to a decimal point. To those who experience the outcome, statistics offer structure, but not comfort.
The 10 per cent
I still think about her. Not because the decision was necessarily wrong. But because it was real. Science asks us to think in populations, while doctors treat individuals. We follow evidence, interpret numbers, balance benefit against harm. Our data may help many future patients avoid unnecessary treatment. It may spare them long-term side effects. It may help refine who truly benefits from additional therapy. That is the reason why we document every patient, question our decisions, look for patterns and publish. So that our learning outlives our memory. But memory is a double-edged being. There will always be patients who do not follow the expected path. The ones who fail treatment. The ones who become exceptions. The guidelines remain. The statistics remain. But how is it that the 90 per cent survival rates remain as numbers to present while the 10 per cent has faces that do not fade? A sister to her brother, daughter to her parents, mother to her child. And a doctor who is not blessed with forgetfulness. The small, silent 10 per cent still burns there.
“Who said numbers do not have faces?”
