the cutting edge: dr. dheerendra prasad

In October of 1989, the World Federation of Neurosurgical Societies held its quadrennial World Congress of Neurosurgery in New Delhi, India. The events of the Congress were centered in New Delhi with satellite symposiums held throughout the region, including in Srinagar–the largest city in Indian-administered Jammu and Kashmir. In 1989, Srinagar was at the center of much unrest as separatists protested Indian administration of the Kashmir Valley and fought over where control should fall. 

As protests raged in one corner of Srinagar, in another corner, outside a quiet auditorium situated on Dal Lake, neurosurgeons, academics, and medical students waited for a symposium on acoustic neuromas–a type of benign brain tumor–to begin. 

Among that crowd, one Dheerendra Prasad, just shy of completing his neurosurgery training, stood at the edge of Dal Lake, listening to the sounds of protests, of people demanding one future or another. That was a chaos easier to hear than to understand or to accept, he thought. 

Inside the auditorium a few moments later, Prasad settled into his seat and listened as Dr. Ladislau Steiner discussed findings from the clinical application of a technology he’d been working to advance for two decades–the Gamma Knife, a tool developed in Sweden that could target and eliminate brain tumors like acoustic neuromas with extreme precision for improved patient outcomes.

Here was something Prasad could understand–data, science, technology applied in medicine for the betterment of people’s medical prognoses and lives. Inspired, he decided that this would be his future; he wrote a letter to Dr. Steiner at the University of Virginia, expressing his interest in becoming a fellow upon completion of his residency in India.

This would mark the beginning of a now 35-year career in neurosurgery that has seen Dr. Dheerendra Prasad become one of the world’s top experts in Gamma Knife radiosurgery, leading the Gamma Knife program at Buffalo, New York’s Roswell Park Comprehensive Cancer Center and supporting the development of similar programs in hospitals across the world.

When I ask Dr. Prasad who he was as a child, he conjures the image of his eight-year-old self, a “nerd” in “thick, horn-rimmed spectacles,” spending his spare time in the library rather than on the sports field, emulating his academic father, a professor of agricultural sciences in New Delhi where Prasad was born, raised, and educated. 

“My memories, even of early grade school, are of getting up at four or five in the morning and studying,” Prasad says, “because that’s what my father was doing. He’d be at his desk, and as a kid I wanted my own desk, I wanted my own books to study.”

When he completed high school, Prasad opted to pursue medicine, attending the All India Institute of Medical Sciences for both his general medical degree and then for his advanced degree
in neurosurgery.

After his residency in New Delhi, Prasad moved to Charlottesville, Virginia, where he completed his fellowship under Dr. Steiner followed by another residency–in radiation oncology–at the University of Virginia.

In 2005, he was recruited to direct the Gamma Knife radiosurgery program at Roswell Park, where he has continued to lead ever since.

Dr. Prasad’s story is inextricably tied to the stories of two neurosurgeons who practiced before him: Ladislau Steiner–Prasad’s inspiration, mentor, and collaborator–and Lars Leksell, the inventor of the Gamma Knife and radiosurgery. 

The first Gamma Knife radiosurgery was performed in Stockholm, Sweden, in 1968, after years of Leksell’s honing of the concept. His initial vision for the Gamma Knife was motivated by a desire to add a tool to the neurosurgeon’s box that would enable a radically precise method of treating diseases of the brain while preserving patient quality of life. 

“He was always tinkering,” Dr. Prasad tells me of Leksell. “And there’s something to be said about tinkering in medicine–I think all innovation comes from people who want to change just a little something, and the journey in radiosurgery has really been one of tinkering around the edges of what’s acceptable, both with technology and ideas.”

Indeed, the idea was not initially accepted by members of the neurosurgical community, many of whom saw the concept of radiosurgery as a threat to operative surgery–a non-invasive replacement for the scalpel.

Nevertheless, Leksell, known for his highly technical approach to medicine, took his vision from concept to reality, and he did it well–today’s Gamma Knife devices, at their core, are not so different from the one Leksell debuted in 1968. 

“It’s a very straightforward tool,” Dr. Prasad explains. “Amazingly simple. And that was Leksell through and through–he always wanted it to be a clinician’s tool, simple to use, little room for error.”

The Gamma Knife is a device that guides a high dose of focused radiation onto a target in the brain–a tumor, say–with extreme precision. Unlike operative brain surgery, there are no incisions involved in Gamma Knife surgery. And unlike conventional radiation therapy, radiosurgery doesn’t touch healthy tissue and fibers with radiation. 

It’s a treatment option that can deliver results without compromising a patient’s post-operative quality of life. 

While Leksell’s genius in prioritizing simplicity in its design has meant that the technology at the Gamma Knife’s core has remained intact, the device and radiosurgery itself have certainly undergone an evolution since 1968.  

First and foremost, the clinical applications for Gamma Knife radiosurgery have expanded significantly since its introduction. Leksell originally sought to treat nerve disorders and pain with Gamma Knife surgery, as well as noncancerous tumors like acoustic neuromas. 

But today, Gamma Knife radiosurgery has a well-defined role in cancer treatment. At Roswell Park and at cancer centers around the world, physicians treat cancerous tumors deep inside the brain with minimal side effects, allowing patients to resume their lives after treatment, often without the cognitive and physical impairments one might expect following an operative brain surgery or conventional radiation treatment. 

“More and more as we win the cancer battle, quality of life preservation becomes the most important,” Dr. Prasad says. “In the past, if a cancer metastasized into the brain, it was considered to mean poor prognosis, deficits in quality of life. That narrative is being rewritten with radiosurgery.”

Today, a typical work day for Dr. Prasad begins early in the morning. He and his staff plan and execute between four and seven Gamma Knife radiosurgeries every day, treating patients with a variety of cancers and other brain disorders. 

Throughout the day, he’s also carrying out other responsibilities as a leader, a teacher, and a physician, guiding residents through clinical cases, seeing new and longtime patients in his outpatient clinics, consulting with other providers on treatment plans, tending to administrative duties, and giving lectures to medical students. 

“But, the best part of my day is the least planned part,” Prasad tells me. “And that is my pager going off, or my cell phone going off.”

These are the moments where he can exercise his mind, when he receives a call from a colleague–sometimes from another hospital in Western New York, other times from across the world–asking for help in solving a problem. Perhaps a radiologist wants a recommendation based on their patient’s imaging; maybe a Gamma Knife operator needs guidance on a particular case or a fellow physician wants to refer a patient. 

Whatever the call, Dr. Prasad takes these opportunities to apply his medical expertise and his technical sensibility. Like Lars Leksell was, Prasad is at his most motivated when he has the chance to be both a caretaker and an engineer.

“In some ways, I’ve always been an engineer at heart, but I chose to go to medical school,” Prasad says. “Of course I gravitated toward neurosurgery, which is technically very involved. Radiosurgery and oncology now add physics into the mix. I think the reason I’ve loved and really narrowed my interest around what I do is because it combines both those passions–that technical way of thinking with the ability to look after patients.”

Perhaps Dr. Prasad–a self-described “nerd” since childhood, naturally drawn to the most mathematical specialties as a medical student–was always destined to land where he has, at the top of his field, a leading expert in Gamma Knife radiosurgery.

Whether it was fate or circumstance that led him here, Prasad’s story has taken him from the edge of Dal Lake, contemplating the uncertainty of a chaotic world, to the cutting edge of medical science, where every day he helps to bring certainty into the lives of his patients and colleagues.

in print photo by mark dellas