Diagnosing Common Cancers and Blood Disorders: Red Flags

Diagnosing common cancers and blood disorders early rests on four things: recognising the red flag, ordering the basic test that confirms suspicion, getting tissue before treatment, and staging before any decision. Dr. Niti Raizada, Principal Director Medical Oncology, Fortis Hospital, Bannerghatta Road, Bengaluru, India, taught this sequence through eight patient cases, from breast cancer in a young woman to a leukaemia that kills within days if missed.

Her starting premise is blunt. More than half of all cancers are curable, and every cancer can receive some treatment, whether to extend life or to control symptoms and protect quality of life. What separates the patient who survives from the one who does not is usually time. "Time is the key," she told the doctors on the session, many of them practising in Africa and seeing these patients first.

Why the time to diagnosis decides the outcome

A cancer diagnosed at the right time and treated correctly carries a significant chance of cure. The same cancer found late often does not. Dr. Raizada's cases make the point repeatedly: a lung cancer treated for two months as tuberculosis, a cervical cancer in a woman who had not been screened regularly, a leukaemia whose first signs were bruised arms and bleeding gums.

Her view is that the reported numbers understate the problem. She described cancer statistics from Africa as the tip of the iceberg: the figures capture only the small share of patients who reach medical attention and take treatment. Finding the rest, wherever possible, and treating them correctly is the challenge she set for every doctor on the call.

How a multidisciplinary tumour board plans treatment

At Dr. Raizada's comprehensive cancer centre, no treatment plan is made by one specialist. Every patient is discussed at a multidisciplinary tumour board, a meeting of medical oncologists, surgical oncologists, radiation oncologists, an oncopathologist and an oncoradiologist. Together they decide whether the patient needs surgery, chemotherapy or radiotherapy, and in what order.

The sequence matters as much as the treatments themselves. In her breast cancer case, the first step was chemotherapy rather than surgery. In her ovarian cancer case, the extent of disease in the abdomen made upfront surgery difficult, so chemotherapy came first and surgery followed.

Cancer red flags and confirming tests: eight cases

Each case in the masterclass was a routine presentation that a general practitioner, gynaecologist or physician could meet in any clinic. The table summarises the red flag that should have triggered suspicion and the test that settled the diagnosis.

The detail behind each case is covered in three companion articles: the diagnostic workup for breast, ovarian and cervical cancer, diagnostic red flags for lung, colon, liver and oral cancer, and acute promyelocytic leukaemia and the basic blood panel.

Diagnosing common cancers and blood disorders: six principles

Across the eight cases, Dr. Raizada returned to the same six rules.

1. A persistent, unexplained symptom earns a test. Fatigue, a cough that does not settle, a lump that grows or an ulcer that does not heal is a signal, not background noise.
2. The basic blood panel comes before the scan. A complete blood count, liver function tests and kidney function tests, with a clotting profile where there is bleeding, give quite a few clues.
3. Family history changes the probability. Several relatives with related cancers on one side of the family, particularly at a young age, point towards an inherited syndrome.
4. Failure of the first treatment is itself a red flag. A presumed infection that does not respond to adequate treatment needs to be re-examined.
5. Tissue is the final word. Whether the question is tuberculosis or cancer, the diagnosis rests on a good biopsy, and the biopsy also carries the molecular information that now shapes treatment.
6. Stage before you treat. Imaging defines how far the disease has spread, which in turn decides between surgery, chemotherapy, radiotherapy or a combination.

The most common and most lethal cancers, worldwide and in Africa

Dr. Raizada set her cases against the global picture. Across both sexes combined, lung cancer is the most common cancer worldwide, followed by breast cancer, colorectal cancer, prostate cancer and stomach cancer. The ranking by deaths is different: lung cancer causes the most cancer deaths, followed by colorectal cancer and liver cancer. Breast cancer falls to fourth place on the mortality list because it is so often curable.

Africa's pattern is distinct. Across both sexes, the three cancers causing the most deaths in Africa are breast cancer, cervical cancer and liver cancer, so cancers affecting women dominate. Among men, prostate cancer has the highest mortality, followed by liver and lung cancer. Patients dying of breast cancer, a curable cancer, is not acceptable, she said, and changing that depends on finding patients and treating them on time.

Cancer screening schedules by age

Dr. Raizada's screening schedules for standard-risk adults cover breast, lung, colorectal and cervical cancer, liver cancer surveillance in chronic liver disease and monthly oral self-examination; ovarian cancer has no screening test. Anyone with a strong family history or a personal history of cancer should see an oncologist, who decides whether they fall into a high-risk category that needs additional tests such as breast MRI or a blood test for inherited mutations.

Breast cancer screening by age

• From 18: breast self-examination once a month, using the flat of three fingers of the opposite hand, and including the armpit and the neck.
• From 30: a clinical breast examination every six months by a trained professional.
• From 40: a mammogram once a year.

Asked whether a general practitioner can perform the clinical examination, Dr. Raizada was clear: training is what matters, and any trained medical professional can do it. In India, the mandate is to train nurse practitioners, physician assistants, internal medicine doctors, general surgeons, gynaecologists and oncologists to examine the breast, because lesions are so often missed. Her advice to clinics is to offer every woman who attends a breast examination (a nurse can perform it where a patient prefers), to order an ultrasound immediately if there is any doubt, and to add a screening mammogram in women over 40.

Lung cancer screening for smokers

Dr. Raizada uses criteria extrapolated from the US Preventive Services Task Force. Adults aged 50 to 80 with a smoking history of at least 20 pack-years, who still smoke or have smoked within the past 15 years, should be offered a low-dose CT scan of the chest once a year.

Colorectal cancer screening from 45

From age 45, a stool test for hidden blood (the faecal occult blood test) once a year. She described it as extremely cheap and extremely useful. Where screening colonoscopy is part of national guidelines, the alternatives from 45 are a colonoscopy every ten years or a sigmoidoscopy every five years.

Cervical cancer screening from 21 to 65

• Ages 21 to 29: a Pap smear every three years.
• Ages 30 to 65: a Pap smear plus HPV testing every five years.

Vaccination does not replace screening. A woman who has received the HPV vaccine still needs her Pap smears. Dr. Punyashree R M's article on cervical cancer screening and HPV vaccination covers the programme from a gynaecological oncology perspective.

Ovarian cancer: no screening test

There is currently no screening recommendation for ovarian cancer in the general population. Where there is a very strong family history, Dr. Raizada recommends a transvaginal ultrasound together with a CA 125 blood test.

Liver cancer surveillance in chronic liver disease

Every patient with cirrhosis, and selected patients with chronic hepatitis B without cirrhosis, needs surveillance every six months with an ultrasound and an alpha-fetoprotein test. The six-month interval matters because a cancer can appear between scans, which is known as an interval cancer.

Oral cancer self-examination

Once a month, standing in front of a mirror with light on the face, everyone should look at the tongue, the cheeks, the soft and hard palate, the lips and the inside of the lips, and feel the neck for lumps. Any red patch, white patch or thickened patch needs clinical attention.

Two vaccines that prevent cancer: hepatitis B and HPV

Dr. Raizada credits two vaccines with changing the landscape of cancer: hepatitis B vaccination, which prevents chronic hepatitis B infection, a leading cause of liver cancer, and HPV vaccination.

Human papillomavirus (HPV) causes cervical, vaginal and vulval cancer in women, penile cancer in men, anal cancer in both sexes, and head and neck cancers including oropharyngeal cancer. Vaccination prevents the infection and therefore these cancers.

Her recommended schedule, for girls and boys from age 9:

This matches the licensed schedules of the main vaccines. Since 2022 the World Health Organization has also endorsed a single-dose schedule for girls and young women aged 9 to 20, an option national programmes increasingly use.

Vaccines come in bivalent, quadrivalent and nine-valent (nonavalent) forms. HPV types 16 and 18 are the most important, and all three cover them. She noted that the nine-valent vaccine is the most expensive and the quadrivalent the most commonly used, and that an indigenously developed vaccine has brought the cost down in India.

A positive HPV test is not a reason to withhold vaccination. Dr. Raizada offers it to patients who already test positive, because a nine-valent vaccine still protects against the eight strains the patient does not carry.

Support for the referring doctor who sees the patient first

Many of Dr. Raizada's patients reach her through general practitioners and internal medicine doctors who noticed something was wrong. Her colon cancer case began with a general practitioner who took a careful family history and ordered a basic blood test; that single decision led to a diagnosis while the disease was still curable by surgery alone.

Her message to referring doctors was practical. Quite a few patients cannot travel for treatment, so the aim is for them to be diagnosed and treated on time wherever they are. She invited doctors to send her their queries directly, because the job, as she put it, is to make sure patients are safe and diagnosed on time. The questions doctors raised during the session, from breast examination by general practitioners to monitoring chronic liver disease, are collected in the masterclass Live Discussion, and her background is on Dr. Niti Raizada's profile.

For a broader view of how cancer is detected, diagnosed and treated, Dr. Nithin S.G.'s guide to cancer from detection to recovery complements this case-based approach. More on cancer care across specialties is on the oncology hub, and on leukaemia and other blood disorders on the haematology hub.