Cancer Detection to Recovery

Modern cancer care runs from detection to recovery along one disciplined pathway: recognise the warning signs early, confirm the diagnosis on tissue rather than on scans alone, stage the disease, and let a multidisciplinary team choose between surgery, chemotherapy, radiation and the newer targeted and immune therapies. Each step decides how well the next one can be done.

Dr. Nithin S.G, Consultant, Medical Oncology, Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj, New Delhi, India, set out this pathway for international doctors in a Jivo Masterclass titled "From Detection to Recovery: Navigating the Future of Cancer Care". His argument was practical rather than theoretical: much depends on the first two steps, noticing that a patient may have cancer, and handling the diagnostic work-up so that the patient arrives at an oncologist with usable tissue and a clear picture of the disease.

This guide covers the whole arc. Three companion articles go deeper: the warning signs of cancer by type, how cancer is diagnosed with blood tests, imaging, biopsy and tumour markers, and precision oncology, targeted therapy and immunotherapy.

How common is cancer worldwide?

Cancer incidence is rising across the world. Around 20 million people are diagnosed with cancer each year and close to 10 million die of it, according to the International Agency for Research on Cancer's GLOBOCAN 2022 estimates. Dr. Nithin described cancer as becoming a new epidemic, and noted that research is steadily improving both care and cure while many parts of the world still lack adequate treatment.

The five most common cancers differ by sex:

• Men: lung, prostate, colorectal, stomach and liver cancer.
• Women: breast, lung, colorectal, cervical and thyroid cancer.

For a general practitioner, the list is a working prior. A persistent cough in a former smoker, urinary symptoms in an older man, a breast lump or post-coital bleeding in a woman: these are the presentations that should prompt the question of cancer first, not last.

What a medical oncologist does

Oncology is not a single discipline. Dr. Nithin is a medical oncologist, and he drew the distinction carefully: a medical oncologist treats cancer with medicines, whether given as an injection, an infusion or a tablet. Surgery and radiation belong to separate branches.

A full cancer service brings together several of these subspecialties:

• Medical oncology: chemotherapy, targeted therapy, immunotherapy and hormonal therapy.
• Radiation oncology: planning and delivering radiotherapy.
• Surgical oncology: cancer operations.
• Interventional radiology: image-guided biopsies and other image-guided procedures.
• Onco-anaesthesia: anaesthesia and perioperative care for cancer surgery.
• Molecular oncology: genetic testing of the tumour that underpins precision treatment.

Dr. Nithin singled out molecular oncology as one of the newest and most important of these, because it has changed how treatment is chosen.

The pathway from detection to recovery

The pathway Dr. Nithin walked through can be summarised in five stages. Each is covered in more depth in the companion articles.

1. Suspect. Recognise the symptom patterns of common cancers, using the CAUTION mnemonic (seven classic warning signs) and organ-specific red flags, and take seriously the two general symptoms most cancers share: loss of appetite and significant weight loss with fatigue.
2. Examine and screen. Examine the patient fully, including the neck and armpits for enlarged lymph nodes and the mouth for ulcers, and order basic blood tests.
3. Image. Choose the right scan: contrast-enhanced CT for most cancers, MRI for specific sites, PET-CT, a whole-body scan that shows metabolically active disease, for staging.
4. Confirm on tissue. Obtain a proper biopsy, not a fine-needle aspiration, so the pathologist can type the cancer and the laboratory can test its genes.
5. Stage and treat. Establish the extent of disease, then decide treatment as a team.

The detail matters at every step. A biopsy taken badly, or a tissue block exhausted on unnecessary stains, can delay or block the molecular testing that now decides treatment in many cancers.

Staging: why it decides the treatment plan

Once cancer is confirmed, scans establish its stage. Staging answers one question: how far has the cancer spread?

In broad terms, which apply across most solid tumours:

• Stage I and II: the cancer is confined to its organ of origin, or has spread only a limited distance locally.
• Stage III: the cancer has spread more extensively into nearby tissues or regional lymph nodes.
• Stage IV: the cancer has spread to distant organs. This is metastatic disease.

Each cancer has its own detailed staging system, but the principle is consistent. Dr. Nithin's message to referring doctors was that stage I, II and III disease in almost all cancers is usually curable with surgery, chemotherapy and radiation, while stage IV disease is difficult to treat. Stage at diagnosis is therefore a major lever a primary-care doctor can pull, and it is pulled at the first consultation.

Conventional treatment: surgery, chemotherapy and radiation

The three established pillars of cancer treatment are surgery, chemotherapy and radiotherapy. How they are sequenced depends on stage.

• Stage I and II: for most cancers, surgery comes first, followed by chemotherapy where it is needed.
• Stage III and early stage IV: chemotherapy is given first to shrink the cancer, making the operation that follows easier.
• Radiation to prevent recurrence: in rectal, breast and head and neck cancers in particular, radiation therapy is used to reduce the risk of the cancer coming back.

Why chemotherapy causes side effects

Chemotherapy works on rapidly dividing cells, and cancer cells divide rapidly. So do several healthy tissues: the bone marrow precursors of red cells, white cells and platelets, the lining of the mouth and intestine, hair follicles and skin. Chemotherapy cannot tell them apart, which is why it causes hair loss, vomiting, mouth ulcers, diarrhoea and falls in haemoglobin and white cell counts.

This mechanism explains why the newer therapies matter. Targeted therapy and immunotherapy are, in Dr. Nithin's words, simpler forms of treatment with fewer side effects and very good response rates. The companion article on precision oncology explains how they work and shows the patient outcomes he presented.

Precision oncology: how genetic testing changes treatment

Precision oncology chooses treatment by the genetic make-up of the individual tumour rather than by its organ alone. A decade ago, ten patients with lung cancer would all receive broadly the same chemotherapy, surgery and radiotherapy. Today, each patient's biopsy is sent for genetic testing, usually next-generation sequencing (NGS), which reads many cancer genes at once. If the cancer carries a mutation for which a targeted drug exists, the patient receives that drug instead of chemotherapy. Patients with the same cancer can therefore receive different treatments. Dr. Nithin's examples included patients with metastatic lung and breast cancer who were living well years later on targeted therapy.

Why multidisciplinary cancer care matters

The best results in cancer treatment, Dr. Nithin said, come from collaboration. When medical, radiation and surgical oncologists discuss a patient together and reach a joint conclusion, outcomes are better than when any one specialty acts alone.

His practical advice follows from that: whenever a patient is diagnosed with cancer, refer them to an oncologist, and preferably to an institution where all the oncology specialties work under one roof. The tumour board, the meeting where these specialists review each case together, is how that collaboration is organised in most cancer centres.

Cancer follow-up after treatment

Recovery does not end with the last treatment cycle. Follow-up aims to detect recurrence early. Two tools from the masterclass play a role here:

• Tumour markers. These are proteins some cancers release into the blood. Where a marker was raised at diagnosis, a fall to normal shows response, and repeating the test every three to six months during follow-up helps detect a return of the cancer.
• Liquid biopsy. Dr. Nithin uses blood tests that detect circulating tumour cells and tumour DNA to look for residual disease after treatment and to estimate the risk of recurrence. For most cancers, this use is still being evaluated in clinical trials.

Both are explained in the companion articles on diagnosis and precision oncology.

Three requests to referring doctors

Dr. Nithin closed with three requests to the doctors who see patients first.

1. Biopsy, not FNAC. Whenever cancer is suspected, obtain a biopsy rather than a fine-needle aspiration cytology (FNAC). Immunohistochemistry (IHC), staining the tissue for specific proteins, is needed to confirm the diagnosis, and FNAC rarely yields enough material for it.
2. Order the minimum IHC markers. Every additional stain uses up part of the tissue block. The remaining tissue is needed for genetic analysis by NGS, which decides whether a targeted therapy is possible. An exhausted block can mean a repeat biopsy, or a lost treatment option.
3. Coordinate with an oncologist before starting any treatment. Treatment begun without oncology input can close off better options.

His closing assessment was optimistic. Oncology is evolving quickly, new targeted treatments keep arriving, and in his view the future of cancer care is very bright.

The questions doctors raised at the end of the session, on breast imaging, testicular swellings, PSA, biopsy technique and targeted therapy in frail patients, are collected on the Live Discussion page for this masterclass. For other cancer topics, see the oncology specialty hub.