Breast Cancer Diagnosis, Staging and Molecular Workup

A non-healing mouth ulcer of 15-20 days in a smoker warrants a biopsy for oral cancer. A voice change over six weeks or dysphagia should raise suspicion. A cough not responding to 4-5 weeks of anti-tuberculosis treatment needs a chest X-ray. Early satiety, feeling full after a much smaller meal than usual, is a classic warning sign for stomach cancer. Unexplained weight loss or easy fatiguability should raise suspicion of pancreatic or liver cancer, and every jaundice patient should get at least an ultrasound rather than being assumed to have hepatitis. A change in bowel habit should prompt investigation for colorectal cancer, and around 30% of bleeding per rectum, usually assumed to be piles, is actually cancer. A painless testicular swelling should not be assumed to be a hydrocele without an ultrasound, and an enlarging soft tissue lump assumed to be a lipoma should get an FNAC to rule out sarcoma.

Complete staging first, chest X-ray, abdominal ultrasound and a skeletal survey or bone scan, to know whether there is metastasis. If there is no distant metastasis and ER/PR is positive, go for surgery, but because this is periareolar, central-quadrant disease, mastectomy with axillary clearance is the better option over breast conservation, even if the rest of the breast looks normal on mammography. If metastasis is found instead, start with chemotherapy.

There are three common causes. Duct papilloma is the most common, a benign lesion that can sometimes transform into papillary carcinoma; ultrasound will show the ducts, and if a papilloma is found, a microdochectomy (removal of the duct under image guidance) is done and sent for histopathology. Invasive ductal carcinoma itself is the second cause; around 10% of breast cancer patients present with nipple discharge, sometimes without any lump. The third is duct ectasia, seen in perimenopausal women around 45-57 years old, usually with brownish discharge, treated the same way with a microdochectomy.

The same operation done as open surgery might mean about ten days of recovery, while a robotic approach can have a patient back to work in three or four days, with less pain and lower rates of bleeding and infection, even when the cure rate is comparable. Where next-generation gene sequencing is available, a lung adenocarcinoma patient can sometimes be managed with a single daily tablet instead of radiation, chemotherapy or surgery. For complex cases with no standard guideline, such as a pregnant patient with ovarian cancer, a full multidisciplinary tumour board, pathologist, radiologist, surgical oncologist, medical oncologist, radiation oncologist and social worker, arrives at a genuinely joint decision rather than each specialist pushing their own preferred treatment.

BLK-Max runs fellowships in surgical oncology across sub-specialties, including head and neck, breast, GI and gynaecological oncology. A fellowship candidate must be a postgraduate in that particular discipline, but not necessarily a surgeon. An MBBS doctor without a postgraduate qualification cannot come as a fellow, but can come as an observer for one or two months and rotate through the various departments of oncology to get a basic understanding of case management.

With a triple test: clinical examination, imaging (mammography after age 40, ultrasound before 40), and a Tru-cut biopsy, with MRI reserved for radiologically unclear cases.

Around 15 to 20 percent of breast cancer cases are triple negative (ER, PR and HER2 all negative), and these are generally treated with neoadjuvant chemotherapy first, followed by surgery and radiation.