Recent Trends in Surgical Oncology

Diagnosing cancer early, at stage 1 or 2, translates into cure; stage 4 offers very minimal chances of cure for any cancer. Where facilities and education are limited, the solution has three parts: awareness, awareness, and awareness, among doctors, the public and government. Over almost 30 years of practice, running thousands of community cancer-awareness camps across India, Nepal, Bhutan and Bangladesh with NGO partners has produced a real shift: around 1997, 75-80% of patients presented in stage 3 or 4; today in metropolitan India, around 60% present at an early stage.

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.

Breast cancer diagnosis, staging and treatment, surgical decision-making, cancer staging alternatives when PET-CT is unavailable, organ-by-organ red flag symptoms for early detection, two real patient case discussions, multidisciplinary cancer care, circulating tumour DNA, personalised and immune-based treatment, and fellowship training opportunities.

Principal Director, Surgical Oncology at BLK-Max Cancer Centre, New Delhi, with 29.5 years of practice across breast, head and neck, thoracic, gastrointestinal, urogenital, gynaecological, soft tissue and bone cancers.