Question 1

Can a general practitioner also perform a clinical breast examination, or does it need to be a specialist?

Dr. Niti Raizada · Accepted Answer

Self-examination should be done by the woman herself, using the opposite hand on the opposite breast with three fingers held flat, including the axilla and neck. Clinical breast examination should be done by anyone properly trained, which can include nurse practitioners, physician assistants, internal medicine doctors, general surgeons, gynaecologists and oncologists. Training, not job title, is what matters, since missing lesions is common when the examiner has not been trained. GPs and internal medicine doctors should learn the technique and offer it to every woman who comes to the clinic.

Question 2

What further investigations are needed to assess disease extension before starting management of this cervical cancer case?

Dr. Niti Raizada · Accepted Answer

Once the diagnosis is confirmed by biopsy, a staging scan, often a PET scan, establishes the exact stage, including whether the bladder, rectum, parametrium or lymph nodes are involved. Fitness for treatment is then assessed with kidney function testing (GFR) and audiometry, since some chemotherapy agents can affect hearing. Weekly chemotherapy is then given alongside radiation, with the potential radiation side effects explained to the patient beforehand.

Question 3

Between MRI and CT scan, which is the better imaging modality for staging this cervical cancer case?

Dr. Niti Raizada · Accepted Answer

MRI of the pelvis is excellent for local pelvic structures, but the upper abdomen and chest still need to be assessed, which is better done on CT. The recommendation is CT of the thorax combined with CT of the abdomen and pelvis with contrast, or alternatively MRI of the abdomen and pelvis with contrast combined with a CT of the chest. The chest is generally better seen on CT, and the pelvis is generally better seen on MRI.

Question 4

I am seeing a Stage III breast cancer patient currently on filgrastim 300 micrograms for 3 days. What further treatment plan would you initiate for this patient?

Dr. Niti Raizada · Accepted Answer

Treatment depends on the patient's oestrogen receptor, progesterone receptor and HER2 status, and on whether she is receiving neoadjuvant chemotherapy followed by surgery, or surgery followed by adjuvant chemotherapy. Filgrastim is supportive care only, a white blood cell growth factor given to prevent a drop in counts after chemotherapy; it is not the primary cancer treatment. Its use depends on which chemotherapy protocol is being followed, but the treatment plan for the cancer itself is a separate, biology-driven decision.

Question 5

Can the HPV vaccine still be given to a patient who has already tested positive for HPV?

Dr. Niti Raizada · Accepted Answer

Yes. If a nine-valent vaccine is given and the patient is positive for one strain of HPV, the vaccine still confers protection against the remaining eight strains it covers.

Question 6

Are there any specific concerns in monitoring chronic liver disease, for example the frequency of ultrasound and the skill set of the radiographer?

Dr. Niti Raizada · Accepted Answer

Ultrasound should be done once every 6 months for a chronic liver disease patient, along with alpha-fetoprotein testing every 6 months. The skill of the radiographer matters because ultrasound is a subjective, operator-dependent test. If there is any doubt on ultrasound, a triple-phase CT scan or a multiphasic MRI should be done immediately.

Question 7

We had a case where a gentleman with no history of alcohol or hepatitis could not get preliminary triple-phase CT staging done. The plan was hepatectomy, but he developed a crisis from bile build-up and passed away during the consultation and visa process. How could such cases be managed by a local doctor with limited information?

Dr. Niti Raizada · Accepted Answer

The key is always the right diagnosis at the right time. Liver cancer carries a real risk of coagulopathy and bleeding, so any patient with chronic liver disease should have regular PT, PTT and INR testing. If there is any bleeding diathesis, it needs to be treated, including with vitamin K and blood products if needed. Chronic liver disease patients also commonly have low white cell counts and low platelets, so basic blood counts should be checked regularly alongside liver and kidney function tests.

Question 8

Could you recap the management of leukemia, including the case you discussed earlier?

Dr. Niti Raizada · Accepted Answer

Leukemias are broadly acute or chronic. Acute leukemias have a short history with low hemoglobin, white cell count and platelets, presenting with fever and bleeding. Chronic leukemias, chronic myeloid leukemia (CML) or chronic lymphocytic leukemia (CLL), generally occur in older age groups and are often managed with tablets alone. Acute leukemias are either AML or ALL. Genetic testing subcategorises each: CML needs confirmation of Philadelphia chromosome or BCR-ABL positivity; CLL needs a FISH panel to check p53 status and risk category; AML is categorised as good, intermediate or high risk. ALL is the most common leukemia in children and young adults and is treated with steroids followed by chemotherapy based on T-cell or B-cell type. AML M3, acute promyelocytic leukemia, is rare but very curable with ATRA or arsenic trioxide tablets; non-M3 AML needs chemotherapy.

Question 9

What comfort or guidance can you give the doctor partners here, who may not always have clarity because of diagnostic challenges? When should a case trigger further action?

Dr. Niti Raizada · Accepted Answer

Please write in with any questions, over WhatsApp or text, at any time. Many patients cannot travel to India, so the goal is to help diagnose and treat them on time wherever they are. Prepare a doctor's note with the relevant clinical details and share it; if the picture is clear, specific pointers on managing the case can be given from that.

Diagnosing Common Cancers & Blood Disorders

Questions Doctors Asked Dr. Niti Raizada