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

Yes, if they are trained. Self-examination should be done by every woman herself: using the opposite hand on the opposite breast, with three fingers held flat, and including the axilla and the neck. Clinical breast examination is always done by trained people. In our country we train nurse practitioners, physician assistants, internal medicine doctors, general surgeons, gynaecologists and oncologists, because missing these lesions is very common. If there is any doubt, an ultrasound should be done immediately, and over the age of 40 a screening mammogram is recommended. Any woman who comes to your clinic should be offered a breast examination; if a male doctor is examining and the patient prefers, a nurse can do it. All GPs and internal medicine doctors should learn how to do it, and do it for all women.

Question 2

Before starting management of this cervical cancer case, what further investigations are needed to assess the extent of disease?

Dr. Niti Raizada · Accepted Answer

First the diagnosis is made with a biopsy. Then a staging scan is done, which in our country is often a PET scan, to show the extent: whether the disease involves the bladder, rectum or parametrium, and whether the lymph nodes are involved. Once the exact stage is confirmed, we check whether the patient is fit for chemotherapy, with kidney function tests including a GFR study (a functional kidney scan) and audiometry to check hearing. Then weekly chemotherapy is given along with radiation, and the patient is informed beforehand that radiation can sometimes cause temporary side effects. So the sequence is biopsy, staging scan, a pre-chemotherapy workup to make sure the treatment will be safe, and then treatment.

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 a very good modality, and pelvic structures are very well seen on MRI, but we also need to assess the upper abdomen and the chest. The recommendation is MRI of the abdomen and pelvis with contrast plus a CT of the chest with contrast, or a CT of the thorax with CT of the abdomen and pelvis with contrast. The chest is always better seen on CT, and the pelvis is 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

I do not know what treatment plan is being followed, but treatment depends on the oestrogen receptor, progesterone receptor and HER2 status, and on whether the patient is having systemic chemotherapy first followed by surgery, or surgery followed by chemotherapy. Filgrastim is only a supportive care injection, not the main treatment. It is a white blood cell growth factor: it is given from the start with chemotherapy regimens that carry a high risk of low counts, or, if a patient's white cell counts have dropped once, as secondary prophylaxis so that it does not happen again. How it is used depends on the protocol, but the primary treatment is a separate decision. If you share the current treatment protocol, more specific guidance can be given.

Question 5

Are alpha-fetoprotein and imaging together enough to diagnose hepatocellular carcinoma, and what then decides treatment?

Dr. Niti Raizada · Accepted Answer

The red flags are a background of chronic liver disease (hepatitis B or C, alcoholic liver disease or non-alcoholic steatohepatitis), a space-occupying lesion in the liver, and a high alpha-fetoprotein. In a cirrhotic liver, a lesion that shows the typical pattern on a triple-phase CT, enhancing in the arterial phase and washing out later, together with an alpha-fetoprotein above 400, confirms liver cancer without a biopsy. But the disease then has to be staged on tumour size, number of lesions, vascular invasion and liver function before deciding treatment: local ablative therapy, surgical resection, or, for liver-limited disease within transplant criteria and not amenable to resection, liver transplant. If there is any vascular involvement, the patient is not a candidate for local therapy and systemic therapy has to be given. And yes, the Child-Pugh score decides treatment.

Question 6

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 9-valent vaccine is given and the patient is positive for one strain of human papillomavirus, the vaccine still confers protection against the remaining eight strains. So we offer HPV vaccination even to patients who are positive on HPV testing.

Question 7

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 offered to a chronic liver disease patient once every 6 months, along with alpha-fetoprotein once every 6 months. The skill of the radiographer is very important, because ultrasound is a subjective, operator-dependent test, and if the skill set is not good we may get into trouble. If there is any doubt, a triple-phase CT scan, or a multiphasic MRI or CT, should be done immediately.

Question 8

In one of our cases, a man underwent workup for a liver lesion, but triple-phase CT staging was not possible. The opinion was liver resection, but he developed a crisis from bile build-up and died during the consultation and visa process. How could a local doctor manage such cases?

Dr. Niti Raizada · Accepted Answer

The key is always the right diagnosis at the right time; that is why we discuss the red flag signs. Remember that liver cancer comes with coagulopathy, so the risk of bleeding is very high. In any patient with chronic liver disease, not just cancer, we always have to check PT, PTT and INR, and if there is any bleeding diathesis we have to treat it, with vitamin K and, if needed, blood products, so that the patient does not bleed. A chronic liver disease patient will also have low white cells and low platelets, so basic blood counts and PT, PTT and INR are recommended on a regular basis.

Question 9

Symptoms like those in the leukaemia case can easily go unnoticed: a patient may feel tired or low, or put bleeding gums down to brushing too hard. How should doctors and patients handle this?

Dr. Niti Raizada · Accepted Answer

If there is any doubt, do basic blood tests. When a patient comes with persistent symptoms that have not been explained, always ask for a CBC (haemoglobin, white cell count, platelets), and often for liver and kidney function tests. These three, CBC, LFT and RFT, give quite a few clues; if they are abnormal, we know something significant is happening and we become more alert. If there is any bleeding diathesis, add PT, PTT and INR. A low haemoglobin, a high bilirubin, deranged kidney function or deranged sodium or potassium all need attention. Instead of jumping to scans, start with a basic blood panel and take it from there. Doing just this can prevent many tragedies.

Question 10

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

Dr. Niti Raizada · Accepted Answer

Leukaemias are broadly acute or chronic. Acute leukaemias have a short history with low haemoglobin and platelets and a white cell count that may be high or low, presenting with fever and bleeding. Chronic leukaemias, chronic myeloid leukaemia (CML) or chronic lymphocytic leukaemia (CLL), generally occur in older age groups and are often managed with tablets alone. Acute leukaemias 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 leukaemia 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 leukaemia, is rare but very curable with ATRA or arsenic trioxide tablets; non-M3 AML needs chemotherapy.

Question 11

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 to me if there is anything: WhatsApp me or text us with any queries. Quite a few patients cannot travel to India, so the intent is that you diagnose and treat them on time where they are. Our job is to make sure that patients are safe and diagnosed on time, so please ask questions whenever there is anything.

Live Discussion with Dr. Niti Raizada