Question 1

PET CT is not available in many countries. What alternatives can doctors use for initial staging before referring a case?

Dr. Rajesh Kumar Jain · Accepted Answer

For a very early case, a small lesion with no palpable nodes, a chest X-ray and an abdominal ultrasound are sufficient for staging. If the lesion is larger than 2 cm or nodes are palpable, the status of the bones must also be known, which traditionally meant a technetium radionuclide bone scan; PET CT has now largely replaced it. Where PET CT is not available, staging can be attempted with a CT scan of the chest and abdomen and a skeletal survey (multiple X-rays of multiple bones), but this is not optimal. In those cases, if a PET scan cannot be done locally, the case can be referred for evaluation with PET CT.

Question 2

Is it possible to start chemotherapy in the home country before sending a patient for further evaluation and management?

Dr. Rajesh Kumar Jain · Accepted Answer

Chemotherapy given first is neoadjuvant chemotherapy. In breast cancer it is indicated in two situations: triple-negative breast cancer, and locally advanced disease, meaning a tumour larger than 5 cm (T3) at presentation, ulceration, peau d'orange, satellite nodules, bulky axillary nodes or a palpable supraclavicular node. In locally advanced disease, surgery follows after around four to four and a half months of chemotherapy. In advanced or metastatic disease, treatment is systemic only, chemotherapy or hormone therapy, with no surgery. Oligometastatic disease, meaning one or two small metastases in the bone or a single small metastasis in the lung or liver, is treated like locally advanced cancer: chemotherapy followed by surgery. Cases can always be discussed jointly over a video call with all the patient's records available; whatever can be done in the patient's own country should be done there, and the decision on referral can be made together.

Question 3

If it is familial, should bilateral surgery be done without any further testing?

Dr. Rajesh Kumar Jain · Accepted Answer

No, a BRCA1 and BRCA2 test should be done first. Indications for testing are all triple-negative breast cancer, a strong family history (a first-degree relative such as a sister or mother, or a second-degree relative such as a maternal or paternal aunt, with breast cancer), and any history of male breast cancer in the family, which alone is enough to warrant testing. If the BRCA test comes back positive, prophylactic mastectomy of the opposite side should be done along with surgery of the affected breast. If BRCA testing isn't available locally, it can be arranged through Dr. Jain's centre.

Question 4

What is the definitive treatment for breast cancer?

Dr. Rajesh Kumar Jain · Accepted Answer

There is no single definitive treatment; breast cancer, like all solid tumours, requires multimodal treatment. Chemotherapy alone, radiotherapy alone, or hormone therapy alone cannot cure it. Surgery has to be part of the treatment plan for a cure, combined with hormone therapy, chemotherapy or radiation as indicated, though surgery alone is occasionally sufficient in very select cases.

Question 5

Is rehabilitative management necessary after breast cancer treatment?

Dr. Rajesh Kumar Jain · Accepted Answer

It is mandatory. Follow-up is very important: patients I operated on 28 to 29 years ago still come to me. Rehabilitation has several aspects. The most important is care of the arm, since many patients develop lymphoedema: arm exercises and physiotherapy, no bangles or rings on the operated side, and lifelong avoidance of needles for blood tests and of blood pressure measurement in the affected arm. Taking hormone therapy on time and diet are also part of it. Psychological rehabilitation is equally important, and the operating surgeon is the best person to provide that support. Social rehabilitation matters too: some patients lose their jobs because of cancer and its treatment, and in some settings marriages break down after a breast cancer diagnosis. As I feel, doing surgery or treatment is only 5% of cancer management; 95% is rehabilitation.

Question 6

What is the prognosis for breast cancer treatment?

Dr. Rajesh Kumar Jain · Accepted Answer

Prognosis is improving steadily. Five-year survival is around 97-98% for stage one, 90-95% for stage two, 80-85% for stage three, and even stage four disease has a 25-30% five-year survival rate. Triple-negative and locally advanced cases carry a higher recurrence risk specifically, so they need especially stringent follow-up to catch any recurrence early enough to treat.

Question 7

What is the cost implication of breast cancer treatment?

Dr. Rajesh Kumar Jain · Accepted Answer

Surgery alone, all-inclusive, costs roughly $5,000. Chemotherapy adds around $10,000, and radiation is roughly $3,500 to $4,000. Extended targeted therapy such as trastuzumab can add another $10,000, though that portion can often be continued at the patient's home location. As a rough guide, surgery plus basic chemotherapy runs around $15,000 for most patients, and cases involving genuine financial hardship can always be discussed.

Question 8

Other than PET CT, how can breast cancer be staged using ultrasound and CT scan in a limited setup?

Dr. Rajesh Kumar Jain · Accepted Answer

A whole-abdomen ultrasound, not just the upper abdomen, checks for liver metastasis and also covers the ovaries and uterus. A chest X-ray checks for lung metastasis. For bone, a skeletal survey, plain X-rays covering the spine, skull and limbs, substitutes for a bone scan where nuclear medicine isn't available. This combination is less accurate than PET CT but is a reasonable, optimal fallback when resources are limited.

Question 9

Does robotic surgery have a place in breast cancer treatment?

Dr. Rajesh Kumar Jain · Accepted Answer

Robotic mastectomy and robotic axillary clearance are emerging, and we have also started doing them, but numbers are very limited: one or two cases so far. I do not see much advantage at present. The technique depends on skin-sparing: the breast is removed through an axillary approach so that no scar is visible on the front of the chest wall, and the axillary clearance is done with the same instruments. It is not widely available, requires considerable experience, and is not yet standard of care; in three or four months we may be able to say more.

Question 10

A patient has a breast lump smaller than 2 cm with no lymphadenopathy, but the chest X-ray shows a left pleural effusion, and biopsy shows triple-negative breast cancer. What is your view?

Dr. Rajesh Kumar Jain · Accepted Answer

With such a small lump and no axillary nodes, it is unlikely that the effusion is metastatic; it may not be related to the breast cancer at all and could be tubercular or something else. If possible, do a PET CT scan, or at least a contrast CT scan of the chest, to check for associated lung metastasis. The pleural fluid should always be aspirated and sent for cytology to establish whether the effusion is malignant or has another cause.

Question 11

For a young unmarried woman with a well-localised, mobile, unilateral lump at stage two or three ductal carcinoma, which surgery is advisable, and can a pre-menopausal patient start tamoxifen before or after surgery?

Dr. Rajesh Kumar Jain · Accepted Answer

For a young patient with early, well-localised disease, breast conservation surgery is advisable over mastectomy: a wide excision with lymph node dissection or sentinel biopsy, followed by pathology review. If the oestrogen receptor is positive on the final specimen, tamoxifen is started after surgery, and chemotherapy is added if indicated by the pathology. Starting tamoxifen before surgery is not advisable.

Live Discussion with Dr. Rajesh Kumar Jain