Question 1

In sub-Saharan Africa, most countries do not have a PET-CT scanner. What alternatives can a doctor use to get a near-accurate estimation of disease stage without one?

Dr. Rajesh Kumar Jain · Accepted Answer

For bone metastasis, use a nuclear bone scan; if that is unavailable, do a skeletal survey, plain X-rays of the spine, ribs, pelvis and limbs. For liver metastasis, a CT abdomen substitutes for PET, and an ultrasound is a fair investigation if CT is also unavailable. For the lungs, a CT chest is the alternative, and a plain chest X-ray is fair enough if CT is not available. Also check the uterus and ovaries with a pelvis ultrasound in every breast cancer patient, to rule out Krukenberg tumours. Ultrasound and X-rays are available almost everywhere in the world, and while less precise than PET-CT, this combination is enough to establish metastatic staging.

Question 2

Many cancer cases referred from outside India are far advanced by the time they reach surgical oncology, with the objective becoming palliative rather than curative. How can doctors be made more aware of the need for timely referral?

Dr. Rajesh Kumar Jain · Accepted Answer

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.

Question 3

Beyond breast cancer, where awareness is already relatively good, when should a general practitioner without easy access to specialists suspect cancers like liver, gastric or lung cancer?

Dr. Rajesh Kumar Jain · Accepted Answer

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.

Question 4

A patient case from Dr. Alem in Ethiopia: right breast masses, two in number near the periareolar region, 3cm and 4cm, attached to each other by fibrous tissue, with core needle biopsy showing invasive ductal carcinoma. How should this proceed, and is breast conservation surgery possible?

Dr. Rajesh Kumar Jain · Accepted Answer

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.

Question 5

A question from Dr. Isaya Mhando in Tanzania, based on a patient seen five years ago: what are the causes of bloody discharge from the breast, with no breast lump and no palpable lymph nodes?

Dr. Rajesh Kumar Jain · Accepted Answer

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.

Question 6

How does treatment at an advanced facility like BLK-Max, compared to a tier-city setup, actually change patient outcomes, including timely referral and cost, in a way that helps doctors counsel patients?

Dr. Rajesh Kumar Jain · Accepted Answer

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.

Question 7

If someone wants to do a fellowship in the surgical oncology department, do they have to already be a surgeon, or can they come from the medicine side as well?

Dr. Rajesh Kumar Jain · Accepted Answer

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.

Question 8

Given a recent breakthrough involving a drug that attacks faulty genes and the use of AI in medicine, how far are we from truly personalised cancer treatment based on genetic sequencing?

Dr. Rajesh Kumar Jain · Accepted Answer

Personalised cancer treatment is already underway, though there is a long way to go. It is similar to culture and sensitivity testing for a urinary infection: molecular sequencing identifies which drug the tumour is sensitive to. Lung cancer has already seen a sea change this way, and a single daily tablet is now available for metastatic pancreatic cancer. If EGFR is mutated, for example, EGFR-targeted tablets can be given depending on what the patient can afford. The next ten years in oncology will be the decade of personalised cancer treatment.

Question 9

To what extent can molecular analysis of pathological samples replace other treatment modalities like surgery, radiotherapy and immunohistochemistry?

Dr. Rajesh Kumar Jain · Accepted Answer

Molecular investigation has a definite role in systemic treatment: where chemotherapy is used, molecular analysis can replace it with targeted therapy or immunotherapy in some cases. For localised cancer, surgery remains the mainstay and the most curative treatment, and cannot be replaced, though in advanced disease chemotherapy can be replaced by immunotherapy or targeted therapy. For radiation, adding radiosensitising drugs identified through molecular analysis can sometimes allow the radiation dose to be decreased. The larger goal should be prevention: a cervical cancer vaccine already exists, and a breast cancer vaccine within two to three years, with vaccines against most cancers within ten to fifteen years, would be the golden day of mankind.

Question 10

A question from Dr. Abubakar in Nigeria, joining partway through the session: what is circulating tumour DNA?

Dr. Rajesh Kumar Jain · Accepted Answer

As a tumour breaks down, its cells release DNA that circulates in the blood. Finding this DNA in a blood sample can be used as a screening test, prompting further investigation like colonoscopy, CT scan or mammography to locate the source. Measured before and after treatment, for example after three months of chemotherapy, a drop to absent or minimal levels indicates a good response. Checked every six months for years after treatment, a previously absent reading reappearing can signal recurrence. It is not yet fully specific and is still being researched, but is expected to be used more heavily in screening, diagnosis, prognosis, monitoring and recurrence detection.

Question 11

The principle behind CAR-T cell therapy is using the body's own cells and modifying immunity to attack cancer. Could the body be developing cancers that our own immunity handles without it becoming a concern, with only cases beyond our immune capacity becoming a real concern for cancer doctors?

Dr. Rajesh Kumar Jain · Accepted Answer

CAR-T cell therapy, and immunotherapy generally, works on a simple concept: our own immune cells are competent enough to fight infection and cancer, but whenever cancer is present, immunity goes down. Immunotherapy retrains the remaining immune cells to fight again, rather than killing the tumour directly. The drugs make our own immunity more competent, cells that were lying idle are retrained and made to recognise the cancer as the enemy, and then they go and fight it.

Question 12

A question from Dr. Innocent Nzili in Kenya: why do some dormant cancer cells survive initial treatment and hide in the body for years before suddenly reactivating to cause a deadly recurrence?

Dr. Rajesh Kumar Jain · Accepted Answer

The exact mechanism is still not fully known. But one clear factor is genetic aberrations that occur over time because of environmental exposure: if a patient achieves a cure but resumes alcohol or smoking, the damage caused by tobacco or other carcinogens affects the DNA again and dormant cells can get reactivated. That is one reason recurrence happens, though most of the time the actual mechanism is not known.

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