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. In breast cancer patients who need staging, also check the uterus and ovaries with a pelvis ultrasound to look for ovarian metastasis. 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 relatively good, when should a general practitioner without easy access to specialists suspect cancers such as liver, gastric or lung cancer?

Dr. Rajesh Kumar Jain · Accepted Answer

A smoker or tobacco user with an ulcer or small lesion in the mouth, tongue or cheek that has not healed in 15 to 20 days should be suspected of oral cancer and undergo a biopsy. A change of voice lasting more than three weeks without response to conservative treatment, or difficulty in swallowing, should also raise suspicion. A cough not responding after three or four weeks is often treated as tuberculosis; at minimum a chest X-ray and sputum testing for TB should be done, and if TB is not confirmed or the patient does not respond to treatment, cancer should be suspected. Early satiety, feeling full after a fraction of a normal meal, is a classic warning sign of stomach cancer, and symptoms labelled as acidity or gastritis that persist beyond four or five weeks warrant an ultrasound and, where available, an endoscopy. Unexplained weight loss, loss of appetite or easy fatiguability should raise suspicion of pancreatic or liver cancer. Every patient with jaundice should have at least an ultrasound rather than being assumed to have hepatitis, because cancers of the pancreas, gallbladder, common bile duct and liver can all present with jaundice. A change in bowel habit, unexplained diarrhoea or unexplained constipation should prompt investigation for colon cancer, and bleeding per rectum should not be assumed to be piles: at least a per rectal examination should be done, and a sigmoidoscopy or colonoscopy where available. A painless swelling of one testicle in a boy or young adult should not be diagnosed as a hydrocele without a scrotal ultrasound to exclude a testicular tumour. A soft tissue lump that looks like a lipoma but is gradually increasing in size should have an FNAC to rule out sarcoma. A high index of clinical suspicion is the key to early cancer diagnosis.

Question 4

How should we proceed with two right breast masses near the periareolar region, 3 cm and 4 cm, attached to each other by fibrous tissue on mammography, with core needle biopsy showing invasive ductal carcinoma? Is breast conservation surgery possible?

Dr. Rajesh Kumar Jain · Accepted Answer

First complete the staging: at least a chest X-ray, an ultrasound of the abdomen and, where possible, a skeletal survey or bone scan, to know whether there is metastasis. Then establish the ER, PR and HER2 status. If the disease is localised, ER/PR positive and HER2 negative, proceed to surgery; if it is HER2 positive or triple negative, chemotherapy with targeted therapy before surgery is preferred. If the rest of the breast is normal on mammography and the two lumps are localised, conservative surgery could be considered, but periareolar disease is central quadrant disease, so a mastectomy with axillary staging is the better option: sentinel node biopsy if the axilla is clinically negative, and axillary clearance if the nodes are involved. If metastasis is found, for example in the lung, liver or bone, start systemic treatment, chosen according to the receptor status.

Question 5

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

This is haemorrhagic nipple discharge, which means there is a problem in a duct. There are three common causes. The most common is duct papilloma, a benign lesion inside the duct that can convert into papillary carcinoma. The first investigation for any nipple discharge is an ultrasound of the breast, which shows the ducts and any content inside them, together with a mammogram in women over 40. If a duct papilloma is found, the particular duct is removed under image guidance with a wire placed inside it (microdochectomy) and the specimen is sent for histopathology; the report comes in two or three days. If it is a duct papilloma, treatment is complete; if it is papillary carcinoma, it is treated as breast cancer with a repeat surgery, mastectomy or conservative surgery depending on the case. The second cause is invasive ductal carcinoma: around 5 to 15% of women with this kind of discharge have an underlying cancer, and they can present without a lump. The third is duct ectasia, seen in perimenopausal women around 45 to 57 years of age, usually with a greenish or brownish discharge from several ducts; it often needs no surgery, and if the discharge is troublesome, the ducts are excised. Infection or mastitis can sometimes also cause discharge. Cytology of the discharge is of limited value, and most of the time a microdochectomy is needed to establish the diagnosis: if benign, that is sufficient; if malignant, treat it as cancer.

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, an advanced 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 targeted tablet is now available for metastatic pancreatic cancer in patients with a BRCA mutation. 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, such as surgery, radiotherapy and immunohistochemistry?

Dr. Rajesh Kumar Jain · Accepted Answer

Molecular investigation has a definite role in systemic treatment: with molecular analysis, a chemotherapy drug can be replaced by targeted therapy, as tablets or injections, or by immunotherapy, which has excellent results in certain 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. In radiotherapy, adding certain drugs that increase the sensitivity of tumour cells to radiation makes the same dose of radiation more effective. The aim should ultimately be prevention rather than treatment: a vaccine already exists for cervical cancer, and the hope is for a vaccine against breast cancer in the next two to three years and against every cancer in another ten to fifteen years, which would be the golden day of mankind.

Question 10

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. Drugs such as checkpoint inhibitors make our own immunity more competent, so cells that were lying idle recognise the cancer as the enemy and go and fight it. In CAR-T cell therapy, the patient's own T cells are taken out, genetically engineered in the lab to recognise the cancer, and given back, where they kill the cancer cells directly.

Question 12

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.

Live Discussion with Dr. Rajesh Kumar Jain