Question 1

How should a doctor practising in a resource-constrained setting, without enough diagnostic facilities to screen large populations, know which symptoms genuinely warrant referral and which could be a false alarm?

Dr. Shubham Jain · Accepted Answer

Any suspected cancer requires resources for investigation and treatment, so it should be evaluated at a good high-volume centre that gives the best chance of cure. It is difficult to assess the outcome or treatment at an initial stage, so the primary reliance has to be on the clinical signs and symptoms already discussed, which are the basis for suggesting a patient be evaluated at a high-volume centre.

Question 2

Can you tell us something about malignant wounds?

Dr. Shubham Jain · Accepted Answer

A malignant wound anywhere needs to be confirmed on biopsy to establish the exact reason for it, and it should not be expected to heal on its own. It should be subjected to a biopsy to confirm the nature of the malignancy and the treatment options, with appropriate imaging to understand the underlying structures involved, and surgery offered if the wound is resectable.

Question 3

A patient had laryngeal cancer and surgery affected his voice box. He wants an aid to help him use his voice but does not want an invasive procedure. Are there any options available for him?

Dr. Shubham Jain · Accepted Answer

Yes, definitely. An electrolarynx is an external prosthesis: once the device is attached to the skin it creates vibrations at high speed and the patient can vocalise using it.

Question 4

What are the latest screening tests available for early detection of different cancers?

Dr. Shubham Jain · Accepted Answer

Tumour markers can be used, but it is important to understand the patient's age, family history and smoking status first. At a basic level, a mammography for women, an ultrasound of the whole abdomen for endometrial or ovarian cancer, a serum PSA blood test for men with suspected prostate cancer, and a CT scan of the chest for smokers can be recommended. The frequency varies: colon cancer screening can be a colonoscopy every ten years, or a sigmoidoscopy with a faecal occult blood test.

Question 5

Biopsy is often the best way to detect cancer, but it usually takes a long time. Are there any faster options or alternatives?

Dr. Shubham Jain · Accepted Answer

This is a real issue even in India, where processing time for biopsies can be high in some regions. One workaround is relying more on FNAC, which is not the best strategy but can guide treatment decisions in select situations where a diagnosis is otherwise delayed. A second option is a frozen section facility, which gives some confirmation quickly but is resource-intensive and usually only available at high-volume cancer centres. Short of that, it is best to refer to an oncologist who can guide where a biopsy should be taken from for the best results.

Question 6

What are the myths in assessing suspected cancer patients?

Dr. Shubham Jain · Accepted Answer

The most important myth is patients' hesitancy to get a biopsy done, fearing it will cause the cancer to spread. A biopsy is one of the most crucial tests a cancer patient needs, and if planned and performed correctly it will not cause the cancer to spread. Another myth is that patients believe cancer is their own fault, from dietary habits or indulgences like tobacco or alcohol. More cases are now understood to happen because of environment or genetics rather than a patient's own fault, and it is important to destigmatise patients suffering from cancer, since stigma is what keeps them from seeking timely treatment.

Question 7

Do you recommend breast conservation surgery for a small breast ductal carcinoma of the left breast?

Dr. Shubham Jain · Accepted Answer

Definitely. Breast conservation surgery is one of the advanced techniques for treating early breast cancer and is routinely discussed as a possibility with patients. It offers a definite cosmetic advantage, but it needs to be followed up with radiotherapy, and there are strict criteria on imaging and family history that must be met before it is offered. It is now combined with oncoplasty, which improves how the scars are closed for a better cosmetic outcome.

Question 8

How do we approach cancer of unknown primary with only liver metastases or oligometastases?

Dr. Shubham Jain · Accepted Answer

This is a tricky situation where metastatic deposits are seen without knowing where they are coming from. A PET scan is needed to confirm there is no other site of disease in the body, and immunohistochemistry on the biopsy can give clues to where the cancer is arising from, guiding directed and targeted imaging afterward. Many times the primary is never found. If there are only liver metastases, treatment starts with a palliative intent, and depending on how the patient responds and their performance status, a curative approach involving surgery may later be attempted, though nothing can be assured to the patient in advance.

Question 9

What is your take on mebendazole and ivermectin as adjunct tablets for cancer treatment?

Dr. Shubham Jain · Accepted Answer

These are being evaluated as adjuvant therapy for cancer, but there is not yet sufficient scientific data backing them, so standard chemotherapy remains the primary reliance. What is showing real results is targeted therapy and immunotherapy, where survival has improved and recurrences and side effects have reduced. Cost has been a sore point since these are expensive medicines, but with generic versions now available and patient assistance programmes extending to international patients, these costs are coming down.

Question 10

How do you see complications from radiotherapy on the left side of the chest?

Dr. Shubham Jain · Accepted Answer

The most common complication with radiotherapy for left-sided breast cancers is cardiotoxicity. Radiation oncologists manage this with deep inspiratory breath-hold and gating techniques, training the patient to hold their breath during the active phase of radiotherapy so toxicity to the heart is reduced, chest wall motion is reduced, and radiation is delivered accurately to the target volume. More precise machines such as IGRT and 4D-CRT are also improving precision for left-sided breast and chest wall tumours.

Question 11

Which cancers have patient assistance programmes, and how do they work, and who is eligible?

Dr. Shubham Jain · Accepted Answer

Until very recently, patient assistance programmes for targeted therapy and immunotherapy were only available to Indian patients. Because these drugs are costly, companies assist with procuring them at up to a half or a third of the usual cost, which is out of reach for many domestic Indian patients too because of regulations. These regulations are now relaxing, and more international patients are able to receive the benefit of these programmes.

Question 12

On the slide about smokers, it said 20 packs. Does that mean 20 packs smoked per day?

Dr. Shubham Jain · Accepted Answer

Not 20 packs per day, that would be 400 cigarettes a day, which is not possible. Pack-years is the number of packs smoked per day multiplied by the number of years smoked. Two packs a day for ten years makes 20 pack-years, as does one pack a day for twenty years, or half a pack a day for forty years.

When to Suspect Cancer and How to Refer

Questions Doctors Asked Dr. Shubham Jain