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

Could a simple checklist or protocol tell doctors which tests to get done to rule out or confirm a suspicion of cancer?

Dr. Shubham Jain · Accepted Answer

At a very basic level, any breast complaint should be evaluated with a clinical examination, at least a mammography or an ultrasound and, if possible, a biopsy or FNAC: the triple assessment. For any suspected abdominal cancer, the minimum is an ultrasound of the abdomen, which guides which other imaging would be better; basic radiological investigations are available in most African countries, and a CT scan can guide further. Even for specialists it can be hard to predict outcomes from clinical findings alone: a patient referred with a large abdominal mass and generalised lymphadenopathy, clinically suspected to have lymphoma, turned out on lymph node biopsy to have a neuroendocrine carcinoma, which changed the treatment options entirely. The basic work-up for most patients is the same: one imaging modality addressing the area of concern, and a biopsy if feasible. Biopsy is a nuanced test: some liver or kidney cancers may not need pathological confirmation, while at the other extreme a poorly planned biopsy can harm the patient. The decision on how and where to biopsy is therefore best left to the treating oncologist rather than the primary care physician.

Question 3

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 4

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 5

The slide on lung cancer screening said 20 pack-years for smokers. Does that mean 20 packs?

Dr. Shubham Jain · Accepted Answer

Pack-years are the number of packs smoked per day multiplied by the number of years of smoking. It does not mean 20 packs a day, which is not possible. 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.

Question 6

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

Dr. Shubham Jain · Accepted Answer

Tumour markers can be used, but they are not screening tests on their own, and it is important to understand the patient's age, family history and smoking status first. At a basic level, a mammography for women, a serum PSA blood test for men after discussing its benefits and harms, a low-dose CT scan of the chest for heavy smokers, and an ultrasound of the whole abdomen for women being evaluated for endometrial or ovarian cancer 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 7

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 8

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 9

A patient with stage 3 breast cancer has had five cycles of chemotherapy. What test can we do to check treatment progress?

Dr. Shubham Jain · Accepted Answer

Patients given neoadjuvant chemotherapy for locally advanced disease usually show clinical improvement: they notice the breast lump shrinking or the skin findings improving. In addition, repeat the imaging that was done before chemotherapy started, ultrasound or CT, to objectively confirm the response. Surgery is an integral part of treatment; without it, treatment is simply palliative, so this patient should now be assessed by a surgeon who can offer surgery.

Question 10

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 11

What complications do you see from radiotherapy to the left side of the chest?

Dr. Shubham Jain · Accepted Answer

The most important complication specific to 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 techniques such as IGRT and 4D-CT based planning are also improving precision for left-sided breast and chest wall tumours.

Question 12

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 13

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

Dr. Shubham Jain · Accepted Answer

This is a tricky situation: metastatic deposits are seen in an organ without knowing where they come from. First, a PET scan confirms there is no other site of disease in the body. Second, the pathologists perform immunohistochemistry on the biopsy, which can give clues to where the cancer is arising; directed, targeted investigation follows, for example endoscopy if an upper GI origin is suspected, or detailed imaging and hysteroscopy for a gynaecological origin. Many times the primary is never found. With only liver metastases, treatment starts with chemotherapy, with palliative intent. If the patient responds very well and their general condition improves, a curative approach that may involve surgery can be attempted, depending on performance status and how the disease responds, provided the patient understands it can be attempted but nothing can be assured.

Question 14

Which cancers have patient assistance programmes, how do they work, and which patients are eligible?

Dr. Shubham Jain · Accepted Answer

Until very recently, patient assistance programmes for targeted therapies and immunotherapies were available only to Indian patients. Because these drugs are very costly, companies assist with procuring them, so they may cost as little as a half or a third of the usual price, which makes them more affordable; even for domestic Indian patients these drugs are often out of reach. Because of the regulations surrounding medical treatment, the benefit of these programmes could not be extended to patients travelling from abroad, but those laws are now relaxing and international patients are increasingly able to benefit.

Live Discussion with Dr. Shubham Jain