Early Warning Signs of Cancer: What to Get Checked, and When

Why the timing of a diagnosis matters so much

The single biggest factor in how a cancer is treated, and in how that treatment turns out, is how far the disease has spread when it is found. A small cancer confined to where it started can often be treated with one approach, an operation or a course of radiotherapy, with a real prospect of cure. The same cancer found after it has spread usually needs several treatments in combination, and the aim may shift from cure to control.

In India, a large share of cancers are diagnosed at an advanced stage. The reason is rarely that there were no warning signs. More often a lump was painless, so it was left; a mouth ulcer was put down to spicy food; bleeding was assumed to be a hormonal change or piles; or fear of the answer kept someone away. This is not a list designed to frighten. It is a list of things that deserve a doctor's examination rather than another month of waiting.

The general warning signs

These signs are not specific to any one cancer, and each has many harmless causes. What they have in common is that they are worth an examination if they are new, have no obvious explanation, and do not go away.

• •A lump or thickening: A new lump in the breast, armpit, neck, groin or anywhere else, particularly one that is hard, painless or growing. Most lumps are benign, but a new one should be examined rather than watched.
• •A sore that does not heal: An ulcer in the mouth, on the tongue or on the skin that has not healed within two to three weeks.
• •Unusual bleeding or discharge: Blood in the stool, urine, sputum or vomit; bleeding between periods, after intercourse or after the menopause; discharge or bleeding from a nipple.
• •Weight loss you cannot explain: Losing weight without trying. As a rough guide, losing more than five per cent of your body weight over six to twelve months without a reason deserves investigation.
• •A persistent cough or hoarse voice: Lasting more than three weeks, or coughing up blood.
• •Difficulty swallowing, or indigestion that keeps coming back: Especially a feeling of food sticking on the way down, or indigestion that is new in middle age and does not settle.
• •A change in bowel or bladder habit: Lasting more than a few weeks: new constipation or loose stools, thinner stools, or passing urine differently.
• •A changing mole or skin patch: A mole that grows, changes shape or colour, itches or bleeds, or a new patch of skin that does not heal.
• •Fevers, night sweats or tiredness without a cause: Particularly together with swollen glands in the neck, armpit or groin.

Warning signs of the cancers most common in India

Some cancers are far more common here than others, and several of the most common give early signs a patient can see or feel. Knowing what they look like is the most practical form of early detection there is.

• •Mouth cancer: White or red patches inside the mouth, an ulcer that does not heal, a lump in the cheek or neck, stiffness that stops the mouth opening fully, or teeth loosening without gum disease. The risk is concentrated in people who use tobacco in any form, whether cigarettes, beedi, gutka, khaini or paan with tobacco, or who chew areca nut, and it rises further with alcohol.
• •Breast cancer: A lump in the breast or armpit, a change in the size or shape of one breast, dimpling or puckering of the skin, a nipple that has turned inwards, blood-stained discharge from the nipple, or redness and scaling of the nipple. Most breast lumps in younger women are benign, but every new lump should be examined.
• •Cervical cancer: Bleeding after intercourse, between periods or after the menopause, and a watery or foul-smelling discharge. Early changes in the cervix cause no symptoms at all, which is why screening matters so much for this cancer in particular.
• •Bowel (colorectal) cancer: Blood in or on the stool, a change in bowel habit lasting several weeks, abdominal pain, and anaemia or tiredness without an explanation. Piles are a common cause of bleeding, but they should not be assumed without an examination.
• •Lung cancer: A cough that lasts more than three weeks or changes in character, coughing up blood, breathlessness, chest pain, or repeated chest infections, especially in smokers and former smokers. In India a persistent cough is often treated as tuberculosis first; if it is not improving on treatment, the diagnosis should be revisited.
• •Head and neck cancers: A hoarse voice lasting more than three weeks, difficulty or pain on swallowing, a lump in the neck, or a blocked nose or ear on one side only that does not clear.

How long is it reasonable to wait?

Two to three weeks is a sensible working threshold for a new symptom with no obvious cause. Many ordinary problems, such as a mouth ulcer from a sharp tooth, a cough after a cold or a gland swollen by an infection, settle within that time. Something still present after it should be examined.

Some situations should not wait even that long: a lump that is growing quickly, heavy or repeated bleeding, difficulty swallowing that is getting worse, or rapid weight loss. And a long-standing complaint that changes its character deserves a fresh look. Someone who has had piles for years and now notices a different pattern of bleeding, or a smoker whose usual cough has changed, should not assume it is the old problem.

What happens when you get checked

The assessment starts with a conversation and an examination. How long has this been going on, is it changing, is there a family history, do you use tobacco or areca nut? A careful examination of the area concerned, and of the lymph glands that drain it, often tells us a great deal before any test is ordered.

Tests are then chosen for the particular symptom: an ultrasound or mammogram for a breast lump, an endoscopy for difficulty swallowing, a chest X-ray or CT scan for a persistent cough, blood tests for anaemia. They can show that something needs further investigation, or reassure that it does not.

Cancer itself is diagnosed on a biopsy, a small sample of tissue examined under a microscope. Nothing else confirms it. Blood tests called tumour markers, such as CEA, CA-125 and PSA, are useful for following a cancer that has already been diagnosed, but they cannot diagnose one on their own, and a normal result does not rule one out. If a biopsy does show cancer, further tests establish its stage, meaning how far it has spread, and the type and stage together decide the treatment.

When it turns out not to be cancer

For most people who come in with one of these symptoms, the examination and tests point to something else: a benign lump, an infection, piles, reflux, a hormonal change, a harmless skin growth. That is not a wasted visit. It replaces weeks of worry with an answer, and it usually brings treatment for whatever the real cause is.

It also sets a baseline. If the same area changes again in future, there is a record of what it looked like before, which makes the next assessment quicker and more accurate.

Lowering your risk

• •Stop tobacco and areca nut in every form: Smoked or chewed, tobacco is the largest single avoidable cause of cancer in India. The risk falls steadily in the years after stopping, and it is never too late for that to be worth doing.
• •Limit alcohol: Alcohol raises the risk of mouth, throat, oesophageal, liver, bowel and breast cancer, and it multiplies the risk from tobacco.
• •HPV vaccination: Recommended for girls aged 9 to 14, before they become sexually active. It protects against the virus types responsible for most cervical cancers.
• •Hepatitis B vaccination: Long-term hepatitis B infection is a major cause of liver cancer, and the vaccine prevents it.
• •Weight and activity: Staying active and keeping to a healthy weight lowers the risk of several common cancers, including breast, bowel and uterine cancer.
• •Screening: Tests for people without symptoms can find some cancers, or the changes that come before them, early. Our guide to cancer screening in India explains which tests are worth having, and at what age.