Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would your follow-up change for a patient, non-surgical candidate, with endometrial cancer treated with definitive radiation?
I assume that the question refers to how follow-up would differ between a patient treated adjuvantly, i.e., following surgery, versus treated definitively, i.e., not a surgical candidate. I think there are quite a few variables here. Probably the most important consideration is the extent to which t...
Do you take patients off anticoagulation for tandem and ovoid or tandem and ring procedures?
We don't take them off anti coagulant for intracaviatry alone unless using a hybrid applicator
Do you routinely discuss HRT with patients that have undergone surgical menopause due to treatment of cervical cancer?
Yes, I routinely discuss it with premenopausal patients and it is an important part of their care. If they will be having chemoradiation for a locally advanced cancer, I will discuss pros/cons of ovarian transposition. With adenocarcinomas, some patients do opt for oophorectomy if a radical hysterec...
Would you use aspirin 81 mg for VTE prophylaxis in patients on adjuvant tamoxifen/SERMs?
In a meta-analysis of over 30,000 patients, VTE was found in 2.8% of patients on tamoxifen and 1.6% of patients on AI. So, yes there is a higher risk of VTE on tamoxifen but the percentage is still very low. I would not use 81 mg aspirin as VTE prophylaxis in all patients on tamoxifen to rescue or p...
Do you provide prophylactic anticoagulation with abemaciclib in the adjuvant setting given known thrombosis risk?
I don’t generally recommend prophylactic anticoagulation with abema, either in the adjuvant or metastatic setting. There does appear to be a small, but real, incidence of thrombosis associated with abema, as well as the other CDK 4/6 inhibitors. While this risk is quite uncommon, it is important cer...
How would you approach a postmenopausal woman with Stage I HR+,HER2- breast cancer who had a CVA while on tamoxifen?
A major co-morbidity such as a stroke should prompt a re evaluation of the benefit risk ratio and overall value of adjuvant endocrine therapy, especially for low risk disease. It would be helpful to unpack this situation a little more. How bad is the stroke and how much loss of mobility and performa...
How would you approach diagnosis of residual ovarian tissue in a patient with ER positive breast cancer, history of BSO, and a rising estradiol level on tamoxifen?
Diagnosing elevated estrogen levels in a patient who has undergone BSO is difficult, since the symptoms are typically very non-specific (e.g., improvement in hot flashes, change in mood). There are multiple potential reasons for elevated estrogen levels following BSO, including an adrenal tumor that...
How would you manage adjuvant endocrine therapy for a postmenopausal patient with early stage HR+ breast CA who develops an ischemic CVA on an AI?
This is a vexing problem that I myself have had to deal with. My patient developed a TIA on aromatase inhibitor (AI). Work up was negative for predisposing risk factors. The choice was easy in this case. This woman was told by her family friend, who was a doctor, that AIs cause stroke and she refuse...
In which scenarios do you use vaginal estrogen in patients with history of HR positive breast cancer?
A recent study (McVicker et al., PMID 37917089) supports the likely safety of vaginal estrogens in breast cancer survivors. Limitations of this study are that it primarily included lower-risk individuals with stage I-II disease and women 50+. In addition, the level of data is limited by the retrospe...
Have you adopted the use of low dose morphine for treatment of cough in patients with IPF?
Yes, I selectively use low-dose morphine for the treatment of chronic cough (lasting more than 8 weeks) in certain patients with idiopathic pulmonary fibrosis (IPF).This includes individuals who demonstrate somewhat preserved lung function (specifically, a forced vital capacity [FVC] of 45% or more ...