Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For what patient groups (if any) do you routinely recommend screening colonoscopy prior to radiation for prostate cancer?
As a cancer care provider treating both GI and GU malignancies, I see this as a commonly. In many healthy men, an elevated PSA may be what allows them to "plug in" to the American health care system, often the first time in many years. Considering most prostate cancer is detected by an elevated PSA,...
What do you advise young low-risk pre-menopausal patients requiring adjuvant hormonal therapy who have endometriosis and are worried about the effects of Tamoxifen?
This is a situation where risks and benefits must be weighed for each scenario so the providers (gyn,med onc) and patient can make the therapy decision together. Low risk can mean different things and that can influence the decision for therapy. Is it low absolute risk with (T2N0 low oncotype dx) or...
For patients at high risk of breast cancer, do you recommend tomosynthesis over traditional two-view screening mammogram?
Currently, there are many radiology based clinical trials to compare the MRI vs US + 2D Mammo vs 3D Mammo. The STORM study (screening with tomosynthesis OR standard mammography) showed around 17% reduction of false positive, and 34% higher cancer detection rate in the 2D+3D combination arm. Among ca...
How would you advise a woman who had a full axillary lymph node dissection on the risk of lymphedema with mountain climbing?
Well, this is obviously a question with no evidence based answer. Overal, the risk of lymphedema after axillary LN dissection is around 20-25%. Most likely these patients will receive regional LN radiation (due to positive LN's) and the risk will increase to 25-30% (Warren et al). Other risk factors...
How do you advise women who are at high risk for breast cancer and for whom annual screening breast MRIs are recommended regarding the long-term risks of gadolinium contrast?
For all breast cancer screening modalities, we need to weigh the benefits for early detection with the potential harms, such as false positive results and over diagnosis. Among young high-risk women with dense breasts, breast MRI has higher sensitivity compared to mammography for early detection of ...
How long do you continue low dose CT screening for lung cancer?
In general, I discontinue LDCT after 3 negative scans for a person undergoing lung cancer screening without symptoms. This is not true if small nodules are seen on imaging. This is based on the best data we have at the time and the possibility of risk associated with continued annual screening. The...
When can tamoxifen be safely resumed after pregnancy?
I am not aware of any formal recommendations on this and there isn't much in the literature to guide us. Certainly, there is concern for Tamoxifen use in breastfeeding mothers as it's excretion into breastmilk is unknown and it is also known to suppress lactation. There is a trial, the POSITIVE (Pau...
What is your strategy for image surveillance for occult breast cancer after treatment?
As the are occult with all imaging including MRI there is no good strategy for imaging . Also risk of IBTR in modern era after RT in these patients is low and would just do routine annual mammogram for screening
How do you counsel patients on multivitamin use during therapy?
I tell patients to stop intake of anti-oxidant multivitamins (A,C and E) at the time of consultation, and if they so wish, they can resume them no sooner than 6-8 weeks after course completion because "radiation continues to work after we're done." I simplify how radiation attacks/kills the cancer D...
Do you recommend routine dental evaluation for all patients before starting bisphosponates in patients with bone metastases?
Yes. The purpose of a dental exam prior to starting IV bisphosphonates or SC denosumab is to survey the mouth and fix any root canals, extractions, or other dental pathology prior to starting of drugs. Why? Because dental extractions during treatment with bisphosphonates or denosumab are one of bigg...