Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider giving tamoxifen prophylaxis to young women with pathogenic BRCA2 muations who are <35 years old?
There is some evidence to support use of tamoxifen in non affected carriers. Secondary analyses of 288 patients who developed cancer in NSABP P-1 trial suggested a 62% risk reduction in incidence of breast cancers in known gBRCA 2 carriers,no benefit in gBRCA 1. This data is limited by fairly low nu...
How would you approach a post-menopausal woman who now wishes to start adjuvant endocrine therapy more than 3 years since surgery?
The short answer is yes. You start endocrine therapy even if it is late. It is important to remember that events in this disease occur later and very few events occur in the first few years anyway. Like starting any treatment, it is a good idea to weigh risk of recurrence and value of treatment, es...
Following oral cavity radiotherapy, how do you advise patients on ongoing bisphosphonate therapy and the risk for osteonecrosis?
I asked the question, but since no one has responded, I will just comment that I have discontinued such therapy in one of my H&N patients for fear of increasing the odds of osteonecrosis occurring.
Do you routinely prescribe PCP prophylaxis for patients who will be on steroids long-term?
Yes. This is something I don't think is emphasized enough given the ease of the intervention and seriousness of infection. In my first year of practice, I saw 3 fatal cases of PCP in patients that were receiving steroids from medical oncology without PCP prophylaxis. So I prescribe it for virtually ...
What is your recommendations for vaccines to prevent shingles in CLL patients?
In October 2017, the U.S. FDA licensed the adjuvanted, recombinant zoster vaccine (Shingrix). Phase 1/2a studies in immunocompromised subjects, including autologous hematopoietic cell transplant recipients and HIV- infected adults, have confirmed that Shingrix is immunogenic and safe with no documen...
How do you manage breast lymphedema after radiation?
We refer to lymphedema physical therapist for management.
How long after prostate radiation do you recommend waiting for routine screening colonoscopy?
Good question. In this regard, I would say that the timing would depend on the nature of the acute reaction in the area of the rectum adjacent to the prostate. This may be patient dependent. Further, the local reaction erythema can last for weeks to months depending on the reaction. Also, if it's >1...
Which criteria do you follow to recommend low-dose CT screening in patients at high risk for lung cancer?
At this time, I still follow the USPSTF/NLST guidelines, but believe the criteria for screening should be updated to include more patients. The current recommendations from the USPSTF based on the National Lung Screening Trial demonstrating an improvement in lung cancer and all cause mortality inclu...
How do you decide whether to obtain dental evaluation to reduce the risk of medication-related osteonecrosis of the jaw prior to initiating non-urgent bone-modifying agent therapy?
I have a practice that I send all patients, even edentulous patients, for a dental screening examination if they have a non-emergent need bone-modifying agents (BMAs). That recommendation comes from osteonecrosis guidelines published in J Clin Oncol 2019. The reason for this recommendation is when s...
Is it safe for a patient to breastfeed during their course of EBRT?
Not aware of any concerns. In our pregnancy-associated breast cancer patients, I encourage women to breastfeed on the side I am not treating as long as med onc has cleared them. We work with pediatricians to ensure that the infant is reaching normal weight/growth milestones, but may need to suppleme...