Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage an elderly patient with GE junction adenocarcinoma who is not interested in surgery and who has ulcerative colitis (not currently on medication or symptomatic)?
Ulcerative colitis is generally a disease limited to the colon, and is an important distinction from Crohn's disease, which is truly anywhere from mouth to anus in the GI tract. These two diseases are on a spectrum of inflammatory bowel disease and there can be some overlap, but in general I would p...
For small peripherally located NSCLC, when do consider referral for mediastinal evaluation prior to curative surgery vs proceeding to resection with mediastinal eval at time of surgery?
Although there is variability among the different guidelines (ACCP, ESTS, NCCN) in regards to mediastinal staging, there is consensus that no invasive staging is required for peripheral nodules which are T1A (T1abcN0) given the low prevalence of occult N2 disease. Invasive mediastinal staging should...
Should breast cancer patients with never-treated latent TB and for whom chemotherapy is indicated be treated for latent TB during chemotherapy?
Interestingly latent tb reactivation while on cyclic combination Chemotherapy is quite rare even in endemic countries like India, including among patients treated for leukemia. This could be due to cyclic nature of immune suppression rather than chronic immune suppression which is required for tb re...
What is a safe time interval from completion of hormones and external beam radiation to TURP in patients who develop refractory obstruction?
Great question. Ordinarily, in my past experience, if a patient had real LUTS >14 AUA score that was not relieved with alpha blockers, and/or had a large median lobe, we would prefer the TURP be done upfront and / or chemical debulking with ADT too. In these instances, we found we had less LUTS then...
How do you approach rectal cancer with a solitary bone metastasis that is biopsy proven?
This is a much less common scenario than oligometastatic disease to the liver or lung, but as control rates for bone metastases treated with SBRT are showing promise, the approach may be similar to that taken for patients with more common sites of oligometastatic rectal cancer. We would typically st...
How long do you continue surveillance imaging for NSCLC after definitive treatment?
Theoretically, many of these patients would likely have the risk factors to qualify for ongoing low dose CT chest surveillance well after addressing their pulmonary malignancy.https://www.ncbi.nlm.nih.gov/pubmed/21714641
When do you recommend patients get vaccinations with respect to their chemotherapy course?
It depends on the nature of the treatment program and on the patient’s immune system. For treatments that are not B-cell lymphodepleting, routine vaccinations can be administered routinely, presuming no underlying immunodeficiency. For patients receiving anti-CD20 monoclonal antibodies, we typically...
How do you approach a patient with IgM monoclonal gammopathy associated with severe neuropathy of unclear etiology?
I usually confirm if the patient does not have AL Amyloidosis or POEMS, and as part of work up for IgM MGUS, I order MYD 88 mutation. If all are negative and I still believe that neuropathy is caused from his/her MGUS, you can try IVIG for the neuropathy as a trial (of course after using gabapentin,...
What screening criteria do you use to give patients IV contrast for the CT sim?
This is an extremely frustrating and commonly encountered scenario in radiation oncology clinic (and the diagnostic CT suite). What is most frustrating is how stubbornly the dogma of contrast-induced nephropathy has persisted, and the vast amount of needlessly wasted resources spent worrying about i...
Do you insist on biopsy confirmation of invasive disease in the setting of in situ pathology findings but otherwise clinical/radiographic evidence of invasive cancer?
Not necessarily. I recently had a case of cervical cancer which was called CIN 3 on 2 consecutive biopsies with a palpable mass approximately 3cm in size on clinical exam. PET/CT showed intense FDG avidity in the cervix with a 5cm mass and pelvic lymph nodes. We treated as a IIIC invasive SCC. While...