Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel young and educated patients with non-metastatic breast cancer who choose non-proven "natural" treatments over standard therapy?
It is extremely difficult to persuade individuals skeptical of medicine to make evidence-based decisions. Most research related to changing scientific beliefs come from literature related to antivaccination attitudes. Previous research has suggested that provaccine messages about safety (messages co...
If a man has been on a 5-alpha reductase inhibitor for urinary symptoms prior to prostate radiation therapy, is there value in continuing it after radiation therapy?
5-alpha reductase inhibitors, e.g. dutasteride, are indicated for the treatment of symptoms related to BPH and an enlarged prostate and have some efficacy for this indication, especially when combined with alpha blockers. 5-alpha reductase reduces a double bond in testosterone to create a more poten...
How do you counsel a patient with a history of breast cancer regarding use of breast MRI for screening?
In our Breast Survivorship Clinic at MD Anderson we do not regularly recommend a surveillance breast MRI to screen for local recurrence or for new breast cancer in all of our breast cancer survivors, since there is lack of data to support this practice. Not to mention the elevated cost and the possi...
How do you manage dry mouth after head and neck RT?
I think it is important to very clearly explain to the patient that xerostomia is common and even should be expected, even in the era of highly conformal treatment plans. If a patient is highly motivated to preserve saliva, pilocarpine can be used concurrently with radiation where it has been shown ...
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...