Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
How do you discuss avoiding pregnancy in the premenopausal patient while on chemotherapy and/or endocrine therapy?
We have an active discussion in any PRE-menopausal patient, which is documented in the chart along with their method of contraception. A pregnancy test is obtained prior to the start of chemotherapy, but not routinely repeated unless there is reason (e.g. patient reports not using an contraception, ...
How do you counsel a young woman carrying a BRCA 1 or 2 mutation and history of breast cancer who desires pregnancy?
Pregnancy subsequent to breast cancer does not worsen the prognosis. If a young BRCA carrier desires to become pregnant she should be supported. Points to emphasize: 1) the rates of ovarian cancer don't begin to rise until after 35 years; 2) she can be screened by breast ultrasound during pregnancy;...
Do you ever consider hormone replacement therapy in a woman who is suffering from early menopause that has been likely cured of her breast cancer and undergone bilateral mastectomies?
A short period of HRT is OK The fact she has or has not had a bilateral mastectomy does not change my answer
At what point do you refer patients to see a pain specialist?
Great question. In these instances, where the patient comes in for palliative RT for painful bone mets, for example, I tend refer back to the 'involved' palliative care professional or the pain specialist. In the last few years, I have rarely had to become involved with directly prescribing opiates...
Should patients who received pelvic radiation get colonoscopy screenings more often than what is recommended for the general population?
The excess risk of secondary cancer after radiation has been estimated at 0.5% in a 15 year follow-up period. This relatively low incidence would not justify a higher interval of screening colonoscopy after pelvic radiation. As a component of our patient-reported quality of life survey, we do screen...
In which patients do you prescribe Marinol?
The short answer to this question is I prescribe dronabinol to patients who are requesting medical marijuana but don't have a state-issued medical marijuana card yet. It can take 2-3 months for Illinois to issue the card (hooray for bureaucracy!) unless the patient is deemed "terminal" (i.e. <6 mont...