Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you sequence follow up mammograms in patients undergoing breast cancer treatment?
In the followup of patients treated with breast conservation therapy, continuation of yearly mammograms is standard practice, even if the cancer in question was not seen mammographically. It would be quite unusual to be undergoing RT when the yearly mammogram was due, since even with the diagnosis o...
How do you manage significant fatigue caused by androgen deprivation therapy in prostate cancer patients?
This is a great question and one that I think comes up regularly in the clinic. The fatigue often is due to the hypogonadal state, lack of muscle mass and subsequent loss of muscle power that may reduce stamina. I generally recommend a regular activity or exercise program. As in many other patient p...
What interventions besides lubricants do you advise to improve sexual satisfaction for patients s/p ChemoXRT for cervical cancer?
Advise a multimodal approach Additional strategies: 1) Vaginal dilator therapy. Additional visits outside of follow-ups may improve adherence 2) Vaginal moisturizers - Replens, Vitamin E oil, etc. This is outside of water-based lubricants during sexual activity 3) Topical estrogens (many of these pa...
Would you consider HRT in a young woman (<35 years old) with gBRCA mutated TNBC who underwent bilateral mastectomies and BSO?
I would use HRT for the beneficial effects of bone preservation, lipid improvement, sexual function, and quality of life. My preference is for women to have a concurrent hysterectomy with the BSO so the HRT can be estrogen alone, which has little, if any, risk for promoting breast cancer. In the les...
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.