Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you handle pregnancy testing for women of childbearing age?
When ordering a simulation we denote whether a pregancy test is needed. If so, it is performed before the simulation takes place. Department policy dictates that all women of childbearing age have a serum pregancy test before the simulation CT scan (excecpt those unable to get pregnant, for example ...
What is your approach to pre-menopausal or male breast cancer patients on adjuvant tamoxifen who develop a DVT, in the absence of other risk factors for thromboembolic disease?
The treatment of male breast cancer is similar to premenopausal female breast cancer with respect to endocrine therapy. The 2 acceptable options for treatment are, therefore, either Tamoxifen or Aromatase Inhibitors + GNRH agonists. In patients with DVT, I would favor switching from Tamoxifen to AI+...
What surveillance strategy do you use for patients after resection of localized renal cell cancer?
Surveillance depends on the pathological stage of the patient. For T1a disease I follow annually. For T1b disease and higher I follow q 6 mos with MRI imaging if abdimen and low dose Ct of chest. I do not perform imaging of bones or brain without a clinical indication. For LN positive disease i star...
How soon after pelvic RT can a routine colonoscopy be completed?
I have had them get it done once acute side effects subside in 8 -12 weeks. I do inform them about avoiding rectal biopsy and informing endoscopist about it.
How would you manage a patient with low risk prostate cancer on active surveillance who develops high risk features but absolutely refuses a repeat biopsy?
In the setting of a suspicious mpMRI lesion, we start by acknowledging the patient's likely negative experience with their transrectal biopsy. We ask if they are referring to the one where they were rolled on their side, had a probe inserted in their rectum, and heard a bunch of loud CLICKs. We empa...
When do you refer patients for acupuncture for AI associated joint pain?
We recently presented the results of S1200, a phase III trial comparing 12 weeks of true acupuncture to sham (fake) acupuncture to a wait list control group (no intervention), and found that acupuncture improved pain more than the other 2 groups and the effects persisted over 24 weeks. Duloxitine, c...
How do you counsel a woman regarding her previous hormonal contraception and the risks with her newly diagnosed invasive breast cancer?
I believe the risk of breast cancer from the use of hormonal contraception is very small, in the absence of other contributing risk factors such as family history.A recent 2017 NEJM article (Morch et al) assessed the associations in a large cohort of 1.8 million women in Denmark followed for > 10 ye...
What is your approach to genetic testing for high risk patients?
At our center, clinical assessment initiated at diagnosis and anybody who meets the NCCN criteria is referred to genetic counsellor
Do you routinely screen for pituitary dysfunction after radiation therapy for nasopharyngeal cancer?
I don’t, only if symptoms
What is your approach to managing patients with recurrent nephrolithiasis who have 24 hour urine chemistry results that demonstrate low risk for stone formation but continue to experience stone events?
My first question is what constitutes a "kidney stone event"? If it is a stone passage, l know of no treatment that will "glue" pre-existing stones in place. Uric acid and cystine stones can be dissolved, however. If the event is the formation of new stones or the growth of preexisting stones with n...