Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you take tumor seeding into account when staging NSCLC?
This is a rare situation but based on the current AJCC staging, if this is in same lobe then would stage as T3 disease. If discovered after treatment of the primary disease, we would still treat this like a localized process, as is not hematogenous spread and not like metastatic disease. Seeding of ...
How are patients on anticoagulation managed in the context of intracranial SRS?
At our institution, we do not withhold heparin or warfarin prior to treatment. This risk of intracranial bleed is not felt to be increased as a consequence of treatment. We do use a traditional headframe (using pins to hold to the skull). While there may be an increased risk of bleeding at the pin s...
For elderly patients with locally advanced rectal cancer who are not candidates for surgery or chemotherapy, what would be an appropriate palliative regimen?
There is an old paper from Princess Margaret Hospital ~1980, called "Is the Miles operation really necessary for the treatment of rectal cancer?". (Editor note: 1993 Update). These are patients who were medically inoperable or refused surgery. I believe doses were about 40 Gy. Remember that this was...
How do you handle post-op, pre-radiation breast seromas and hematomas?
It depends on what I'm doing. If the patient is being treated to only the whole breast, like with the Canadian protocol, then I tend to do nothing. I just go ahead and treat. The hematoma usually won't resolve enough to change the volume over the three weeks. If I feel this patient needs a boost, th...
When do you perform HER2 testing in patients with colorectal cancer?
HER2 amplification is seen in a small but distinct subset of colorectal cancer. This subset has 2 unique characteristics: They are predominantly RAS wild type tumors. They do not respond to anti-EGFR agents, i.e. HER2 amplification is a negative predictor of anti-EGFR antibody (cetuximab and panitu...
How do you perform geriatric assessment for cancer patients?
This is a HUGE topic. I would like to suggest the following 2 resources that you may find helpful. https://www.mycarg.org/?page_id=898 and the following one helps predict residual life expectancy independent of cancer diagnosis: https://eprognosis.ucsf.edu
How do you manage dabrafenib fever?
Tough problem to manage. I've tried numerous strategies with unpredictable success. Prednisone 5mg BID usually works if you want to keep full dose. Otherwise, a dose delay and likely reduction of dab will be necessary.
For patients with brain tumors without a history of seizure, what is your policy on driving?
There is no standard in the United States.We have no written policy. However, if there is clear neurocognitive impairment or there are clinical findings that can impair one's driving ability, I report to the state with a form from the Driver License Bureau that is filled out and then the DMV perform...
When does a rising PSA after prostatectomy indicate growth just of normal prostate?
The concept of residual prostate tissue after prostatectomy has been around since the advent of the PSA. The idea that BPH could exist within this residual tissue has been suggested for nearly the same amount of time. Very little data exists regarding this concept. It has been demonstrated that resi...
What is the best way to discuss an early palliative care referral with a patient?
Patients (and providers) often struggle with the assumption that palliative care implies end of life care. While that is true in many cases, if you can overcome this false assumption, your patients can benefit. I often explain that palliative care like this: Palliative care serves as an extra set of...