Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage an open wound that is not healing after radiation treatment for an ulcerated SCC of the scalp?
There always has to be high suspicion for persistent disease, so consider a punch biopsy. Sometimes repeat biopsies are needed to confirm recurrence. Sometimes localized surgery without general anesthesia can be performed to freshen the wound and promote graft placement. Tertiary centers may have ex...
What scans do you order for follow-up in locally advanced non-small cell lung cancer patients who have completed definitive radiation with concurrent chemotherapy?
To my knowledge, there are no randomized studies that have examined the role and frequency of surveillance imaging in locally advanced NSCLC treated with chemoradiation. There is an ongoing randomized study looking at two follow up schedules in completely resected NSCLC (PMID 17519819).NCCN recommen...
How do you approach disease monitoring in patients with localized rectal cancer who have received treatment with chemoradiation?
MRI can provide useful results about tumor stage before and after re-operative chemoradiation. If tumors show a good response to chemoradiation this is a good prognostic sign. For tumors that are initially very large, another reason to do an MRI after chemoradiaiton is to see if the tumor is surgica...
How would you approach the management of a patient with oligometastatic NSCLC characterized by a LUL mass and a solitary adrenal metastasis, assuming a good performance status?
Induction chemotherapy (platinum-doublet x3 cycles) followed by lobectomy, mediastinal lymph node dissection, and adrenalectomy if no progression after induction chemotherapy.Reference: Gomez DR et al, Lancet Oncology 2016
How do you manage intractable hiccups from radiation?
Hiccups can be extremely vexing for patients while they receive radiotherapy. I gauge my need for medical intervention based on their history of hiccup frequency and pattern through the day (e.g., night-time hiccups only), as well as the kind of other interventions the patient may have attempted. I ...
In a patient with a history of treated stage II seminoma with rising bHCG while on surveillance, do you routinely recheck the bHCG with a different assay?
In this setting, it depends a lot of the confidence you have in the treatment and the degree of HCG elevation. It also depends to some degree on whether the patient had an HCG elevation when he presented with stage II disease. In most of these cases these are very low level HCG elevations that bounc...
When TPN is a barrier to enrollment in hospice for an eligible cancer patient with an irreversible malignant bowel obstruction, how do you approach the conversation about discontinuation of TPN?
This is such a tough question with no great answer. With any difficult conversation like this, I usually take this approach: 1) Understand what the patient's goals are. ("What's most important to you?") 2) Usually they say living as long as possible/as well as possible 3) Acknowledge that goal as r...
How do you treat hiccups in cancer patients?
Personal success has lead me to use Baclofen to control chemotherapy induced hiccups. A single 10 mg dose is usually effective for patients who experience hiccups upon administration of chemotherapy. Occasionally 10 mg q 8 h prn is needed for a few doses. I have seen this side effect and used Baclof...
Do you treat pre- or post-operatively for HO prophylaxis?
At our institution, we typically treat postoperatively rather than preoperatively, although many studies have shown preoperative to be as effective as postoperative. That said, there is one study by Seegenschmeidt et al reported in IJROPB in 1997 that showed preopeartive was less effective for Brook...
How do you manage a rib fracture caused by SBRT?
Chest wall pain, with or without a radiographically evident rib fracture, is an infrequent complication of SBRT--and, it should be remembered, rib fracture is also an infrequent complication of conventionally fractionated RT, reported in numerous series of patients treated with RT to the breast/ches...