Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage dental care, oral hygiene, and nutrition in patients with trismus?
This can be remarkably challenging. Each case must be tailored to the oncologic presentation and discussed with the multidisciplinary team (surgeon, med onc, rad onc, dentist, speech pathologist) and patient. Ideally, your team can try to anticipate short and long-term expections regarding resolutio...
Would you ever omit adjuvant therapy for rectal cancer in patients who underwent primary resection (TME), without any neoadjuvant therapy?
When is it appropriate to recommend a diverting colostomy for treatment of anal cancer or low lying rectal cancer?
If there is bowel obstruction/ near obstruction, recto-vaginal or rectovesical fistula formation.
How do you interpret and utilize PSA values in patients on dialysis?
There appears to be no clinically relevant impact on total serum PSA, whereas free PSA and % of total can be impacted in a membrane type-dependent manner to where % free PSA is of less utility for screening. Thus, total serum PSA seems reasonable to continue as marker of biochemical control post-tre...
How would you qualify and treat a patient with neutropenia, anemia, and abnormal NK cell population with normal trilineage marrow maturation?
I would run a molecular test to confirm that the clonality does not show a CD8-positive clone, as that is more common in LGL. The findings of a clonal NK population by flow cytometry would be enough, in the setting of neutropenia and anemia, to consider a diagnosis of NK cell LGL.
How do you handle the situation where a curative-intent patient unexpectedly passes away while under treatment?
As many of the patients we treat are older and have numerous co-morbidities, this is not that rare an occurrence. Of course, we would presume to avoid treating patients with curative intent if it is readily apparent that their life span will be short due to other non-malignant illness. That said, I ...
What is your approach to a low grade appendiceal mucinous neoplasm found incidentally at appendectomy?
If there is no high-grade component (adenocarcinoma), appendectomy is sufficient. There is no role for adjuvant therapy and no need for surveillance imaging in this setting. Low-grade appendiceal mucinous neoplasms with disseminated peritoneal adenomucinosis (pseudomyxoma peritonei) constitute an en...
How do you approach rising gastrin and chromogranin levels without radiographic evidence of disease in patients with gastrinoma that has been fully resected?
We see this scenario with some frequency - rising hormone or peptide levels in functional NETs without radiographic evidence of disease. My next step would be to get the new Ga68 DOTA TATE PET/CT - essentially a new generation octreoscan with high sensitivity and specificity. These scans often pick ...
For patients with a history of seizures secondary to brain metastases, what are your criteria for discontinuing antiepileptic medications if the seizures have been controlled since SRS or surgery?
Brain metastases patients are discussed at our multidisciplinary brain metastases tumor board whether they have received SRS, surgery or WBRT. In general, I like to keep antiepileptics for up to three months in patients who have seizures that are controlled. Factors that I consider for discontinuing...
What is the appropriate follow up after chemoradiotherapy for patients with anal SCC?
A few points of note. First, the evaluation of the primary site is usually better done by a physical exam than by any imaging study. Therefore, a careful rectal/anal exam is essential at each follow-up. I will usually observe residual abnormalities in the canal as long as it is regressing and there ...