Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In what situations do you obtain both a pelvic MRI and EUS for rectal cancer staging and treatment planning?
I'm not sure that T2N1 is boderline - preop CRT is still a standard of care for node positive disease. Generally, thin slice (3mm or less) MRI with external (if available) or internal coil is the preferred staging modality for patients with newly diagnosed rectal cancer. Utilize the T2 images and c...
Among the many assays/tests available for "liquid biopsies" in metastatic NSCLC, are there any situations where you would want to use one specific assay over the others?
There are many commercial and academic assays under development. None are approved at the moment and none have been shown to be superior. Use of a well reported commercial assay with whom your institution has experience is reasonable
When would you recommend hyperbaric oxygen treatments for skin ulceration/non-healing wounds in a radiated field?
I agree with @Dr. First Last' answer. Careful planning and attempts to avoid non-healing wounds is important, but this can happen. Conservative management should be used before hyperbaric O2 except for severe toxicities such as radiation optic neuropathy where all reasonable measures should be consi...
How do you talk to patients about clinical trials?
I try to incorporate the clinical trial idea into the standard of care recommendation/discussion at the time of initial treatment decision making. After making a standard of care rx recommendation, I tell patients that my recommendation is based upon this treatment being the winner of a prior trial ...
How do you decide which lab to use for multi-gene hereditary testing?
Many commercial companies offer multi-gene panel testing for cancer susceptibility genes. The decision about whether to choose small, medium, and large multi-gene panels depends upon the patient's personal and family history of cancer and also personal preferences. Larger panels have higher rates of...
How are you making the diagnosis of chronic lymphocytic leukemia transforming to prolymphocytic leukemia?
Looking at the trend of pro-lymphocyte increase will help in addition to clinical signs of progressive disease (splenomegaly). It is useful to check for TP53 and MYC translocations since these are common in PLL. As you mentioned, >55% pro-lymphocytes has been used to diagnosed PLL based on a report ...
How do you balance aspiration risks with encouraging PO intake for HN cancer patients during and after chemoradiation?
The main challenge is to identify the patients who are most prone to aspirate during and after Tx. Chemo-RT-related aspiration is frequently “silent”: the patient does not recognize he/she aspirates, and neither does the observer. The risk of aspiration is assessed by modified barium swallow perform...
How do you manage urgency and frequency of bowel movements secondary to radiation proctitis?
In the acute setting we try anusol HC suppository to decrease tenesmus like symptoms
Is it possible to have diffuse, bilateral pulmonary fibrosis as a late side effect of unilateral radiation therapy for breast cancer?
The only context you may see this is in a patient with underlying Interstitial Lung Disease (ILD). I had a woman with a small pulmonary nodule adjacent to the heart and was unresectable. She had moderately severe ILD, and I used a proton plan to try and keep the low dose RT out of the rest of the lu...
How would you manage a patient who presented with synchronous squamous cell carcinoma of the anus (cT2N0) and adenocarcinoma of the rectum (cT3N0) at 7cm from the anal verge?
There is clearly no "correct" answer to questions such as these. However, a reasonable approach would be to treat as one would treat an anal cancer with pelvic RT with 5-FU and mitomycin C and then follow with a low anterior resection for the rectal cancer. If this were a small T2 cancer it would be...