Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage acute esophagitis that persists > 1-2 months after completing chemoradiation for lung cancer?
Harsh protracted esophagitis was reported in 4% of Int. O139(1999)i.e., grade 4 regardless of once or twice daily cycle 1 concurrent. CONVERT reports 18% grade 3!or higher, either QD 66 or BID 45. No reports of > 1 mo duration. Consider endoscopy and culture. Empiric carafate and anti-fungal/candida...
Should patients with idiopathic pulmonary fibrosis be placed on nintedanib or pirfenidone before starting radiotherapy for lung cancer?
This is an interesting question but this is a small patient population in our practice and we have not initiated either drug in the setting of IPF to prevent possible radiation related side effects to the lung because we are unaware of any information to suggest that there would be a benefit.
How do you approach rectal spacer for the patient with renal failure?
Have not come across this but I would presume it would be filtered with dialysis in pts with renal failure.
Do you refer patients to cardiology if they have no history of cardiac disease but will be receiving XRT with high mean doses to the heart?
Great question! Yes, we are starting to refer patients to cardiology who have Stage III NSCLC or LS-SCLC and are receiving high-dose radiation therapy. Trying to tease out whether its heart dose or central tumor location, or some combination of the two, that confers a poorer prognosis is challenging...
Do you perform a bone health assessment in men who will be receiving short term androgen deprivation for localized prostate cancer?
I do not order bone densitometry on patients I am treating with short term (<= 6 months) of AD, unless they have a risk factor like long-term glucocorticoid use or prior fracture. For patients I am treating with long term >=18 months I perform a baseline bone densitometry. If that is normal-mild ost...
What stage is bilateral orbital/conjunctival NHL (limited only to the bilateral orbit/conjunctiva)?
By the Ann Arbor staging system, this is stage IV disease because more than one extranodal site is involved at initial presentation. However, NCCN and other guidelines acknowledge that MALT lymphoma involving both paired organs (e.g., bilateral orbital/conjunctiva) is often best treated with RT alon...
How do you manage soft tissue necrosis in a patient who underwent TORS followed by RT?
Close observation Minimize trauma Don’t biopsy unless something very suspicious
How would you manage an elderly patient with GE junction adenocarcinoma who is not interested in surgery and who has ulcerative colitis (not currently on medication or symptomatic)?
Ulcerative colitis is generally a disease limited to the colon, and is an important distinction from Crohn's disease, which is truly anywhere from mouth to anus in the GI tract. These two diseases are on a spectrum of inflammatory bowel disease and there can be some overlap, but in general I would p...
For small peripherally located NSCLC, when do consider referral for mediastinal evaluation prior to curative surgery vs proceeding to resection with mediastinal eval at time of surgery?
Although there is variability among the different guidelines (ACCP, ESTS, NCCN) in regards to mediastinal staging, there is consensus that no invasive staging is required for peripheral nodules which are T1A (T1abcN0) given the low prevalence of occult N2 disease. Invasive mediastinal staging should...
Should breast cancer patients with never-treated latent TB and for whom chemotherapy is indicated be treated for latent TB during chemotherapy?
Interestingly latent tb reactivation while on cyclic combination Chemotherapy is quite rare even in endemic countries like India, including among patients treated for leukemia. This could be due to cyclic nature of immune suppression rather than chronic immune suppression which is required for tb re...