Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you wait a period of time before collecting a 24 hour urine stone risk study in a patient with nephrolithiasis who recently underwent a urologic stone removal procedure?
I generally recommend waiting until the patient is back to steady state, stents are out, pain controlled, and they are back to their usual diet. This time period after urologic procedure varies depending on what the procedure is and if any post-procedure complications and their management.
How do you approach pre-conception counseling in males who are on medications for which there is limited or no data such as Jak inhibitors, apremilast, or belimumab?
I am transparent about the lack of data, but discuss the differences in mechanism of action between cyclophosphamide and thalidomide (the only medications we recommend against conception with a partner) and JAKi, Apremilast, and Benlysta. Prior data has demonstrated a clinically insignificant amount...
Do you treat hypercalciuria in post menopausal osteoporosis with normal serum calcium and PTH?
I ABSOLUTELY recommend treating! This is the sine qua non of secondary osteoporosis with the osteoporosis being a direct consequence of the underlying hypercalciuria. Thiazides are great in this setting. I use chlorthalidone in preference to HCTZ because it has a longer half-life and can be used onc...
What is your institution's active surveillance protocol?
The topic of active surveillance continues to evolve in light of the PIVOT trial and rapid adoption of mpMRI for initial staging. The 2014 NCCN guidelines summarize commonly used approaches, does not yet advocate for mpMRI, but declares an urgent need for more research. Meanwhile, the 2014 NICE Guid...
Should we be more concerned about cardiac toxicity following breast radiotherapy?
The way I interpret the data with all caveats that threshold dose and time period for any cardiac morbidity is significantly lower than what was expected. For that reason, all efforts should be made to avoid any direct photon beam wherever possible to go through any portion of heart by using any one...
What is the difference between involved node and involved site irradiation?
In both involved node and involved site (ISRT), prechemotherapy GTV determines the CTV. However, ISRT accommodates cases in which optimal prechemotherapy imaging is not available to the radiation oncologist. In ISRT, clinical judgment in conjunction with the best available imaging is used to contour...
Should I decline to treat a patient with a first site of metastasis who refuses a biopsy?
Ideally, all patients with a first site of metastatic disease should have a biopsy. However, the details are critical. Is the location amenable to a bx? Is the patient's performance status poor? Has it been an extended period of time since treatment for the primary disease? Is it a solitary metastas...
Has pelvic MRI replaced EUS as the standard of care for rectal cancer staging?
I think looking at data both show very similar sensitivity and specificity for staging and is matter of expertise and resources available at the institution.
Should early referral to palliative care be standard of care for all patients with metastatic cancer?
There are data to support that early palliative care involvement can improve patient quality of life. One study that specifically comes to mind is a study published by Temel et al in NEJM 2010 (http://www.ncbi.nlm.nih.gov/pubmed/20818875) in the setting of metastatic NSCLC. This study randomized pat...
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 ...