Chapter 15: Disorders of the Skin, Breast, and Musculoskeletal System

BACK PAIN, LOW

Population

• –Adults.

Recommendation

AAFP 2004, USPSTF 2004

• –Insufficient evidence for or against the use of interventions to prevent low-back pain in adults in primary care settings.

Sources

• –AAFP. Clinical Recommendations: Low Back Pain. 2004.

• –USPSTF. Low Back Pain. 2004.

Comment

1. Insufficient evidence to support back strengthening exercises, mechanical supports, or increased physical activity to prevent low-back pain.

BREAST CANCER

Population

• –Adult women

Recommendation

NCCN 2018

• –If a woman is at high-risk secondary to a strong family history or very early onset of breast or ovarian cancer, offer genetic counseling.

• –Healthy lifestyle:

  • Breast cancer risks associated with combined estrogen/progesterone therapy ≥3–5 y duration of use.

  • Limit alcohol consumption to less than 1 drink per day (serving equals: 1 oz of liquor; 6 oz of wine, or 8 oz of beer).

  • Exercise.

  • Weight control.

  • Breast-feeding.

• –Risk-reducing agents:

  • Discussion of relative and absolute risk reducing with tamoxifen, raloxifene, or aromatase inhibitors.

  • Contraindications to tamoxifen or raloxifene: history of deep vein thrombosis, pulmonary embolus, thrombotic stroke, transient ischemic attack, or known inherited clotting trait.

  • Contraindications to tamoxifen, raloxifene, and aromatase inhibitors: current pregnancy or pregnancy potential without effective nonhormonal method of contraception. Common and serious adverse effects of tamoxifen, raloxifene, or aromatase inhibitors with emphasis on age-dependent risks.

• –Risk-reducing surgery:

  • Risk-reducing mastectomy should generally be considered only in women with a genetic mutation conferring a high risk for breast cancer, compelling family history, or possibly with prior thoracic RT at <30 years of age. While this approach has been previously considered for LCIS, the currently preferred approach is risk-reducing therapy. The value of risk-reducing mastectomy in women with deleterious mutations in other genes associated with a 2-fold or greater risk for breast cancer (based on large epidemiologic studies) in the absence of a compelling family history of breast cancer is unknown.

Minimize Known Risk Factor Exposure

• –Hormone Replacement Therapy

  • Approximately 26% increased incidence of invasive breast cancer with combination hormone replacement therapy (HRT) (estrogen and progesterone-Prempro).

  • Estrogen alone with mixed evidence—unlikely to increase risk of breast cancer significantly (decreases risk in African-Americans).

• –Ionizing Radiation to Chest and Mediastinum

  • Increased risk begins approximately 10 y after exposure. Risk depends on dose and age at exposure (woman with radiation from age 15 to 30 y at highest risk). These patients often have received mediastinal radiation for Hodgkin Lymphoma.

• –Obesity

  • In Women’s Health Initiative (WHI), relative risk (RR) = 2.85 for breast CA for women >82.2 kg compared with women <58.7 kg only in postmenopausal women.

• –Alcohol

  • RR for intake of 4 alcoholic drinks/day is 1.32.

  • RR increases approximately 7% ...