Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + BACK PAIN, LOW Download Section PDF Listen +++ +++ 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 ++ Insufficient evidence to support back strengthening exercises, mechanical supports, or increased physical activity to prevent low-back pain. + BREAST CANCER Download Section PDF Listen +++ +++ 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% for each drink per day. Family history—risk is doubled if a single first-degree relative develops breast cancer. Fivefold increased risk if 2 first-degree relatives are diagnosed with breast cancer. (Breast CA Res Treat. 2012;133:1097) –Factors of Unproven or Disproven Association Abortions. Environmental factors. Diet and vitamins. Underarm deodorant/antiperspirants—no evidence to support increased risk of breast ca. (J Natl Cancer Inst. 2002;94:1578). ++ Therapeutic Approaches to Reduce Breast Cancer Risk ++ –Tamoxifen (Postmenopausal and High-Risk Premenopausal Women) Treatment with tamoxifen for 5 y reduced breast CA risk by 40%–50%. USPSTF reemphasizes discussion with women at increased risk of breast cancer to strongly consider chemoprevention with selective estrogen receptor modulators (SERMs) or aromatase inhibitors (AIs in postmenopausal women only). (Ann Intern Med. 2013;159:698-718) Meta-analysis shows RR = 2.4 (95% confidence interval [CI], 1.5–4.0) for endometrial CA and 1.9 (95% CI, 1.4–2.6) for venous thromboembolic events. –Raloxifene (Postmenopausal Women) Similar effect as tamoxifen in reduction of invasive breast CA, but does not reduce the incidence of noninvasive tumors—studied only in postmenopausal women. Similar risks as tamoxifen for venous thrombosis, but no risk of endometrial CA or cataracts. (Lancet. 2013;381:1827) –Aromatase Inhibitors Anastrozole reduces the incidence of new primary breast CAs by 50% compared with tamoxifen; similar results have been reported with letrozole and exemestane treatment (Lancet. 2014;383:1041). Aromatase inhibitor use as a prevention of breast cancer will reduce the risk of developing breast cancer by 3%–5%. Harmful effects of aromatase inhibitors include decreased bone mineral density and increased risk of fracture, hot flashes, increased falls, decreased cognitive function, fibromyalgia, and carpal tunnel syndrome. There are no life-threatening side effects. –Prophylactic Bilateral Mastectomy (High-Risk Women) Reduces risk of breast cancer as much as 90%. Approximately 6% of high-risk women undergoing bilateral mastectomies were dissatisfied with their decision after 10 y. Regrets about mastectomy were less common among women who opted not to have breast reconstruction. –Prophylactic Salpingo-oophorectomy among BRCA-Positive Women Breast CA incidence decreased as much as 50%. Nearly all women experience some sleep disturbances, mood changes, hot flashes, and bone demineralization, but the severity of these symptoms varies greatly. Salpingo-oophorectomy should be done in BRCA 1 patients at 35 y of age and >40 y of age in BRCA 2 patients. In patients who have uterus removed as well, it is safe to give estrogen replacement. (Eur J Cancer. 2016;52:138) –Exercise Exercising >120 min/wk results in average risk reduction of developing breast cancer by 30%–40%. There is also a 30% reduction in breast cancer recurrence in patients who have had breast CA. (Eur J Cancer. 2016;52:138) The effect may be greatest for premenopausal women of normal or low body weight. –Breast-Feeding The RR of breast CA is decreased 4.3% for every 12 mo of breast-feeding, in addition to 7% for each birth. –Pregnancy before Age 20 y Approximately 50% decrease in breast CA compared with nulliparous women or those who give birth after age 35 y. –Dense Breasts Women have increased risk of breast CA proportionate to breast density. Relative risk 1.79 for 50% density and 4.64 for women with >75% breast density. (Cancer Epidemiol Biomarkers Prev. 2006;15:1159) (Br J Cancer. 2011;104:871) No known interventional method to reduce breast density. Adding ultrasound to mammography will improve sensitivity and specificity and is more accurate than tomosynthesis without radiation exposure. (J Clin Oncol. 2016;34:1840, 1882) + GOUT Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ American College of Rheumatology 2012 ++ –Recommend a urate-lowering diet and lifestyle measures for patients with gout to prevent exacerbations. –Urate-lowering medicationsa are indicated for gout with Stage 2–5 CKD or recurrent gout attacks and hyperuricemia (uric acid >6 mg/dL). –Anti-inflammatory prophylaxisb indicated for 6 mo after an attack and for 3 mo after uric acid level falls <6 mg/dL. ++ Source ++ –Arthritis Care Res. 2012;64(1):1431-1446. +++ Comments ++ Minimize or avoid alcohol and purine-rich meat and seafood. Limit consumption of high-fructose corn syrup–sweetened soft drinks and energy drinks. Increase low-fat dairy products and vegetable intake. + ++ aColchicine 0.6 mg daily-bid; naproxen 250 mg bid is second-line; low-dose prednisone is third-line. ++ bAllopurinol, febuxostat, probenecid; goal uric acid level <6 mg/dL. + ORAL CANCER Download Section PDF Listen +++ +++ Population ++ –Adults +++ Recommendations ++ National Cancer Institute 2018 ++ –Minimize Risk Factor Exposure. Risk factors include: Tobacco (in any form, including smokeless). Alcohol and dietary factors—double the risk for people who drink 3–4 drinks/d vs. nondrinkers. (Cancer Causes Control. 2011;22:1217) Betel-quid chewing. (Cancer. 2014;135:1433) Oral HPV infection—found in 6.9% of general population and found in 70%–75% of patients with oropharyngeal squamous cell cancer. (N Engl J Med. 2007;356:1944) Lip cancer—avoid chronic sun exposure and smokeless tobacco. ++ Source ++ –https://www.cancer.gov/types/head-and-neck/hp/oral-prevention-pdq +++ Comments ++ Oropharyngeal squamous cell CAs (tonsil and base of tongue) are related to HPV infection (types 16 and 18) in 75% of patients. This correlates with sexual practices, number of partners, and may be prevented by HPV vaccine. HPV (+), nonsmokers have improved cure rate by 35%–45%. (N Engl J Med. 2010;363:24, 82) There is inadequate evidence to suggest change in diet will reduce risk of oral cancer. + PRESSURE ULCERS Download Section PDF Listen +++ +++ Population ++ –Adults or children with impaired mobility. +++ Recommendations ++ NICE 2014, ACP 2015 ++ –Assess risk for in both outpatient and inpatient settings (eg, the Braden Scale in adults and Braden Q Scale in children). –Educate patient, family, and caregivers regarding the causes and risk factors of pressure ulcers. –Use compression stockings cautiously in patients with lower-extremity arterial disease. Avoid thigh-high stockings when compression stockings are used. –Move patients with caution Avoid dragging patient when moving. Lubricate or powder bed pans prior to placing under patient. –Minimize pressure on skin, especially areas with bony prominences. Turn patient side-to-side every 2 h. Pad areas over bony prominences. Pad skin-to-skin contact. Use heel protectors or place pillows under calves. Consider a bariatric bed for patients weighing over 300 lb. Consider high-specification foam (not air) mattress for high-risk patients admitted to secondary care or who are undergoing surgery. –Manage moisture. Moisture barrier protectant on skin. Frequent diaper changes. Scheduled toileting. Treat candidiasis if present. Consider a rectal tube for stool incontinence with diarrhea. –Maintain adequate nutrition and hydration. –Keep the head of the bed at or <30° elevation. ++ Sources ++ –National Clinical Guideline Centre. Pressure Ulcers: Prevention and Management of Pressure Ulcers. London (UK): National Institute for Health and Care Excellence; 2014. –Ann Intern Med. 2015;162(5):359-369. +++ Comments ++ Outpatient risk assessment for pressure ulcers: Is the patient bed or wheel chair bound? Does the patient require assistance for transfers? Is the patient incontinent of urine or stool? Any history of pressure ulcers? Does the patient have a clinical condition placing the patient at risk for pressure ulcers? DM. Peripheral vascular disease. Stroke. Polytrauma. Musculoskeletal disorders (fractures or contractures). Spinal cord injury. Guillain—Barré syndrome. Multiple sclerosis. CA. Chronic obstructive pulmonary disease. Coronary heart failure. Dementia. Preterm neonate. Cerebral palsy. Does the patient appear malnourished? Is equipment in use that could contribute to ulcer development (eg, oxygen tubing, prosthetic devices, urinary catheter)? + SKIN CANCER Download Section PDF Listen +++ +++ Population ++ –All people +++ Recommendations ++ USPSTF 2018 ++ –Counsel to minimize UV exposure for people age 6 mo to 24 y with fair skin types. –Offer selective counseling to adults over 24 y with fair skin types. –Insufficient evidence to recommend skin self-exam. ++ National Cancer Institute ++ –Avoid sunburns and tanning booths,a especially severe blistering sunburns at a younger age. ++ Source ++ –JAMA. 2018;319(11):1134-1142. –http://www.cancer.gov/types/skin/hp/skin-prevention-pdq +++ Comments ++ Use sunscreen (SPF ≥15) and protective clothing, spend limited time in the sun, avoid indoor tanning and blistering sunburn in adolescents and young adults. Phenotypic risk factors (fair skin) include ivory or pale skin color, light eye color, red or blond hair, freckles, or easily sunburned skin. Nicotinamide (Vitamin B3) shows promise in preventing skin cancers but further studies are required. (J Invest Dermatol. 2012;132:1498) Chemopreventive agents (beta carotene, isoretinoin, selenium, and celecoxib) have not shown prevention of new skin cancers in randomized clinical trials. (Arch Dermatol. 2000;136:179) + ++ aTwenty-eight million Americans per year use indoor tanning salons—increased risk of squamous cell and basal cell cancers greater than melanoma. Source: http://www.cancer.gov/cancertopics/pdq/prevention.