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 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.

Comments

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

2. Meta-analyses in Lancet 2018;391:2368-2383, Am J Epidemiol. 2018;187(5):1093-1101, and JAMA Intern Med. 2016;176(2):199-208:

   1. Exercise alone or exercise in combination with education is effective for preventing low-back pain.

   2. Education alone, back belts, and shoe insoles are not effective.

   3. Exercises that were studied and shown to be effective are a combination of strengthening with either stretching or aerobic exercise, 2–3 times/wk.

BREAST CANCER

Population

• – Adult women.

Recommendations

NCCN 2019

• – 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.

• – Lifestyle

  • Limit alcohol consumption. 4 drinks per day increases relative risk 1.32.

  • Exercise: at least 150 min/wk of moderate intensity, or at least 75 min/wk of vigorous aerobic physical activity.

  • Weight control. Relative risk 2.8 if weight >82 kg vs. <59 kg.

  • Breast-feeding. Relative risk decreases 4% for every year of breast-feeding.

  • Pregnancy. Pregnancy <20 y carries 50% risk reduction vs. first pregnancy after age 35. Each pregnancy reduces risk 7%.

  • Combined estrogen/progesterone therapy (≥3–5 y duration of use raises incidence by 26%).

• – Risk-reducing agents for high-risk patients:

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

  • Treatment with tamoxifen for 5 y reduced breast CA risk by 40%–50%. (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 has similar effect & risk as tamoxifen, except no reduction in noninvasive tumor and no increased risk of endometrial CA or cataracts (Lancet. 2013;381:1827).

  • Aromatase inhibitor use as a prevention of breast cancer will reduce the risk of developing breast cancer by 3%–5% (Lancet. 2014;383:1041). Harmful effects include decreased bone mineral density and increased risk of fracture, hot flashes, increased falls, decreased cognitive function, fibromyalgia, and carpal tunnel syndrome but no life-threatening side effects.

• – 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 ...