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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% 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 ...

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