Day: March 23, 2009

Where Can I Get Information About CAM?

Patient Presentation
A 19-year-old female came to clinic with a one month history of left breast pain. It occurred constantly but was worse at night or other times when she would not wear a bra. The pain was in the superior half of the breast and radiated to the axilla. There was no nipple tenderness or discharge, and the pain did not change with menses. She said that it was a 6-7 on a scale of 10. She denied trauma, sexual activity, stimulation of the breast or nipple, any medications or complementary or alternative medications.

The past medical history showed menarche at age 12 year with regular periods at age 13 years.

The family history was negative for any benign or malignant breast disease. There was some diabetes in older relatives.

The review of systems showed no fevers, weight changes, sweating, skin changes, or masses.

The pertinent physical exam revealed a patient with normal vital signs and growth parameters. Her left breast was larger than the right breast and was very painful in the top 1/2 of the breast. The pain radiated to the axilla approximately 1/3 of the way toward the back. She had no skin changes, or increase in warmth. No masses were palpable and there was no nipple discharge. There appeared to be no lymphedema of the breast, axilla or arm. The axilla had no palpable nodes. She had some anterior cervical shoddy and groin adenopathy but no other nodes or masses.

The laboratory evaluation of a urine β HCG was negative.

The radiologic evaluation of a breast ultrasound also was negative and showed only normal breast tissue.

The diagnosis of mastodynia was made and the patient was instructed to use ibuprofen in anti-inflammatory dosing, to use a supportive bra and heat or cold as would provide her some relief.

The patient’s clinical course over the next two weeks found the pain to increase and now involved the entire axilla and underside of her arm. It also involved 3/4 of the breast vertically. The rest of the examination was unchanged. She was referred to a general surgeon who could find no other reasons for the pain. The surgeon did recommend to try using primrose oil, Vitamin E and increasing the iodine in her diet as possible measure to improve the pain. She also recommended to limit caffeine as a possible adjuvant therapy. The primary care physician had not used these complementary medications and so used the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health and Memorial Sloan Kettering’s Herbal and Botanical Information Resource to learn more about these medications.

Discussion
Mastodynia or mastalgia (i.e. painful breast) can be a worrisome problem when it first presents as it may be the herald of problems such as breast cancer. However most mastodynia is associated with normal hormonal changes such as menstrual cycles, pregnancy, breastfeeding and menopause. Other non-cyclical causes of mastodynia include:

  • Breast
    • Breast cancer
    • Cooper ligament stretching
    • Cysts
    • Mastitis
    • Sclerosing periphlebitis of the breast veins
  • Skin
    • Dermatitis
    • Hidradenitis supprative
  • Musculoskeletal
    • Costochondritis
    • Fibromyalia and other pain syndromes
    • Localized or diffuse lateral chest-wall pain
    • Radicular pain from cervical spine
  • External
    • Pressure from brassiere
    • Trauma
  • Miscellaneous
    • Estrogen-containing topical or oral medications
    • Gallbladder disease
    • Ischemic heart disease

When the pain does not resolve and a cause of the pain is not apparent, it can be especially frustrating for the patient and also the healthcare providers trying to provide relief for the patient.

Learning Point
Check for bold/italics and then delete this
It is estimated that 50% of adult patients use complementary and alternative medications and therapy (CAM). Most do not reveal this information to their healthcare providers because they do not view it as CAM or don’t want their providers to know they are using it. Health care providers may also feel uncomfortable asking about CAM as they are less familiar with the vast range of the different medications and therapies, and their actual usage. Evidence supporting their efficicacy and potential side effects can be unavailable, contradictory, done in small studies or done in poorly designed studies. Adding to this is the problem that most of the herbal, botanical and other medications are not regulated therefore available preparations and dosages can be inconsistent.

The American Academy of Pediatrics recommends partnering with families by seeking information and sharing it with families, evaluating the scientific merits of the therapeutic approaches, identifying risks or potential harmful effects, providing information and educating families on a range of therapies and their options, assisting in evaluating and monitoring therapeutic outcomes of CAM or other therapies, and during the conversations acknowledging the families’ perspective on the use of CAM and avoid becoming personally defensive.

Healthcare providers do have quality information sources available through the Internet including:

Questions for Further Discussion
1. How often are your own patients using complementary and alternative medications and therapies?
2. What information resources do you have locally for complementary and alternative medications and therapies?

Related Cases

    Symptom/Presentation
    Pain

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Breast Diseases and Complementary and Alternative Medicine.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Kessler JH. The effect of supraphysiologic levels of iodine on patients with cyclic mastalgia. Breast J. 2004 Jul-Aug;10(4):328-36.

Santen RJ, Mansel R. Benign breast disorders. N Engl J Med. 2005 Jul 21;353(3):275-85.

Memorial Sloan-Kettering Cancer Center. About Herbs, Botanicals and Other Products. Available from the Internet at http://www.mskcc.org/mskcc/html/11570.cfm (rev. 2009, cited 1/29/09).

National Institutes of Health National Center for Complementary and Alternative Medicine. Available from the Internet at http://nccam.nih.gov/ (rev. 1/16/2009, cited 1/29/09).

National Institues of Health Office of Dietary Supplements. Available from the Internet at http://ods.od.nih.gov/ (cited 1/29/09).

American Academy of Pediatrics Policy Statement. Counseling Families Who Choose Complementary and Alternative Medicine for Their Child With Chronic Illness or Disability.Available from the Internet at http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b107/3/598 (rev. 5/1/2005, cited 1/29/09).

American Academy of Pediatrics’ Clinical Report. The Use of Complementary and Alternative Medicine in Pediatrics. http://pediatrics.aappublications.org/cgi/content/full/122/6/1374 (rev. 12/6/2009, cited 1/29/09).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital