COMPLEMENTARY AND ALTERNATIVE MEDICINE SERIESSeries Editors: David M. Eisenberg, MD, and Ted J. Kaptchuk, OMD Academia and Clinic The Placebo Effect in Alternative Medicine: Can the Performance of aHealing Ritual Have Clinical Significance?Ted J. Kaptchuk, OMD In alternative medicine, the main question regarding placebo has
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Layoutfor the Federal Government n Increase federal funding through the National Institutes of Health (NIH) to promote greater research into the prevention of breast cancer.
n Increase funding for research into the causes of disparities in breast cancer incidence and outcomes among the different ethnic groups. Increased research must address the economic,social and cultural factors that interfere with access to modern, curative therapies, deliveredin a timely fashion so as to maximize their benefit. Particular attention should be paid tothe higher risk and mortality in younger African-American women. n Increase funding aimed at eliminating barriers to screening for breast cancer for all women, especially those groups with the lower utilization of these services and moreadverse outcomes after treatment. Hispanic women in our study reported more barriersto access for screening and had lower rates of mammography.
n Recommend that women at high risk consider screening before age 40. African-Americans, Ashkenazi Jews, andwomen with a strong family history of breast cancer are atpotentially higher risk and may warrant earlier screeningthan the general population. These screenings shouldremain available and insurable. n Provide guidance to state and local governments to assist them in the publication and distribution of informational materials so that women canbetter understand that the majority of breast cancer cases occur among women who haveno family history of breast cancer. All women need to understand the importance of yearlyscreening mammograms beginning at age 40, as well as other measures important inlimiting risk. Information should highlight differences among ethnic groups with regard tobreast cancer risk. Women surveyed uniformly overestimated the role of family history andgenetics in breast cancer, which may adversely affect many women's screening behavior.
EHHI's study showed that if women where made aware that over 80% of all breastcancers occur in women with no family history, they would be more vigilant aboutmammographic screening. n Expand the effort to identify or exclude causal roles for a variety of environmental contaminants in breast cancer. Increased effort should be directed to assessing exposuresthat occur both during the prenatal period, as well as in early childhood and adolescentyears, in relationship to breast cancer risk.
Recommendationsfor State Governments n States should provide information about known risk factors for breast cancer to allow women to assess their own relative risks. Materials should describe prevention strategiesand how to access screening opportunities within the state.
n States should establish and regularly update a website that provides information about the known and suspected risk factors for breast cancer. The website should include: n The number of women diagnosed with the disease, both nationally and within each state, updated on an annual basis.
Data should include ethnic differences within those statistics; n How women can reduce their risk factors for breast cancer within their control; n How and where women can access screening opportunities within each state.
n States should provide free or limited-cost (by sliding scale) counseling and breast cancer screening services targeted to minorities and the uninsured. These services should be available at convenient locations and times to ensure accessibility for women facingeconomic and social barriers. Innovative efforts to partner with not-for profit organizations, corporate and local businesses, as well as the medical community, shouldbe encouraged to widen access to these services.
n States should undertake a broad public health campaign targeted to enhancing women's understanding of breast cancer risks to increase women's utilization of screening tests.
Women in this survey uniformly overestimated the role of family history and genetics in breast cancer. This overestimation may adversely affect many women's screening behavior. When women were made aware that more than 80% of all breast cancersoccur in women without a family history, they reported that they would be more vigilant about mammographic screening. States should use the media to publicize thisfact, along with other breast cancer prevention strategies. EHHI's study showed that the majority of women surveyed said they obtained their information about breast cancerfrom media sources.
for Foundations n Both increased funding and education are needed to address the disparities in both breast cancer incidence and mortality in the minority community, particularly among youngAfrican-American women.
n Women uniformly overestimate the role of family history and genetics in breast cancer, which may adversely affect many women's screening behavior. EHHI's study shows thatwomen would be more vigilant about getting mammographic screening if they wereaware that more than 80% of all breast cancers occur in women without a family historyof the disease. This fact needs to be publicized.
n Assist in the dissemination of information about breast cancer to women at high risk for the disease, including African American women, Ashkenazi Jews, and those with a strongfamily history of the disease. Women in high-risk groups need to be better informed of theirrisk of early-onset breast cancer so they can consider screening before age 40.
Mammographic screenings should remain available and insurable for these vulnerablegroups.
n Increase funding for research into effective treatments for breast cancer in all women, paying particular attention to African-American women and other at-risk minority populations.
n There is a growing need for research and education efforts devoted to lifestyle factors that may contribute to adverse breast cancer outcomes. The growing obesity epidemic in earlychildhood, adolescence, and young adulthood is a critical influence in breast cancerdevelopment and outcome, and should be a priority for research and intervention.
Partnerships among organizations can broaden these efforts and serve as models for thegovernmental, corporate and the not-for-profit community.
n The majority of women get their breast cancer information from the media. Given the many areas of misunderstanding about breast cancer among the surveyed women, there isa great need for wider dissemination of accurate information through media sources.
Foundations can be helpful in supporting these educational efforts.
n Access to breast cancer screening should be improved. Women would also benefit from better education about the critical need for timely screenings and the importance of yearlyfollow-up exams for all women, irrespective of level of risk, beginning at age 40.
Foundations, in cooperation with the medical community, can offer significant supportfor these activities.
Recommendationsfor the Medical Community: Institutions,Physicians and Healthcare Providers n Healthcare providers and institutions must focus their educational efforts on emphasizing the importance of screening for all women,paying particular attention to vulnerable populations.
n Healthcare institutions should educate primary care providers, including internists, family practitioners, gynecologists, and physicians in training—as well as nurses working with minority populations—about the higher incidence of breast cancer among younger African-American women who have a higher risk of more aggressive cancers. The critical need for patient follow-up, appropriate screenings, and lifestyle interventions cannot be overemphasized.
n Institutions should maximize continuity of care for women who lack a single primary care provider. Fragmentation of care for minority women remains a significant barrier thatreduces the likelihood of timely and appropriate care. n To limit barriers to screening and treatment, institutions should strongly consider the use of patient "navigators" who can facilitate timely follow-up studies and care involvingmultiple practitioners and services. n African-American women should be educated about their higher risk for early-onset breast cancer and the critical importance of early detection through mammographic screening.
Educational efforts could be facilitated by African-American groups, including theNational Medical Association (NMA) and the NAACP, as well as local community andchurch-affiliated organizations. The goal should be to encourage understanding of breastcancer risk factors and the benefits of early detection in improving cancer survival.
Medical institutions should partner with community organizations in these efforts.
n Assure the timely start of adjuvant therapy for early-stage breast cancer, including chemotherapy in the most effective dose and schedule; hormonal treatments whenappropriate; and localized breast irradiation in the appropriate setting. Healthcareproviders and institutions should make every effort to educate minority populations, inparticular, about treatment benefits, while limiting barriers (social, economic, educationalor geographic) that may impair full and timely compliance with these importanttherapies.
n Women should be apprised of the potential benefits of breast-feeding and, whenever possible, be encouraged to breast-feed for at least six months, in line with the AmericanAcademy of Pediatrics recommendations. African-American women, who are at higher risk for premenopausal breast cancer, but whose breast-feeding rates are lower, should be made aware of the the protective effects of breast-feeding.
n Institutions should recognize the barriers to care represented by the costs incurred by low-income women for screening, transportation and childcare needs, as well as the out-of-pocket expenses for treatment. This is particularly problematic for women requiring on-going chemotherapy and radiation with multiple visits to a variety of service n Additional resources and education should be devoted to systems that facilitate rapid and complete follow-up after abnormal tests and studies.
n Minority women are more likely to receive care that does not reflect standards of the 2000 National Comprehensive Cancer Network. All institutions should strive to providecare in accordance with evidence-based guidelines for all patients diagnosed with breast cancer.
n Increased research should be devoted to the role of genetic risk factors in breast cancer within the minority community.
n Institutions and practitioners must be knowledgeable about modifiable breast cancer risk factors, including obesity, inactivity, alcohol consumption and hormone replacementtherapy, in order to counsel patients about healthy lifestyles. Physicians need to be awareof the role of excessive weight in adverse outcomes. Most research indicates that physician recommendations about diet, exercise and weight control are important in ensuringcompliance.
n Multiple programs have been instituted to provide financial assistance to low-income women, such as the National Breast and Cervical Cancer Early Detection Program(NBCCEDP), the Breast and Cervical Cancer Prevention Act of 2000, and the Avon Foundation's AVONCares. These and similar programs should be accessed whereverpossible to help disadvantaged populations. n Women should follow recommended guidelines for mammographic screening, including follow-up studies on a regular basis. This is particularly important for African-Americanwomen who are, according to our survey, largely unaware of their higher risk for early- onset breast cancer. Mammographic screening at a younger age should be considered for n In addition to African-American women, others at high risk, such as those with a strong family history and those with the BRCA-1 or BRCA-2 gene, should consider obtaining a screening mammogram before age 40. They should also consider MRI screening atappropriate intervals based on their physician's recommendations.
n Women should avoid weight gain in early adulthood by eating a healthy diet, rich in vegetables and fruit, low in saturated fat, with a moderate intake of monounsaturated fat (olive and canola oils), along with regular exercise and physical activity. Avoiding weight gain is crucial for all women, but is of particular concern for African-American women, in whom increased body weight may contribute to their adverse breast cancer outcomes.
n Beginning in childhood, parents should foster a healthy diet and include regular exercise for their children. Avoidance of obesity and providing physical activity is critical.
n Women should avoid the use of long-term HRT, particularly combinations of estrogen and progestins.
n Women at higher risk for breast cancer should limit alcohol intake to one to two drinks per week. If women consume alcohol on a regular basis, they should consider taking adaily multivitamin containing folic acid.
n Women at high risk should exercise at least four to five times a week.
n Women at significantly higher risk, such as those with a family history or prior benign breast disease, should discuss with their physicians the option of preventive medications,such as tamoxifen, or other hormonal treatments. In many cases, the benefit of these agents may significantly exceed theirrisk. Because EHHI's survey showed thatmost women are unfamiliar with this option, greater effort should be made to explain the potential benefits of SelectiveEstrogen Receptor Modulator (SERMs).
Recent data support the use of the alternative SERM agent raloxifene (Evista), which provides benefits similar totamoxifen in reducing breast cancer risk,while also improving bone density. Raloxifene has been shown to cause fewer adverse effects, including an absence of increased endometrial cancer risk, lower risks of bloodclots and strokes, and lower rates of cataract formation. Because of its improved riskprofile, many women may find raloxifene a more acceptable alternative to tamoxifen.
n Because we do not know the exact interplay between environmental contaminants and breast cancer, women should avoid exposures to carcinogens and endocrine disrupters.
Exposures to pesticides and other chemicals should be avoided, especially during vulnerable periods of growth, such as pregnancy, early childhood and adolescence.
Until there is more data about the role that chemical exposures play in breast cancerincidence, reducing pesticide and chemical exposures will remain the most prudentcourse of action.
Diagnóstico y tratamiento de la Luis Miguel Rodríguez Fernández1 Salvador Gracia Manzano2 1Unidad de Nefrología Pediátrica Servicio de Pediatría. Hospital de León 2Nefrología Pediátrica. Hospital Universitario Virgen de la Arrixaca. Murcia deben producirse a una edad socialmente (¿A qué llamamos enuresis nocturna y qué