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THE BREAST CANCER Oncology Nursing
June 13, 2013 Ms. Beverly S. Angot
Breast cancer is a malignant tumor that starts in the cells of the breast. A malignant tumor is a group of cancer cells that can grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body. The disease occurs almost entirely in women, but men can get it, too. – One of every 13 Filipino women is expected to develop breast cancer in her lifetime. (Philippine Star, 2013) – Breast cancer is the most common cancer in the Philippines, taking at least 16 percent of the 50,000 cases diagnosed. (Department of Health and Philippine Cancer Society, 2010) – In men, less than 1% of all breast cancers. (Dr. Aldine Basa, 2010) The Normal Breast The female breast is made up mainly of lobules (milk-producing glands), ducts (tiny tubes that carry the milk from the lobules to the nipple), and stroma (fatty tissue and connective tissue surrounding the ducts and lobules, blood vessels, and lymphatic vessels). Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in the cells that line the lobules (lobular cancers), while a small number start in other tissues.
The lymph (lymphatic) system of the breast The lymph system is important to understand because it is one way breast cancers can spread. This system has several parts. Lymph nodes are small, bean-shaped collections of immune system cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the breast. Lymph contains tissue fluid and waste products, as well as immune system cells. Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes.
cells escape the normal controls on their growth and proliferation. Because of this. Wyeth Paul R. When cancer occurs. Angot Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes). Pathogenesis of Breast Cancer Normal cells in the body communicate with each other and regulate each other's proliferation (division). • Proto-oncogenes (acquired) – They become oncogenes and then can promote tumor formation or growth. The more lymph nodes that have breast cancer. not all women with cancer cells in their lymph nodes develop metastases.Alcantara. 2 . Alejandro. Some lymphatic vessels connect to lymph nodes inside the chest (internal mammary nodes) and those either above or below the collarbone (supraclavicular or infraclavicular nodes). but have not spread to the nearby tissue or beyond. Two Categories of Breast Cancer Noninvasive Breast Cancer Ductal Carcinoma in Situ – located within the duct and have not invaded the surrounding fatty breast tissue. • Proto-oncogenes – Responsible for promoting cell growth. What are the genes that are being damaged? • Tumor Suppressor Genes – They control the processes of cell growth and cell death (called apoptosis). finding cancer in one or more lymph nodes often affects the treatment plan. Beverly S. If the cancer cells have spread to lymph nodes. How do cells escape their normal growth and proliferation? • By acquiring damage (mutations) to genes that normally regulate cell proliferation. What happens to the genes when mutated? • Tumor Suppressor Genes (acquired/inherited) – This can lead to tumor formation or growth.Cells proliferate to replace worn-out cells. 2013 Ms. Lobular Carcinoma in Situ – abnormal cells grow inside the lobules of the breast. there is a higher chance that the cells could have also gotten into the bloodstream and spread (metastasized) to other sites in the body. and some women can have no cancer cells in their lymph nodes and later develop metastases. THE BREAST CANCER Oncology Nursing June 13. John Renefrank B. the more likely it is that the cancer may be found in other organs as well. Still.
• 10% suffer from brain metastases. Angot Invasive Breast Cancer Infiltrating Ductal Carcinoma – originates in the mammary glands and grows in the epithelial cells lining these ducts.Alcantara. Possible Outcomes of Metastasis of Breast Cancer • 70% of breast cancer patients suffer from bone metastases. Beverly S. – behavioral and personality changes. Manifestation of Metastases Metastatic breast cancer to the lung or pleura causes – chronic cough. Metastatic disease to the liver causes – Jaundice – elevated liver enzymes – abdominal pain – loss of appetite – nausea – vomiting • • • • 3 . – progressive pain – less commonly – pathological fracture – erythema over the affected bone – swelling Metastatic breast cancer to the brain causes the following symptoms: – persistent. – progressively worsening headache. THE BREAST CANCER Oncology Nursing June 13. – vertigo. nausea or vomiting. • 20% suffer from lung and liver metastases. John Renefrank B. Alejandro. Wyeth Paul R. – seizures. – Increased intracranial pressure. – dyspnea – abnormal chest X-ray – chest pain Metastatic disease to the bone causes – severe. – visual changes. 2013 Ms.
but this disease is about 100 times more common among women than men. Personal history of Breast Cancer • A woman with cancer in one breast has a 3. Wyeth Paul R. John Renefrank B. White women are slightly more likely to develop breast cancer than are African-American women. Alejandro. • However. They seem to raise a woman's risk of breast cancer slightly (1½ to 2 times normal). but African-American women are more likely to die of this cancer. which can promote breast cancer cell growth Aging • Your risk of developing breast cancer increases as you get older. Certain benign breast conditions • Non-proliferative lesions: These conditions are not associated with overgrowth of breast tissue. 4 . • Proliferative lesions without atypia: These conditions show excessive growth of cells in the ducts or lobules of the breast tissue. Dense Breast Tissue • Women with dense breasts are four to five times more likely to get breast cancer than women with less dense breasts. • The BRCA1 and BRCA2 are Tumor Suppressor Genes that are inherited. Beverly S. Genetics • Inherited DNA changes can increase the risk for developing cancer and are responsible for the cancers. in women under 45 years of age. Angot Causes of Gene Mutation: Resulting to Cancer Gender • Simply being a woman is the main risk factor for developing breast cancer. • About 1 out of 8 invasive breast cancers are found in women younger than 45 .to 4-fold increased risk of developing a new cancer in the other breast or in another part of the same breast. • This is likely because men have less of the female hormones estrogen and progesterone. 2013 Ms. breast cancer is more common in African-American women. and Native-American women have a lower risk of developing and dying from breast cancer. • Men can develop breast cancer.Alcantara. while about 2 of 3 invasive breast cancers are found in women age 55 or older. Race and Ethnicity • Overall. Hispanic. THE BREAST CANCER Oncology Nursing June 13. • Asian.
• It is “Suggestive but not Sufficient” evidence of a link at this point. Angot Proliferative lesions with atypia: In these conditions. Beverly S. Having more fat tissue especially after menopause can increase your chance of getting breast cancer by raising the estrogen levels. The Health Consequences of Involuntary Exposure to Tobacco Smoke) Signs and Symptoms The most common symptom of breast cancer is a new lump or mass. with some of the cells no longer appearing normal.Alcantara. (The 2006 US Surgeon General's report. there is an overgrowth of cells in the ducts or lobules of the breast tissue. raising it 3 1/2 to 5 times higher than normal. the International Agency for Research on Cancer concluded that there is limited evidence that tobacco smoking causes breast cancer. Having children • Women who have had no children or who had their first child after age 30 have a slightly higher breast cancer risk. They can even be painful. Wyeth Paul R. Tobacco Smoking • For a long time. – In 2009. Hormone Therapy and Birth Control Pills • Women using these therapeutic regimens can increase the risk of developing breast cancer due to the prolonged exposure of estrogen and progesterone. Other possible signs and symptoms: – Swelling of all or part of a breast (even if no distinct lump is felt) – Skin irritation or dimpling – Breast or nipple pain – Nipple retraction (turning inward) – Redness. They have a stronger effect on breast cancer risk. scaliness. soft. John Renefrank B. studies found no link between cigarette smoking and breast cancer. a process known as angiogenesis. A painless. 2013 Ms. Alejandro. Alcohol • Alcohol causes cancer cells' blood vessels to grow which in turn fuels the growth of the tumor. hard mass that has irregular edges is more likely to be cancerous. or rounded. • THE BREAST CANCER Oncology Nursing June 13. but breast cancers can be tender. • The increase in risk may be due to a longer lifetime exposure to the hormones estrogen and progesterone. or thickening of the nipple or breast skin – Nipple discharge (other than breast milk) – Lymph nodes under the arm 5 . Overweight and Obese • Most of a woman's estrogen comes from fat tissue. Menstrual periods • Women who have had more menstrual cycles because they started menstruating early (before age 12) and/or went through menopause later (after age 55) have a slightly higher risk of breast cancer.
smooth touch with the first few finger pads of your hand. Alejandro. or yellow fluid or blood). raise your arms and look for the same changes. Early Cancer Detection THE BREAST CANCER Oncology Nursing June 13. 2013 Ms. Step 4: Next. Wyeth Paul R. Breasts that are evenly shaped without visible distortion or swelling If you see any of the following changes. keeping the fingers flat and together. Breast self-examination (BSE) is an option for women starting in their 20s. women should have a CBE by a health professional every year. puckering. Observe for: Breasts that are their usual size. Step 3: While you're at the mirror. feel your breasts while lying down.Alcantara. Use a circular motion. John Renefrank B. Starting at age 40. look for any signs of fluid coming out of one or both nipples (this could be a watery. shape. and color. bring them to your doctor's attention: – – – Dimpling. Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Angot Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health. using your right hand to feel your left breast and then your left hand to feel your right breast. or swelling Step 2: Now. milky. Screening Procedures for Early Detection Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional preferably every 3 years. about the size of a 6 . Beverly S. or bulging of the skin A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out) Redness. soreness. Use a firm. Women should be told about the benefits and limitations of BSE. rash. Women should report any breast changes to their health professional right away.
This up-and-down approach seems to work best for most women. feel your breasts while you are standing or sitting. It is the best screening tool used today to find breast cancer early. 7 . Anxiety related to the diagnosis of cancer Fear related to specific treatments and body image changes Risk for ineffective coping related to the diagnosis of breast cancer Decisional conflict related to treatment options. Angot Cover the entire breast from top to bottom. Mammogram images can be stored on film (standard) or on a computer (digital). and from the armpit to the breastbone. Step 5: Finally. Nursing Diagnosis Deficient knowledge about the planned surgical treatments. A clinical breast exam includes a visual examination and carefully feeling the entire breast — from the collarbone to the bra line. and from your armpit to your cleavage. using the same hand movements described in Step 4. A mammogram can find cancer at an early stage when it is small and easier to treat. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery. as if you were mowing a lawn. 2013 Ms. Follow a pattern to be sure that you cover the whole breast. If you are 40 or older. Cover your entire breast. schedule your mammogram close to the time of your clinical breast exam. you should be able to feel down to your ribcage. use firm pressure for the deep tissue in the back. in rows. Alejandro. Clinical Breast Exam — a breast exam by a health care provider should be part of your regular medical checkup. Be sure to feel all the tissue from the front to the back of your breasts: for the skin and tissue just beneath. If it is not. moving in larger and larger circles until you reach the outer edge of the breast. so they like to do this step in the shower. You can also move your fingers up and down vertically.Alcantara. Mammogram — a mammogram is an X-ray of the breast. When you've reached the deep tissue. Wyeth Paul R. Beverly S. You can begin at the nipple. use medium pressure for tissue in the middle of your breasts. John Renefrank B. quarter. Disturbed body image related to loss or alteration of the breast Screening Procedures • Self-Breast Examination • Clinical Breast Examination • Mammogram Diagnostic exams in Breast CA Biopsy • It is the examination of affected tissue in detecting presence of cancer cells. side to side — from your collarbone to the top of your abdomen. ask for it. THE BREAST CANCER Oncology Nursing June 13. use light pressure.
• Prepare the patient for the effects of chemotherapy. fatigue. • Involve the patient in planning and treatment. weight gain or loss. for patients receiving chemotherapy. Provide psychological support to the patient throughout the diagnostic and treatment process. stomatitis. 2013 Ms. and plan ahead for alopecia. nausea and vomiting. • Administer I. • Administer antiemetics prophylactically. • Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. THE BREAST CANCER Oncology Nursing June 13. 8 . alopecia. as directed. Angot Nuclear Magnetic Resonance Imaging • This is viewing the structure of the breast using a high tech radiation imaging in detecting presence of mass or tumors. anorexia. John Renefrank B. dry cough. Wyeth Paul R. Alejandro. and depression. anxiety. nausea.V. fluids and hyperalimentation as indicated. Beverly S. sore throat. fatigue.Alcantara. • Monitor for adverse effects of chemotherapy. A ductogram can show if there is a mass inside the duct at the nipple Treatment • Lumpectomy • Partial or segmental mastectomy • Simple mastectomy • Modified radical mastectomy • Axillary lymph node dissection • Chemotherapy • Radiation Therapy Surgical Nursing Intervention • Pre-operative – Obtain informed consent – Provide good care for a breast care – Be sure to know what kind of surgery to be performed in order to prepare the patient – If mastectomy is scheduled: • Prevent pulmonary complications and thromboembolism • Place patient on the affected side • Post-operative – Inspect dressing anteriorly and posteriorly – Check circulatory status – Encourage coughing exercises and turning schedule every two hours – Provide psychological and emotional support – Explain to the patient that she may experience phantom breast syndrome Nursing Intervention • Monitor for adverse effects of radiation therapy such as fatigue. bone marrow suppression. Ductogram • A type of X-ray that helps determines the cause of nipple discharge. • Describe surgical procedures to alleviate fear.
Beverly S. depression. • • THE BREAST CANCER Oncology Nursing June 13. Angot Help patient identify and use support persons or family or community. 2013 Ms. or sexual problems.Alcantara. Suggest to the patient the psychological interventions may be necessary for anxiety. Alejandro. Wyeth Paul R. John Renefrank B. • Teach all women the recommended cancer-screening procedures. Medications • Trastuzumab (Herceptin) • Pertuzumab (Perjeta) • Ado-trastuzumab emtansine (KadcylaLapatinib (Tykerb) • Bevacizumab (Avastin) 9 .
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