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Most patients present with an asymptomatic lump discovered during examination or screening mammography. Diagnosis is confirmed by biopsy. Treatment usually includes surgical excision, often with radiation therapy, with or without adjuvant chemotherapy, hormonal therapy, or both. About 213,000 new cases were identified in 2006. It is the 2nd leading cause of cancer death in women (after lung cancer), with about 41,000 deaths in 2006. Male breast cancer accounts for < 1% of total cases; manifestations, diagnosis, and management are the same, although men tend to present later. Anatomy and Physiology Mammary Glands (Breast) The breast or mammary gland is a highly efficient organ mainly used to produce milk and is a mass of glandular, fatty, fibrous tissues. Mammary glands are exocrine glands that are enlarged and developmentally are modified sweat glands that are actually part of the skin. They are also classified as tubualveolar glands and are located in the breast lying on the top of the pectoralis major muscles. These glands are present in males and females; however, they normally function in the latter gender only. Function The biological role of the mammary glands is to produce milk to nourish a newborn baby and to pass antibodies needed for baby’s protection against infections (passive immunity) while the immature immune is initiating its function. Breast Anatomy The breast is internally composed of the following parts: Lobes and Lobules Internally, the mammary gland is composed of 15-25 lobes that radiates around the nipple. Each lobe consists of about 20-40 lobules, a smaller milk duct that contains 10-100 supporting alveoli. • Glandular tissue Glandular tissues are responsible for milk production and transportation which is composed of: 1. Alveoli – epithelial grape-like cluster of cells where milk is produced. 2. Ductules – branch-like tubules extending from the clusters of alveoli and empties to larger ducts called lactiferous ducts. 3. Lactiferous ducts – widen underneath the areola and nipple to become lactiferous sinuses. 4. Lactiferous sinuses – collect milk from lactiferous ducts and narrows to an opening in the nipple (nipple pore). • Connective tissue Connective tissue supports the breast. Cooper’s ligaments are fibrous bands that attach the breast to the chest wall and keep the breast from sagging. • Blood – nourishes breast tissue and supplies the nutrients to the breast needed for milk production. • Nerves – make the breast sensitive to touch, hence allowing the baby’s suck to stimulate the release of hormones that trigger the let-down or milk ejection reflex (oxytocin) and the production of milk (prolactin). Lymph nodes – removes waste products • Adipose tissue (fat) – protects the breast from injury.
Presence of progesterone stimulates the growth and maturation of the duct system.000 women). risk may be 5 to 6 times higher. Hormonal therapy: Postmenopausal hormone (estrogen plus a progestin) therapy appears to increase risk modestly after only 3 yr of use. Women with BRCA1 mutations also have a 20 to 40% lifetime risk of developing ovarian cancer. milk will not be produced and ejected out of the breast. risk among women with BRCA2 mutations is increased less. sclerosing adenosis. and papilloma. Stimulation of the female sex hormone. Women with BRCA1 or BRCA2 mutations may require closer surveillance or preventive measures. BRCA1 or BRCA2. Nipple – protruding area at the center of each breast. late menopause. estrogen. Benign lesions that may slightly increase risk of developing invasive breast cancer include complex fibroadenoma. Men who carry a BRCA2 mutation also have an increased risk of developing breast cancer. Gynecologic history: Early menarche. Risk is highest in women who began to use contraceptives before age 20 (although absolute risk is still very low).000 . Physiology The function of producing milk is regulated by hormones. the increased risk is about 7 or 8 more cases per 10. sister. Increase estrogen levels during pregnancy causes the breast size to increase in size through the accumulation of adipose tissues. although men tend to have poorer outcomes due to delays in diagnosis. During pregnancy levels of estrogen and progesterone rises (levels are needed to sustain pregnancy) that further enhances the development of the mammary glands. Women without a family history of breast cancer in at least 2 1st-degree relatives are unlikely to carry this gene and thus do not require screening for BRCA1 and BRCA2 mutations. Another hormone important for the implementation of mammary gland function is the presence of prolactin and oxytocin. causes the development of glandular tissue in the female breast during puberty. The genes are more common among Ashkenazi Jews. Breast cancer gene: About 5% of women with breast cancer carry a mutation in one of the 2 known breast cancer genes. they have a 50 to 85% lifetime risk of developing breast cancer. When ≥ 2 1stdegree relatives have breast cancer. daughter) with breast cancer doubles or triples risk of developing the cancer. Women who have a first pregnancy after age 30 are at higher risk than those who are nulliparous.The breast is externally composed of the following parts: Areola – pigmented area at the center of each breast. Women with multiple breast lumps but no histologic confirmation of a high-risk pattern should not be considered at high risk. This is the main reason why pregnant women has larger and more enhanced breast. Etiology: Predisposing Factors Sex: Breast cancer is more than 100 times more common in women than in men. Risk increases primarily during the years of contraceptive use and tapers off during the 10 yr after stopping. but breast cancer in more distant relatives increases risk only slightly. Without these hormones. After 5 yr of use. moderate or florid hyperplasia (with or without atypia). Increased breast density seen on screening mammography is associated with an increased risk of breast cancer Use of oral contraceptives: Oral contraceptive use increases risk very slightly (by about 5 more cases per 100. such as taking tamoxifen. If relatives of such a woman also carry the gene. Age: 60 years and older Family history: Having a 1st-degree relative (mother. or late first pregnancy increases risk. Prolactin from the anterior pituitary gland stimulates the production of milk in the glandular tissues while oxytocin causes the ejection of milk from the glands. Risk is about 4 or 5 times higher than average in patients with atypical ductal or lobular hyperplasia and about 10 times higher if they also have a family history of invasive breast cancer in a 1st-degree relative. Precipitating Factors Breast changes: History of fibrocystic changes that require biopsy for diagnosis increases risk slightly.
liver. scalp metastases are also common. but conclusive evidence about the effect of a particular diet (eg. Blood testing detects metastasis. Use of estrogen alone does not appear to increase risk of breast cancer. bone scans. also. Incidence of ER+ tumors is lower among premenopausal patients. but there is no evidence that dietary modification reduces risk. For obese women who are menstruating later than normal. present in some breast cancers. such as microcalcification. HER2/neu or ErbB2). lungs. Estrogen or progesterone receptor assays. proliferation or S phase study (tumor aggressive). Selective estrogen-receptor modulators (eg. its presence correlates with a poorer prognosis at any given stage of cancer. Ultrasonography may be used to distinguish cysts from solid masses. Medical Management: . Radiation therapy: Exposure to radiation therapy before age 30 increases risk. Metastatic breast cancer may affect almost any organ in the body—most commonly. or possible brain and chest CT scans detect matastasis. raloxifene reduce the risk of developing breast cancer. one high in fats) is lacking. this includes liver function tests to detect liver metastasis and calcium and alkaline phosphatase levels to detect bony metastasis. Smoking: Smoking tobacco appears to increase the risk of breast cancer with the greater the amount of smoked and the earlier in life smoking began the higher the risk. brain.women for each year of use (about a 24% increase in relative risk). Symtomatology: Lump that feels different from breast tissue One breast becoming larger or lower than the other Nipple changing position Nipple changing shape Nipple inverted Skin puckering or dimpling Rash on or around nipple Discharge from nipple Constant pain in part of the breast or armpit Swelling beneath the armpit or collarbone Pathophysiology: Breast cancer invades locally and spreads initially through the regional lymph nodes. bone. Diet: Diet may contribute to development or growth of breast cancers. bloodstream. In those who are long term smokers the risk is increased 35% to 50%. About two thirds of postmenopausal patients have an estrogen-receptor positive (ER+) tumor. Obese postmenopausal women are at increased risk. Diagnostic Tests: Mammography (most accurate method of detecting non-palpable lesions) shows lesions and cancerous changes. Most skin metastases occur near the site of breast surgery. Mantle-field radiation therapy for Hodgkin lymphoma about quadruples risk of breast cancer over the next 20 to 30 yr. and other test of tumor cells determine appropriate treatment and prognosis. Chest x-rays. Estrogen and progesterone receptors. and skin. drugs that block these receptors may be useful in treating tumors with the receptors. or both. are nuclear hormone receptors that promote DNA replication and cell division when the appropriate hormones bind to them. Biopsy or aspiration confirms diagnosis and determines the type of breast cancer. Thus. Metastatic breast cancer frequently appears years or decades after initial diagnosis and treatment. Another cellular receptor is human epidermal growth factor receptor 2 (HER2. risk may be decreased.
(i. Standard surgeries include: Mastectomy: Removal of the whole breast. Stage 2 and 3 cancers with a progressively poorer prognosis and greater risk of recurrence are generally treated with surgery (lumpectomy or mastectomy with or without lymph node removal). Chemotherapy is uncommon for other types of stage 1 cancers. chemotherapy (plus trastuzumab for HER2+ cancers) and sometimes radiation (particularly following large cancers. radiation. and monoclonal antibodies. Chemotherapy or other types of therapy prior to surgery are called neoadjuvant therapy. The NPI Nottingham Prognostic Index is a useful tool in assessing the prognosis Stage 1 cancers (and DCIS) have an excellent prognosis and are generally treated with lumpectomy and sometimes radiation. may be performed to create an aesthetic appearance. 10 year  survival rate is 5% without treatment and 10% with optimal treatment. Hormone blocking therapy Chemotherapy Monoclonal antibodies-Trastuzumab Radiation Radiotherapy is given after surgery to the region of the tumor bed and regional lymph nodes. spread to distant sites) has poor prognosis and is managed by various combination of all treatments from surgery. There are currently three main groups of medications used for adjuvant breast cancer treatment: hormone blocking therapy. a type of cosmetic surgery. Stage 4. Lumpectomy: Removal of a small part of the breast. Quadrantectomy: Removal of one quarter of the breast. to destroy microscopic tumor cells that may have escaped surgery. It may also have a beneficial effect on tumor microenvironment. A multidisciplinary approach is preferable. typically along with some of the surrounding tissue and frequently sentinel node biopsy. chemotherapy and targeted therapies. or both. multiple positive nodes or lumpectomy). Medication Drugs used after and in addition to surgery are called adjuvant therapy. In other cases. then breast reconstruction surgery. Hormone positive cancers are treated with long term hormone blocking therapy.e. chemotherapy. Surgery Surgery involves the physical removal of the tumor. HER2+ cancers should be treated with the trastuzumab (Herceptin) regime. or choose a flat chest. Treatments are given with increasing aggressiveness according to the prognosis and risk of recurrence. Radiation therapy can be delivered as external beam radiotherapy or as brachytherapy . metastatic cancer. women use breast prostheses to simulate a breast under clothing.Breast cancer is usually treated with surgery and then possibly with chemotherapy or radiation. If the patient desires.
dry cough. sore throat. and plan ahead for alopecia. Describe surgical procedures to alleviate fear. fluids and hyperalimentation as indicated. weight gain or loss. or sexual problems. 11. 3. NURSING INTERVENTIONS 1. for patients receiving chemotherapy. anorexia. as directed. alopecia. Suggest to the patient the psychological interventions may be necessary for anxiety. . 2. bone marrow suppression. depression. nausea and vomiting. Monitor for adverse effects of radiation therapy such as fatigue. 7. Provide psychological support to the patient throughout the diagnostic and treatment process. nausea. Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. 5. 10. stomatitis. The largest randomised trial to test this approach was the TAR-GIT-A Trial which found that targeted intraoperative radiotherapy was equally effective at 4-years as the usual several weeks' of whole breast external beam radiotherapy. 4. 6.V. fatigue. 9.(internal radiotherapy). Conventionally radiotherapy is given after the operation for breast cancer. anxiety. Administer I. Radiation can reduce the risk of recurrence by 50–66% (1/2 – 2/3 reduction of risk) when delivered in the correct dose and is considered essential when breast cancer is treated by removing only the lump (Lumpectomy or Wide local excision). Prepare the patient for the effects of chemotherapy. 8. Teach all women the recommended cancer-screening procedures. Radiation can also be given at the time of operation on the breast cancer.intraoperatively. Administer antiemetics prophylactically. Monitor for adverse effects of chemotherapy. and depression. Help patient identify and use support persons or family or community. fatigue. Involve the patient in planning and treatment.
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