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Breast Cancer Definition: Breast cancer most often involves glandular breast cells in the ducts or lobules.

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 babys 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. Coopers 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 babys 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.

The breast is externally composed of the following parts: Areola pigmented area at the center of each breast. Nipple protruding area at the center of each breast. Physiology The function of producing milk is regulated by hormones. Stimulation of the female sex hormone, estrogen, causes the development of glandular tissue in the female breast during puberty. Increase estrogen levels during pregnancy causes the breast size to increase in size through the accumulation of adipose tissues. Presence of progesterone stimulates the growth and maturation of the duct system. During pregnancy levels of estrogen and progesterone rises (levels are needed to sustain pregnancy) that further enhances the development of the mammary glands. This is the main reason why pregnant women has larger and more enhanced breast. Another hormone important for the implementation of mammary gland function is the presence of prolactin and oxytocin. Without these hormones, milk will not be produced and ejected out of the breast. 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. Etiology: Predisposing Factors Sex: Breast cancer is more than 100 times more common in women than in men, although men tend to have poorer outcomes due to delays in diagnosis. Age: 60 years and older Family history: Having a 1st-degree relative (mother, sister, daughter) with breast cancer doubles or triples risk of developing the cancer, but breast cancer in more distant relatives increases risk only slightly. When 2 1stdegree relatives have breast cancer, risk may be 5 to 6 times higher. Breast cancer gene: About 5% of women with breast cancer carry a mutation in one of the 2 known breast cancer genes, BRCA1 or BRCA2. If relatives of such a woman also carry the gene, they have a 50 to 85% lifetime risk of developing breast cancer. Women with BRCA1 mutations also have a 20 to 40% lifetime risk of developing ovarian cancer; risk among women with BRCA2 mutations is increased less. 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. Men who carry a BRCA2 mutation also have an increased risk of developing breast cancer. The genes are more common among Ashkenazi Jews. Women with BRCA1 or BRCA2 mutations may require closer surveillance or preventive measures, such as taking tamoxifen. Gynecologic history: Early menarche, late menopause, or late first pregnancy increases risk. Women who have a first pregnancy after age 30 are at higher risk than those who are nulliparous.

Precipitating Factors Breast changes: History of fibrocystic changes that require biopsy for diagnosis increases risk slightly. Women with multiple breast lumps but no histologic confirmation of a high-risk pattern should not be considered at high risk. Benign lesions that may slightly increase risk of developing invasive breast cancer include complex fibroadenoma, moderate or florid hyperplasia (with or without atypia), sclerosing adenosis, and papilloma. 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. 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 100,000 women). Risk increases primarily during the years of contraceptive use and tapers off during the 10 yr after stopping. Risk is highest in women who began to use contraceptives before age 20 (although absolute risk is still very low). Hormonal therapy: Postmenopausal hormone (estrogen plus a progestin) therapy appears to increase risk modestly after only 3 yr of use. After 5 yr of use, the increased risk is about 7 or 8 more cases per 10,000

women for each year of use (about a 24% increase in relative risk). Use of estrogen alone does not appear to increase risk of breast cancer. Selective estrogen-receptor modulators (eg, raloxifene reduce the risk of developing breast cancer. Radiation therapy: Exposure to radiation therapy before age 30 increases risk. Mantle-field radiation therapy for Hodgkin lymphoma about quadruples risk of breast cancer over the next 20 to 30 yr. Diet: Diet may contribute to development or growth of breast cancers, but conclusive evidence about the effect of a particular diet (eg, one high in fats) is lacking. Obese postmenopausal women are at increased risk, but there is no evidence that dietary modification reduces risk. For obese women who are menstruating later than normal, risk may be decreased. 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. In those who are long term smokers the risk is increased 35% to 50%.

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, bloodstream, or both. Metastatic breast cancer may affect almost any organ in the bodymost commonly, lungs, liver, bone, brain, and skin. Most skin metastases occur near the site of breast surgery; scalp metastases are also common. Metastatic breast cancer frequently appears years or decades after initial diagnosis and treatment. Estrogen and progesterone receptors, present in some breast cancers, are nuclear hormone receptors that promote DNA replication and cell division when the appropriate hormones bind to them. Thus, drugs that block these receptors may be useful in treating tumors with the receptors. About two thirds of postmenopausal patients have an estrogen-receptor positive (ER+) tumor. Incidence of ER+ tumors is lower among premenopausal patients. Another cellular receptor is human epidermal growth factor receptor 2 (HER2; also, HER2/neu or ErbB2); its presence correlates with a poorer prognosis at any given stage of cancer. Diagnostic Tests: Mammography (most accurate method of detecting non-palpable lesions) shows lesions and cancerous changes, such as microcalcification. Ultrasonography may be used to distinguish cysts from solid masses. Biopsy or aspiration confirms diagnosis and determines the type of breast cancer. Estrogen or progesterone receptor assays, proliferation or S phase study (tumor aggressive), and other test of tumor cells determine appropriate treatment and prognosis. Blood testing detects metastasis; this includes liver function tests to detect liver metastasis and calcium and alkaline phosphatase levels to detect bony metastasis. Chest x-rays, bone scans, or possible brain and chest CT scans detect matastasis.

Medical Management:

Breast cancer is usually treated with surgery and then possibly with chemotherapy or radiation, or both. A multidisciplinary approach is preferable. Hormone positive cancers are treated with long term hormone blocking therapy. Treatments are given with increasing aggressiveness according to the prognosis and risk of recurrence. 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. HER2+ cancers should be treated with the trastuzumab (Herceptin) regime. Chemotherapy is uncommon for other types of stage 1 cancers. 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 (plus trastuzumab for HER2+ cancers) and sometimes radiation (particularly following large cancers, multiple positive nodes or lumpectomy). Stage 4, metastatic cancer, (i.e. spread to distant sites) has poor prognosis and is managed by various combination of all treatments from surgery, radiation, chemotherapy and targeted therapies. 10 year [76] survival rate is 5% without treatment and 10% with optimal treatment.

Surgery Surgery involves the physical removal of the tumor, typically along with some of the surrounding tissue and frequently sentinel node biopsy. Standard surgeries include: Mastectomy: Removal of the whole breast. Quadrantectomy: Removal of one quarter of the breast. Lumpectomy: Removal of a small part of the breast.

If the patient desires, then breast reconstruction surgery, a type of cosmetic surgery, may be performed to create an aesthetic appearance. In other cases, women use breast prostheses to simulate a breast under clothing, or choose a flat chest. Medication Drugs used after and in addition to surgery are called adjuvant therapy. Chemotherapy or other types of therapy prior to surgery are called neoadjuvant therapy. There are currently three main groups of medications used for adjuvant breast cancer treatment: hormone blocking therapy, chemotherapy, and monoclonal antibodies. Hormone blocking therapy Chemotherapy Monoclonal antibodies-Trastuzumab Radiation Radiotherapy is given after surgery to the region of the tumor bed and regional lymph nodes, to destroy microscopic tumor cells that may have escaped surgery. It may also have a beneficial effect on tumor microenvironment. Radiation therapy can be delivered as external beam radiotherapy or as brachytherapy

(internal radiotherapy). Conventionally radiotherapy is given after the operation for breast cancer. Radiation can also be given at the time of operation on the breast cancer- intraoperatively. 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. Radiation can reduce the risk of recurrence by 5066% (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). NURSING INTERVENTIONS 1. 2. Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and depression. 3. Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological support to the patient throughout the diagnostic and treatment process. 4. 5. 6. 7. 8. 9. Involve the patient in planning and treatment. Describe surgical procedures to alleviate fear. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy. Administer I.V. fluids and hyperalimentation as indicated. Help patient identify and use support persons or family or community.

10. Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual problems. 11. Teach all women the recommended cancer-screening procedures.