CANCER


• • In a cancerous cell, permanent gene alterations, or mutations, cause the cell to malfunction. For a cell to become cancerous, usually three to seven different mutations must occur in a single cell. These genetic mutations may take many years to accumulate, but the convergence of mutations enables the cell to become cancerous.

HOW CANCER DEVELOPS A. Proto-oncogenes become onco-genes • • When the growth factor message reaches the cell nucleus, it activates genes called protooncogenes. These genes produce proteins that stimulate the cell to divide. In cancerous cells, mutations in proto-oncogenes cause these genes to malfunction. When a proto-oncogene mutates, it becomes an oncogene—a gene that instructs the cell to grow and divide repeatedly without stimulation from neighboring cells. Some oncogenes overproduce growth factors, causing the cell to divide too often. Other oncogenes stimulate the cell to reproduce even when no growth factor is present.

B. Tumor Suppresor genes Stop Working


• •

Tumor suppressor genes are like brakes for cell growth. When activated, these genes halt the cell cycle, preventing further cell division. But if tumor suppressor genes malfunction due to mutations, the rapidly dividing cell ignores messages from its neighbors telling it to stop dividing. Malfunctioning tumor suppressor genes are not enough to cause cancer—the cell still must overcome a host of other safety mechanisms before it can cause truly significant damage.

CAUSES OF CANCER • Viruses  Prolonged or frequent viral infections may cause breakdown of the immune system or overwhelm the immune system (Failure of the Immune System Response Theory)  Cancer-causing viruses include the human papilloma virus (HPV), a sexually transmitted virus responsible for 70 to 80 percent of all cases of cancer of the cervix.  Hepatitis B and C viruses cause almost 80 percent of all liver cancer in the world.  Epstein-Barr virus can also be carcinogenic, causing cancer of the lymphatic system.  Human immunodeficiency virus (HIV) or a type of herpesvirus can lead to rare cancers of the lymphatic and circulatory systems.  Helicobacter pylori, a bacterium associated with stomach ulcers, likely causes cancer of the stomach. Chemical carcinogens  Acts by causing cell mutation or alteration in cell enzymes and proteins – altered cell replication  Industrial compounds  Vinyl chloride (plastic manufacture, asbestos factories, construction works)  Polycyclic aromatic hydrocarbons (burning, auto and truck emissions, oil refineries), air pollution  Fertilizers, weed killers  Dyes 1

   Food,     

 Analine dyes  Hair bleach Tobacco, alcohol Drugs

preservatives Nitrites (bacon, smoked meat) Talc Food sweeteners Nitroamines (rubber baby nipples) Aflatoxins (mold in nuts and grains, milk, cheese, peanut butter)  Polycyclic hydrocarbons (charcoal burning)

Physical agents  Exposure to electromagnetic radiation, invisible, high-energy light waves such as sunlight and X rays, accounts for about 2 percent of all cancer deaths  Most cancer deaths from radiation are from skin cancer, which is triggered by too much sun exposure. Sunlight that reaches the Earth’s surface contains two kinds of ultraviolet (UV) radiation. UV-A and UV-B both contribute to sunburn and skin cancer as well as to conditions such as premature wrinkling of the skin.  Depletion of the ozone layer, which absorbs ultraviolet radiation in the upper atmosphere, will continue to increase skin damage and skin cancer rates in the future.  Physical Irritation

Hormones  In women, relatively high or long exposure to the female sex hormone estrogen seems to increase the risk of breast and uterine cancers.  Thus, early age at first menstruation, late age at menopause, having children after age 30, and never having children, all of which affect the duration of estrogen exposure in the body, increase the risk for these cancers.  Some evidence also suggests that estrogen replacement therapy (ERT), in which women take estrogen to offset the unpleasant effects of menopause, may also increase the risk of some cancers of the reproductive organs.  The risk appears to go down significantly, however, when estrogen and another female sex hormone, progesterone, are taken together. At one time studies showed a link between birth control pills and cancer.  Male sex hormones, particularly testosterone, also appear to play a role in cancers of the male reproductive organs, but this role is not yet well understood. Genetics  Some gene mutations associated with cancer are inherited. For example, inheritance of the mutated tumor suppressor genes BRCA1 or BRCA2 greatly increases the risk of breast cancer in young women.  About 50 to 60 percent of women with inherited BRCA1 or BRCA2 mutations will develop breast cancer by the age of 70. Inherited mutations in the genes MSH2, MLH1, PMS1, and PMS2, all of which repair DNA, are especially prevalent in a rare form of hereditary colon cancer.  Scientists suspect that many other hereditary factors contribute to cancer. In addition to inherited mutations, other genetic variations, particularly those influencing how the body responds to carcinogens, may create a greater susceptibility to cancer. The identities of the majority of these genetic variations are not yet known.

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PREDISPOSING FACTORS • Age • Sex  Women – more prone to breast, uterus, cervix cancer  Men – more prone to prostate, lung cancer • Urban VS. Rural residence  Cancer common among urban dweller than rural dwellers • • • • • • Geographic distribution  Japan – cancer of the stomach, U.S. – breast cancer  National diet, ethnic customs, type of pollution Occupational hazards  Chemical factory workers, farmers, radiology department personnel Hereditary Stress  Immunodeficiency Precancerous lesions Obesity

WARNING SIGNALS OF CANCER  C – change in bowel or bladder habits o pencil-thin stools with colon cancer. o o Occasionally, cancer exhibits continuous diarrhea.

    

If any of these abnormal bowel complaints last more than a few days, they require evaluation. A – sore that does not heal U – unusual bleeding or discharge U – unexplained sudden weight loss U – unexplained anemia T – thickening or lump in the breast or elsewhere o Lumps may represent cancer or a swollen lymph gland related to cancer. o A lump or gland that remains swollen for 3-4 weeks should be evaluated. I – indigestion or difficulty in swallowing O – obvious change in wart or mole N- nagging cough or hoarseness of voice o Anyone with a cough that lasts more than a month or with blood in the mucus that is coughed up should see a doctor.

  

Metastasis:

Cancer cells divide and grow without control or order to form a mass of tissue, called a growth or tumor. As the tumor grows, it can invade nearby organs and tissues. Cancer cells can also break away from the tumor and enter the bloodstream or lymphatic system. By moving through the bloodstream or lymphatic system, cancer can spread from the primary site to form new tumors in other organs. The spread of cancer is called metastasis.

GENERAL CONSIDERATIONS Cancer can be considered a chronic disease requiring ongoing management, rather than a terminal illness. It consists of more than 100 different conditions characterized by uncontrolled growth and spread of abnormal cells. Normal mechanisms of growth and proliferation are
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disturbed which results in distinctive morphologic alterations of the cell and aberrations in tissue patterns. TABLE 8-1 Differences Between Malignant and Benign Tumors CHARACTERISTIC BENIGN MALIGNANT Growth Differentiation Metastasis Recurrence Capsule Slow, expansive Fully differentiated Invasive, grows rapidly Immature, poorly differentiated Present Common following surgery Not encapsulated

Absent Extremely unusual when surgically removed Encapsulated

The malignant cell is able to invade the surrounding.
STAGING Staging describes the extent or severity of an individual’s cancer based on the extent of the original (primary) tumor and the extent of spread in the body. Stages of cancer:

• •

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Stage 0 or carcinoma in situ Carcinoma in situ is very early cancer. The abnormal cells are found only in the first layer of cells of the primary site and do not invade the deeper tissues. Stage I Cancer involves the primary site, but has not spread to nearby tissues. Stage II Cancer has spread to nearby areas but is still inside the primary site. o stage IIA: cancer has spread beyond the primary site. o stage IIB: cancer has spread to other tissue around the primary site. Stage III Cancer has spread throughout the nearby area. Stage IV Cancer has spread to other parts of the body. o stage IVA: cancer has spread to organs close to the pelvic area o stage IVB: cancer has spread to distant organs, such as the lungs Recurrent Recurrent disease means that the cancer has come back (recurred) after it has been treated.

Once a stage is assigned and treatment given, the stage is never changed. For example: If a stage I cancer of the cervix is treated, and two years later a metastasis is found in the lung, it is not now stage IV, but remains a "stage I, with recurrence to the lung." However, some cancers may be re-staged. 4

The important thing about staging is that it determines the appropriate treatment, provides a prognosis, and allows for comparison of treatment results between different treatments.

The TNM Staging System
o In the TNM system, each cancer is assigned a T, N, and M category.

The T category describes the original (primary) tumor. The tumor size is usually measured in centimeters (2 and 1/2 centimeters is about 1 inch) or millimeters (10 millimeters = 1 centimeter.)
   

TX means the tumor can't be measured or evaluated. T0 means there is no evidence of primary tumor (the primary tumor cannot be found). Tis means the cancer is in situ (the tumor has not started growing into the structures around it). The numbers T1–T4 describe the tumor size and/or level of invasion into nearby structures. The higher the T number, the larger the tumor and/or the further it has grown into nearby structures.

The N category describes whether or not the cancer has reached nearby lymph nodes.
  

NX means the nearby lymph nodes can't be measured or evaluated. N0 means nearby lymph nodes do not contain cancer. The numbers N1–N3 describe the size, location, and/or the number of lymph nodes involved. The higher the N number, the more lymph nodes are involved.

The M category tells whether there are distant metastases (spread of cancer to other parts of body).
    

MX means metastasis can't be measured or evaluated. M0 means that no distant metastases were found. M1 means that distant metastases were found (the cancer had spread to distant organs or tissues.) For example, breast cancer T3 N2 M0 refers to a large tumor that has spread outside the breast to nearby lymph nodes, but not to other parts of the body. Prostate cancer T2 N0 M0 means that the tumor is located only in the prostate and has not spread to the lymph nodes or any other part of the body.

Summary staging
 This system is used for all types of cancer. It groups cancer cases into five main categories:
• In situ is early cancer that is present only in the layer of cells in which it began. • Localized is cancer that is limited to the organ in which it began, without

evidence of spread. • Regional is cancer that has spread beyond the original (primary) site to nearby lymph nodes or organs and tissues. • Distant is cancer that has spread from the primary site to distant organs or distant lymph nodes. • Unknown is used to describe cases for which there is not enough information to indicate a stage. Grade

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• • • •

The grade of the cancer reflects how abnormal the cancer cells look under the microscope. Grade is important because cancers with more abnormal-looking cells tend to grow and spread more quickly. Higher grade cancers (meaning that the cancer cells look very abnormal) usually have a worse prognosis, and sometimes need different treatments. The American Joint Committee on Cancer (AJCC) recommends the following cancer grading classifications:
    

GX: Grade cannot be determined G1: Well-differentiated (the cancer cells look a lot like normal cells) G2: Moderately well-differentiated (cancer cells look somewhat like normal cells) G3: Poorly differentiated (cancer cells don't look much like normal cells) G4: Undifferentiated (the cancer cells don’t look anything like normal cells)  The lower the cancer grade the better the prognosis.  G1 cancers are linked to the best outcomes. G4 is associated with the worst outcomes and the others fall in between.

The types of tests used for staging depend on the type of cancer.
• Physical exams are used to gather information about the cancer. • Imaging studies produce pictures of areas inside the body. These studies are

important tools in determining stage. Procedures such as x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and positron emission tomography (PET) scans can show the location of the cancer, the size of the tumor, and whether the cancer has spread.

• Laboratory tests are studies of blood, urine, other fluids, and tissues taken from

the body. For example, tests for liver function and tumor markers (substances sometimes found in increased amounts if cancer is present) can provide information about the cancer. (PSA)

Pathology reports may include information about the size of the tumor, the growth of the tumor into other tissues and organs, the type of cancer cells, and the grade of the tumor (how closely the cancer cells resemble normal tissue). A biopsy (the removal of cells or tissues for examination under a microscope) may be performed to provide information for the pathology report (Fine-needle aspiration (FNA) is used most commonly to differentiate between solid and cystic masses. It is inexpensive, causes little discomfort, and can be performed in an outpatient or office setting. ). Cytology reports also describe findings from the examination of cells in body fluids.
• Surgical reports tell what is found during surgery. These reports describe the

size and appearance of the tumor and often include observations about lymph nodes and nearby organs. EFFECTS: A. Proliferation of Cancer cells    Pressure – due to increase in size of neoplastic growth Obstruction – as tumor continues to grow, hollow organs and vessels become compressed and obstructed Pain 6

 Pressure on nerve endings  Distention of organs/vessels  Lack of O2 to tissues and organs  Release of pain mediators by the tumors  Effusion  When lymphatic flow is obstructed, there may be effusion in serous cavities  Ulceration and necrosis  Results as the tumor erodes blood vessels and pressure on tissues – causes ischemia – tissue damage and bleeding – infection  Vascular thrombosis, embolus, thrombophlebitis  Tumors tend to produce abnormal coagulation factors that causes increased clotting B. Paraneoplastic Syndrome – malignant cells produce enzymes, hormones and other substances  Anemia  cancer cells produce chemicals that interfere with rbc production  iron uptake is greater in the tumor than that deposited in the liver  blood loss may result from bleeding  Hypercalcemia  Tumors of the bone, squamous cell lung Ca, Ca of the breast produce a parathyroid – like hormone that increases or accelerates bone breakdown and release of calcium  Results from metastasis to the bones  Enhance by immobilization and dehydration  DIC  Precipitated by the release of tissue thromboplastin or endothelial injury C. Anorexia-Cachexia Syndrome     Malignant neoplasms deprive normal cells of nutrition Tumors revert to anaerobic metabolism – consume glucose – deplete glycogen stores in the liver Protein depletion, serum albumin levels decrease Tumors take up sodium 7

 

Ca cells produce anorexigenic substances that act on the satiety center of the hypothalamus, causing anorexia Taste sensation diminishes and the individual may have aversion to eating

THERAPEUTIC MODALITIES
RADIATION THERAPY  Radiation therapy is the use of high-energy ionizing rays to destroy a cancer cell's ability to grow and multiply.  The goal of radiation therapy is to deliver a precisely measured dose of irradiation to a defined tumor volume with minimal damage to surrounding healthy tissue.  This results in eradication of tumor, high quality of life, prolongation of survival, and allows for effective palliation or prevention of symptoms of cancer, with minimal morbidity. Goals of Therapy
• •

Curative: When there is a probability of long-term survival after adequate therapy; some adverse effects of therapy, although undesirable, may be acceptable. Palliative: When there is no hope of survival for extended periods, radiation can be used to palliate symptoms, primarily pain. Lower doses of irradiation (75% to 80% of curative dose) can control the tumor and palliate symptoms without excessive toxicity.

Principles of Therapy
• • • • • • • •

Higher doses of irradiation produce better tumor control. For every increment of irradiation dose, a certain fraction of cells will be killed. A boost is the additional dose administered through small portals to residual disease. Radiosensitivity is the degree and speed of response. This measure of susceptibility of cells to injury or death by radiation depends on cancer diagnosis and its inherent biologic activity. Role of oxygen: Oxygen must be present at the time of radiation's maximal killing effect. Poor circulation with resultant hypoxia can reduce cellular radiosensitivity. Cellular response can be modified by changing the dose rate, manipulating the process of cell repair, and using hyperthermia (above 104° F , 40° C]). Radioresistance is the lack of tumor response to radiation because of tumor characteristics (slow-growing tumor, less responsive), tumor cell proliferation, and circulation. Radiation is most effective during the mitotic stage of the cell cycle. Radioresistant tumors: Many tumors are resistant to radiation, such as squamous cell, ovarian, soft tissue sarcoma. Many other tumors can become resistant after a period of time. Normal radioresistant tissues include mature bone, cartilage, liver, thyroid, muscle, brain, and spinal cord.

Types of Radiation Therapy
A. Brachytherapy

 the radiation device is placed within or close to the target tissue. 8

 Radiation is delivered in a high dose to a small tissue volume with less radiation to adjacent normal tissue, but requires direct tumor access.
o

o o

Interstitial therapy utilizes solid radioactive material such as seed implants. These may be temporary (removed after several days) or permanent. The permanent type remains in place with gradual decay. Implant procedure is performed under local or general anesthesia. (Used in breast and prostate disease) Intracavitary therapy utilizes radioactive material that is inserted into a cavity such as the vagina, as in cancer of the uterine cervix. Other forms of brachytherapy are systemic irradiation (parenteral or I.V.), oral 131 I for thyroid cancer, or intraperitoneal radiation.

B. Teletherapy

 is external beam irradiation and uses a device located at a distance from the patient.  It produces X-rays of varying energies and is administered by machines a distance from the body 31½ to 39 inches (80 to 100 cm). Acute Adverse Effects
• •

• • • • • • •

Fatigue and malaise Skin: may develop a reaction as soon as 2 weeks into the course of treatment (Skin erythema may range from mild to severe with possible dry-to-wet desquamation. Areas having folds, such as the axilla, under the breasts, groin and gluteal fold, are at an increased risk because of increased warmth and moisture.) GI effects: nausea and vomiting, diarrhea, and esophagitis Oral effects: changes in taste, mucositis, dryness, and xerostomia (dryness of mouth from lack of normal secretions) Pulmonary effects: dyspnea, productive cough, and radiation pneumonitis (Usually occurs 1 to 3 months after radiation to the lung.) Renal and bladder effects: cystitis and urethritis Cardiovascular: damage to vasculature of organs, thrombosis Recall reactions: acute skin and mucosal reactions when concurrent or past chemotherapy (doxorubicin [Adriamycin], dactinomycin [Actinomycin D]) Bone marrow suppression: more common with pelvic or large bone radiation

Chronic Adverse Effects After 6 months with variability in time of expression:
• • • • • •

Skin effects: fibrosis, telangiectasia, permanent darkening of the skin, and atrophy GI effects: fibrosis, adhesions, obstruction, ulceration, and strictures Oral effects: permanent taste alterations, and dental caries Pulmonary effects: fibrosis Renal and bladder effects: radiation nephritis, fibrosis Second primary cancer: patients who have received combined radiation and chemotherapy with alkylating agents have a rare risk of developing acute leukemia

Nursing Assessment
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Assess skin and mucous membranes for adverse effects of radiation. Assess GI, respiratory, and renal function for signs of adverse effects. Assess patient's understanding of treatment and emotional status.

Nursing Diagnoses

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Risk for Impaired Skin Integrity, Infection, Hemorrhage, Stomatitis related to radiation effects Ineffective Protection related to brachytherapy

Nursing Interventions Maintaining Optimal Skin Care
• • • • • • • •

Inform the patient that some skin reaction can be expected, but that it varies from patient to patient. Examples include dry erythema, dry desquamation, wet desquamation, and tanning. Do not apply lotions, ointments, or cosmetics to the site of radiation unless prescribed. Discourage vigorous rubbing, friction, or scratching because this can destroy skin cells. Avoid wearing tight-fitting clothing over the treatment field; prevent irritation by not using rough fabric such as wool and corduroy. Take precautions against exposing the radiation field to sunlight and extremes in temperature. Do not apply adhesive or other tape to the skin. Avoid shaving the skin in the treatment field. Use lukewarm water only and mild soap when bathing.

Preventing Infection • • • Monitor blood counts weekly Good personal hygiene, nutrition, adequate rest Inform about signs of infection and report to physician

Preventing Hemorrhage • • • • Avoid physical trauma and use of aspirin Teach signs of hemorrhage Monitor stool and skin for signs of hemorrhage Use direct pressure over injection sites until bleeding stops

Ensuring Protection from Radiation

To avoid exposure to radiation while the patient is receiving therapy, consider the following: o Time - exposure to radiation is directly proportional to the time spent within a specific distance to the source. (limit contact for 5 minutes each time, a total of 30 minutes per shift)

o

o

Distance - amount of radiation reaching a given area decreases as distance increases. (maintain a distance of at least 3 feet when not performing nursing procedures) Shield - sheet of absorbing material placed between the radiation source and the nurse decreases the amount of radiation exposure.

• •

If exposed to penetrating radiation (X-ray or gamma rays), wear film badges on the front of the body. Take appropriate measures associated with sealed sources of radiation implanted within a patient (sealed internal radiation). o Follow directives on precaution sheet that is placed on the charts of all patients receiving radiotherapy. o Do not remain within 3 feet (1 meter) of the patient any longer than required to give essential care. 10

• • • • • • •

Do not linger longer than necessary in giving patient care, even though all precautions are followed. Be alert for implants that may have become loosened (those inserted in cavities that have access to the exterior); for example, check the emesis basin following mouth care for a patient with an oral implant. Notify the radiation therapist of any implant that has moved out of position. Use long-handled forceps or tongs and hold at arm's length when picking up any dislodged radium needle, seeds, or tubes. Never pick up a radioactive source with your hands. Do not discard dressings or linens unless you are sure that no radioactive source is present. After the patient is discharged from the hospital, it is a good policy for the radiologist to check the room with a radiograph or survey meter to be certain that all radioactive materials have been removed. Continue radiation precautions when a patient has a permanent implant, until the radiologist declares precautions unnecessary.

CHEMOTHERAPY  Chemotherapy is the use of antineoplastic drugs to promote tumor cell destruction by interfering with cellular function and reproduction. It includes the use of various chemotherapeutic agents and hormones. 
• •

Principles of Chemotherapy Administration The intent of chemotherapy is to destroy as many tumor cells as possible with minimal effect on healthy cells. Chemotherapeutic agents can be effective on one of the four phases of the cell cycle or during any phase of the cell cycle. The cell cycle is divided into four stages: o G1 (gap one) phase: RNA and protein synthesis (enzymes for DNA synthesis are manufactured) o S (synthesis) phase: During a long time period the DNA component doubles for the chromosomes in preparation for cell division. o G2 (gap two) phase: This is a short time period; protein and RNA synthesis occurs, and the mitotic spindle apparatus is formed. o M (mitosis) phase: In an extremely short time period, the cell actually divides into two identical daughter cells. Routes of administration: o Oral - capsule, tablet, or liquid o I.V. - push (bolus) or infusion over a specified time period o Intramuscular o Intrathecal/intraventricular - given by injection by lumbar puncture o Intra-arterial o Intracavitary such as peritoneal cavity o Intravesical into uterus or bladder o Topical

• • •

Dosage is based on surface area (mg/m2) in both adults and children. Most chemotherapeutic agents have dose-limiting toxicities that require nursing interventions Chemotherapy predictably affects normal, rapidly growing cells (eg, bone marrow, GI tract lining, hair follicles). It is imperative that these toxicities be recognized early on by the nurse.

Safety Measures in Handling Chemotherapy 11

Personal Safety to Minimize Exposure via Inhalation
• • • •

Wrap gauze or alcohol pads around the neck of ampules when opening to decrease droplet contamination. Wrap gauze or alcohol pads around injection sites when removing syringes or needles from I.V. injection ports. Do not dispose of materials by clipping needles or removing needles from syringes. Use puncture- and leak-proof containers for non-capped, non-clipped needles.

Personal Safety to Minimize Exposure via Skin Contact
• • • • • • • • • • •

Wear nitrile examination gloves at all times when preparing or working with chemotherapeutic agents. Wash hands before putting on and after removing gloves. Change gloves after each use, tear, puncture, or medication spill or after every 60 minutes of wear. Wear a long-sleeve, nonabsorbent gown with elastic at the wrists and back closure. Eye and face shields should be worn if splashes are likely to occur. Use syringes and I.V. tubing with Luer locks (which have a locking device to hold needle firmly in place). Label all syringes and I.V. tubing containing chemotherapeutic agents as hazardous material. Place an absorbent pad directly under the injection site to absorb any accidental spillage. If any contact with the skin occurs, immediately wash the area thoroughly with soap and water. If contact is made with the eye, immediately flush the eye with water and seek medical attention. Spill kits should be available in all areas where chemotherapy is stored, prepared, and administered.

Personal Safety to Minimize Exposure via Ingestion
• • • •

Do not eat, drink, chew gum, or smoke while preparing or handling chemotherapy. Keep all food and drink away from preparation area. Wash hands before and after handling chemotherapy. Avoid hand-to-mouth or hand-to-eye contact while handling chemotherapeutic agents or body fluids of the person receiving chemotherapy.

Safe Disposal of Antineoplastic Agents, Body Fluids, and Excreta
• • • • •

Discard gloves and gown into a leak-proof container, which should be marked as contaminated or hazardous waste. Use puncture- and leak-proof containers for needles and other sharp or breakable objects. Linens contaminated with chemotherapy or excreta from patients who have received chemotherapy within 48 hours should be contained in specially marked hazardous waste bags. Wear non-sterile nitrile gloves for disposing of body excreta and handling soiled linens within 48 hours of chemotherapy administration. In the home, wear gloves when handling bed linens or clothing contaminated with chemotherapy or patient excreta within 48 hours of chemotherapy administration. Place linens in a separate, washable pillow case. Wash separately in hot water and regular detergent.

Adverse Effects of Chemotherapy  Adverse effects of chemotherapy are graded on a scale of 0 to 4, with 0 being normal and 4 indicating life-threatening. Scoring of adverse effects will determine if a delay in therapy is necessary, dose modification is necessary, or cessation of therapy must occur. 12

Alopecia
• • •

Most chemotherapeutic agents cause some degree of alopecia. This is dependent on the drug dose, half-life of drug, and duration of therapy. Usually begins 2 weeks after administration of chemotherapy. Regrowth takes about 3 to 5 months. The use of scalp hypothermia and tourniquets is highly controversial.

Anorexia
• • •

Chemotherapy changes the reproduction of taste buds. Absent or altered taste can lead to a decreased food intake. Concurrent renal or hepatic disease can increase anorexia.

Fatigue The cause of fatigue is generally unknown but can be related to anemia, weight loss, altered sleep patterns, and coping. Nausea and Vomiting
• • •

Caused by the stimulation of the vagus nerve by serotonin released by cells in the upper GI tract. Incidence depends upon the particular chemotherapeutic agent and dosage. Patterns of nausea and vomiting: o Anticipatory - conditioned response from repeated association between therapy and vomiting. o Acute - occurs 0 to 24 hours after chemotherapy administration. o Delayed - can occur 1 to 4 days after chemotherapy administration.

Mucositis
• • •

Caused by the destruction of the oral mucosa, causing an inflammatory response. Initially presents as a burning sensation with no changes in the mucosa and progresses to significant breakdown, erythema, and pain of the oral mucosa. Consistent oral hygiene is important to avoid infection.

Anemia
• •

Caused by suppression of the stem cell or interference with cell proliferation pathways. May require red blood cell transfusion or injection of erythropoietin

Neutropenia
• • • • • •

Defined as an absolute neutrophil count (ANC) of 1,500/mm3 or less. Risk of infection is greatest with an ANC less than 500/mm3. Caused by suppression of the stem cell. Usually occurs 7 to 14 days after administration of chemotherapy. Patients should be taught to avoid infection through proper hand washing, avoiding those with illness, proper hygiene. Patients need to be monitored and treated promptly for fever or other signs of infection.

Thrombocytopenia
• • • • •

Caused by suppression of megakaryocytes. Incidence depends on the agent being used. Risk of bleeding is present when platelet count falls below 50,000/mm3. Risk is high when count falls below 20,000/mm3. Risk is critical when count falls below 10,000/mm3. 13

• •

Patient should be taught to avoid injury, eg, no razors, avoid vaginal douches and rectal suppositories, and avoid dental floss during the period of thrombocytopenia. May require platelet transfusions if count drops below 20,000/mm3.

Hypersensitivity Reactions
• • •

The mechanism is unknown for most of the chemotherapeutic agents in use. Signs and symptoms include hives, pruritus, back pain, shortness of breath, hypotension, and anaphylaxis. All unexpected drug reactions should be reported to the manufacturer.

Nursing Assessment
Integumentary System
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Inspect for pain, swelling with inflammation or phlebitis, necrosis, or ulceration. Inspect for skin rash, characteristics, whether pruritus, general or local. Assess areas of erythema and associated tenderness or pruritus. Instruct patient to avoid irritation to skin, sun exposure, or irritating soaps. Assess changes in skin pigmentation. Note reports of photosensitivity, tearing of the eyes. Assess condition of gums, teeth, buccal mucosa, and tongue. o Determine whether any taste changes have occurred. o Check for evidence of stomatitis, erythematous areas, ulceration, infection, or pain on swallowing. o Determine whether the patient has any complaints of pain or burning of the oral mucosa or on swallowing.

GI System

• •

• •

Assess for frequency, timing of onset, duration, and severity of nausea and vomiting episodes before and after chemotherapy. o Usually occurs from 1 to 24 hours after chemotherapy but may be delayed. Anticipatory vomiting may occur after first course of therapy. Can be initiated by various cues, including thoughts, smell, or even sight of the medical personnel. Observe for alterations in hydration, electrolyte balance. Assess for diarrhea or constipation. o Ascertain any changes in bowel patterns. o Discuss the consistency of stools. o Consider the frequency and duration of diarrhea (the number of stools each day for the number of days). Assess for anorexia. o Discuss taste changes and changes in food preferences. o Ask about daily food intake and normal eating patterns. Assess for jaundice, right upper quadrant abdominal pain, changes in the stool or urine, and elevated liver function tests that indicate hepatotoxicity. Monitor liver function tests and total bilirubin.

Hematopoietic System

Assess for neutropenia - ANC less than 500/mm3. o Assess for any signs of infection (pulmonary, integumentary, central nervous system, GI, and urinary). o Auscultate lungs for adventitious breath sounds. o Assess for productive cough or shortness of breath. o Assess for urinary frequency, urgency, pain, or odor. o Monitor for elevation of temperature above 101° F, chills. Assess for thrombocytopenia - platelet count less than 50,000/mm3 (mild risk of bleeding); less than 20,000/mm3 (high risk of bleeding). o Assess skin and oral mucous membranes for petechiae, bruises on extremities. 14

Assess for signs of bleeding (including nose, urinary, rectal, or hemoptysis). Assess for blood in stools, urine, or emesis. Assess for signs and symptoms of intracranial bleeding if platelet count is less than 20,000/mm3; monitor for changes in level of responsiveness, vital signs, and pupillary reaction. Assess for anemia. o Assess skin color, turgor, and capillary refill. o Ascertain whether patient has experienced dyspnea on exertion, fatigue, weakness, palpitations, or vertigo. Advise rest periods as needed.
o o o

Respiratory and Cardiovascular Systems
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• •

Assess lung sounds. Assess for pulmonary fibrosis, evidenced by a dry, nonproductive cough with increasing dyspnea. Patients at risk include those over age 60, smokers, those receiving or having had pulmonary radiation, those receiving cumulative dose of bleomycin (Blenoxane), or those with any preexisting lung disease. Assess for signs and symptoms of heart failure or irregular apical or radial pulses. Verify baseline cardiac studies before administering doxorubicin (Adriamycin) or highdose cyclophosphamide (Cytoxan).

Nursing Diagnoses
• • • • • • •

Risk for Infection related to neutropenia Risk for Injury related to bleeding from thrombocytopenia Fatigue related to anemia Imbalanced Nutrition: Less Than Body Requirements related to adverse effects of therapy Ineffective protection and risk for hypersensitivity reaction related to chemotherapy Impaired Oral Mucous Membranes related to stomatitis Disturbed Body Image related to alopecia and weight loss

Nursing Interventions Preventing Infection
• •

• • •

Monitor vital signs every 4 hours; report occurrence of fever greater than 101° F (38.3° C) and chills. Provide patient education. o Instruct patient to report signs and symptoms of infection:  Fever greater than 101° F and/or chills  Mouth lesions, swelling, or redness  Redness, pain, or tenderness at rectum  Change in bowel habits  Areas of redness, swelling, induration, or pain on skin surface  Pain or burning when urinating or odor from urine  Cough or shortness of breath o Reinforce good personal hygiene habits (routine bathing [preferably a shower], clean hair, nails, and mouth care). o Avoid contact with people who have a transmissible illness. o Encourage deep breathing and coughing to decrease pulmonary stasis. Avoid performing invasive procedures - rectal temperatures, enemas, or insertion of indwelling urinary catheters. Monitor white blood cell count (WBC) and differential. Administer prophylactic antibiotics as prescribed (if WBC is less than 500).

Preventing Bleeding
• •

Avoid invasive procedures when platelet count is less than 50,000/mm3, including I.M. injections, suppositories, enemas, and insertion of indwelling urinary catheters. Apply pressure on injection sites for 5 minutes. 15

• •

Monitor platelet count; administer platelets as prescribed. Monitor and test all urine, stools, and emesis for blood.

Provide patient education.
o o o o o

Instruct patient to avoid straight-edge razors, nail clippers, vaginal or rectal suppositories. Avoid intercourse when platelet count is less than 50,000/mm3. Encourage patient to blow nose gently. Avoid dental work or other invasive procedures while thrombocytopenic. Avoid the use of NSAIDs, aspirin, and aspirin-containing products.

Minimizing Fatigue
• • •

Monitor blood counts (hemoglobin and hematocrit). Administer blood products as prescribed. Provide patient education and counseling o Information about fatigue o Reassurance that treatment-related fatigue does not mean your cancer is worse o Why fatigue and shortness of breath may occur o Suggestions for ways to cope with fatigue  Energy conservation  Caution the patient about physical overexertion; encourage rest frequently and warn patient to expect a tired feeling  Plan frequent rest periods between daily activities; take naps that do not interrupt nighttime sleep  Set priorities and delegate tasks to others o Stress management o Explain that blood transfusions, if given, are a part of therapy and not necessarily an indication of a setback o Observe skin color o Monitor nutritional status

Promoting Nutrition
• • • • • • • • • •

Administer antiemetics before chemotherapy and on a routine schedule (not as needed). Be aware that certain antiemetic combinations are more effective than single agents. Consider alternative measures for relief of anticipatory nausea, such as relaxation therapy, imagery, and distraction. Encourage small, frequent meals appealing to patient preferences. Encourage patient to eat a diet high in calories and proteins. Provide a high-protein supplement as needed. Discourage smoking and alcoholic beverages, which may irritate mucous membranes. Encourage fluid intake to prevent constipation. Monitor intake and output, including emesis. Consult dietitian about patient's food preferences, intolerances, and individual dietary interventions. Recognize that the patient may have alterations in taste perception, such as a keener taste of bitterness and loss of ability to detect sweet tastes.

Minimizing Stomatitis

Encourage good oral hygiene. o Soft nylon bristled toothbrush, brush 2 to 3 times daily, rinse frequently o Floss once daily 16

• • •

Encourage the use of oral agents to promote cleansing, debridement, and comfort. Mouthwashes with more than 25% alcohol should be avoided. Assess the need for antifungal, antibacterial, or antiviral therapy (each infection has a different appearance). Administer local oral therapy such as combinations with viscous lidocaine (Xylocaine) for symptomatic control and maintenance of calorie intake.

Preventing and Managing Hypersensitivity Reactions
• •

Be alert for signs of allergic reactions such as pruritus, urticaria, and difficulty breathing, as well as back pain. Situation may worsen suddenly to hypotension and anaphylaxis. Stop the medication or infusion immediately, notify the health care provider, and monitor the patient closely. Treatment is supportive and dependent on type of reaction and its severity. o Do not administer the agent again if there was a severe reaction resulting in significant hypotension. o Premedicate the patient with antihistamine or corticosteroid as directed if there is a history of moderate reaction.

Strengthening Coping for Altered Body Image
• • • •

Reassure patient that hair will usually grow back; however, it may grow back a different texture or different color. Suggest wearing a turban, wig, or headscarf, preferably purchased before hair loss occurs. Many insurance companies will pay for a wig with a prescription. Encourage patient to stay on therapeutic program. Be honest with the patient.

Patient Education and Health Maintenance
• • • • •

Make sure that patient uses good hygiene, knows symptoms of infection to report, and avoids crowds and people with infection while neutropenic. Advise patient to avoid using a razor blade to shave, contact sports, manipulation of sharp articles, use of hard bristle toothbrush, and passage of hard stool to prevent bleeding while thrombocytopenic. Advise women to report symptoms of vaginal infection due to opportunistic fungal or viral infection. Encourage patient participation in plan for chemotherapy and to set realistic goals for work and activities. Assure patient that changes in menses, libido, and sexual function are usually temporary during therapy.

Cancer Screening Recommendations
• Most cancers are treatable if they are detected before they have spread to other parts of the body. For this reason, the American Cancer Society recommends the following regular screening tests for people who have no apparent symptoms. People who have certain risk factors, such as a family history of cancer, may elect to consult with their doctor to determine a more aggressive cancer screening program.

Type of Cancer

Screening Procedure

Frequenc y

Cancers of the thyroid, oral cavity, skin, lymph nodes, testes, and ovaries General cancer-related physical examination Colorectal cancer Stool examination for the Yearly after age 50 presence of occult (hidden) blood Every three years for people aged 20 to 40; yearly after age 40

17

One of the following: Sigmoidoscopy examination and digital rectal examination Colonoscopy and digital rectal examination Double-contrast barium enema and digital rectal examination Prostate cancer Digital rectal examination Blood test measuring levels of prostate-specific antigen Cervical cancer Pelvic examination and Pap Yearly for women who are or have been sexually active or have smear reached age 18. After three or more consecutive normal exams, a Pap smear may be performed less frequently at the physician's discretion. Breast cancer Breast self-examination Breast examination by a physician Mammography Monthly after age 20 Every three years for women aged 20 to 40; yearly after age 40 Yearly after age 40 Yearly after age 50 Yearly after age 50 Every five years after age 50

Every ten years after age 50 Every five to ten years after age 50

Source: American Cancer Society.

18

BREASR CANCER

The breasts are made of fat, glands, and connective (fibrous) tissue. The breast has several lobes, which are divided into lobules that end in the milk glands. Tiny ducts run from the many tiny glands, connect together, and end in the nipple.
• • •

These ducts are where 80% of breast cancers occur. This condition is called ductal cancer. Cancer developing in the lobules is termed lobular cancer. About 10-15% of breast cancers are of this type. Other less common types of breast cancer include inflammatory breast cancer, medullary cancer, phyllodes tumor, angiosarcoma, mucinous (colloid) carcinoma, mixed tumors, and a type of cancer involving the nipple termed Paget's disease.

Precancerous changes, called in situ changes, are common.
• • •

In situ is Latin for "in place" or "in site" and means that the changes haven't spread from where they started. When these in situ changes occur in the ducts, they are called ductal carcinoma in situ (DCIS). DCIS may be identified on routine mammography. When in-situ changes happen in the lobules, it is called lobular carcinoma in situ (LCIS).

When cancers spread into the surrounding tissues, they are termed infiltrating cancers. Cancers spreading from the ducts into adjacent spaces are termed infiltrating ductal carcinomas. Cancers spreading from the lobules are infiltrating lobular carcinomas. The most serious cancers are metastatic cancers. Metastasis means that the cancer has spread from the place where it started into other tissues distant from the original tumor site. The most common place for breast cancer to metastasize is into the lymph nodes under the arm or above the collarbone on the same side as the cancer. Other common sites of breast cancer metastasis are the brain, the bones, and the liver. Breast Cancer Causes Many women who develop breast cancer have no risk factors other than age and sex.
• •

Gender is the biggest risk because breast cancer occurs mostly in women. Age is another critical factor. Breast cancer may occur at any age, though the risk of breast cancer increases with age. The average woman at age 30 years has one chance in 280 of developing breast cancer in the next 10 years. This chance increases to one in 70 for a woman aged 40 years, and to one in 40 at age 50 years. A 60-year-old woman has a one in 30 chance of developing breast cancer in the next 10 years. 19

• •

White women are slightly more likely to develop breast cancer than African American women in the U.S. A woman with a personal history of cancer in one breast has a three- to fourfold greater risk of developing a new cancer in the other breast or in another part of the same breast. This refers to the risk for developing a new tumor and not a recurrence (return) of the first cancer.

Genetic Causes Family history has long been known to be a risk factor for breast cancer. Both maternal and paternal relatives are important. The risk is highest if the affected relative developed breast cancer at a young age, had cancer in both breasts, or if she is a close relative. First-degree relatives, (mother, sister, daughter) are most important in estimating risk. Several seconddegree relatives (grandmother, aunt) with breast cancer may also increase risk. Breast cancer in a male increases the risk for all his close female relatives. Having relatives with both breast and ovarian cancer also increases a woman's risk of developing breast cancer. There is great interest in genes linked to breast cancer. About 5-10% of breast cancers are believed to be hereditary, as a result of mutations, or changes, in certain genes that are passed along in families.

BRCA1 and BRCA2 are abnormal genes that, when inherited, markedly increase the risk of breast cancer to a lifetime risk estimated between 40 and 85%. Women with these abnormal genes also have an increased likelihood of developing ovarian cancer. Women who have the BRCA1 gene tend to develop breast cancer at an early age. Testing for these genes is expensive and may not be covered by insurance. The issues around testing are complicated, and women who are interested in testing should discuss this with their health-care providers.

• •

Hormonal Causes Hormonal influences play a role in the development of breast cancer.

Women who start their periods at an early age (11 or younger) or experience a late menopause (55 or older) have a slightly higher risk of developing breast cancer. Conversely, being older at the time of the first menstrual period and early menopause tend to protect one from breast cancer. Having a child before age 30 years may provide some protection, and having no children may increase the risk for developing breast cancer. Oral contraceptives have not been shown to definitively increase or decrease a woman's lifetime risk of breast cancer. A large study conducted by the Women's Health Initiative showed an increased risk of breast cancer in postmenopausal women who were on a combination of estrogen and progesterone for several years. Therefore, women who are considering hormone therapy for menopausal symptoms need to discuss the risk versus the benefit with their health-care providers.

• • •

Lifestyle and Dietary Causes Breast cancer seems to occur more frequently in countries with high dietary intake of fat, and being overweight or obese is a known risk factor for breast cancer, particularly in postmenopausal women.

This link is thought to be an environmental influence rather than genetic. For example, Japanese women, at low risk for breast cancer while in Japan, increase their risk of developing breast cancer after coming to the United States. 20

Several studies comparing groups of women with high- and low-fat diets, however, have failed to show a difference in breast cancer rates.

Benign Breast Disease

Fibrocystic breast changes are very common. Fibrocystic breasts are lumpy with some thickened tissue and are frequently associated with breast discomfort, especially right before the menstrual period. This condition does not lead to breast cancer. However, certain other types of benign breast changes, such as those diagnosed on biopsy as proliferative or hyperplastic, do predispose women to the later development of breast cancer.

Environmental Causes Radiation treatment increases the likelihood of developing breast cancer but only after a long delay. For example, women who received radiation therapy to the upper body for treatment of Hodgkin disease before 30 years of age have a significantly higher rate of breast cancer than the general population. Breast Cancer Symptoms Early breast cancer has no symptoms. It is usually not painful. Most breast cancer is discovered before symptoms are present, either by finding an abnormality on mammography or feeling a breast lump. A lump in the armpit or above the collarbone that does not go away may be a sign of cancer. Other possible symptoms are breast discharge, nipple inversion, or changes in the skin overlying the breast.
• •

Most breast lumps are not cancerous. All breast lumps, however, need to be evaluated by a doctor. Breast discharge is a common problem and is rarely a symptom of cancer. Discharge is most concerning if it is from only one breast or if it is bloody. In any case, all breast discharge should be evaluated. Nipple inversion is a common variant of normal nipples, but nipple inversion that is a new development can be of concern. Changes in the skin of the breast include redness, changes in texture, and puckering. These changes are usually caused by skin diseases but occasionally can be associated with breast cancer.

• •

How to Perform a Breast Self-Exam Women older than 20 years should perform monthly breast self-examinations (BSE). If you still have menstrual periods, you should perform the examination a few days after your period has ended. During this time, your breasts are not tender. If you are not menstruating (such as in menopause), BSE should be performed on the same day each month. Use the following techniques to perform a BSE. Choose the method that is best for you. Facing a mirror Stand before a mirror and compare both breasts for differences in size, nipple inversion (turning in), bulging, or dimpling. Note any skin or nipple changes, such as a hard knot or nipple discharge.

Inspect your breasts in the following 4 steps:
o o

With your arms at your sides With your arms overhead 21

o o

With your hands on hips - Press firmly to flex your chest muscles.

Bent forward - Inspect your breasts. In these positions, your pectoral muscles are contracted, and a subtle dimpling of the skin may appear if a growing tumor has affected a ligament.

Lying down

Right breast
o o o o o o

Place a pillow under your right shoulder. Put your right hand under your head. Check the entire breast area with the finger pads of your left hand. Use small circles and follow an up-and-down pattern. Use light, medium, and firm pressure over each area of the breast. Feel the breast with the surfaces of the second, third, and fourth fingers, moving systematically and using small, circular motions from the nipple to the outer margins.

o o

Gently squeeze the nipple for any discharge.

Left breast
o

Repeat these steps on your left breast using your right hand.

In the shower

A BSE can easily be performed while you're in the bath or shower. Some women discover breast masses when their skin is moist.
o o o

Raise your right arm. With soapy hands and fingers flat, check your right breast. Use the same small circles and up-and-down pattern described earlier. 22

o

Repeat on the left breast.

When to Seek Medical Care Breast cancer develops over months or years. Once it is identified, however, a certain sense of urgency is felt about the treatment, because breast cancer is much more difficult to treat as it spreads. You should see your health-care provider if you experience any of the following:
• • • •

Finding a breast lump Finding a lump in your armpit or above your collarbone that does not go away in two weeks or so Developing nipple discharge Noticing new nipple inversion or skin changes over the breast

Redness or swelling in the breast may suggest an infection of the breast.
• •

You should see your health-care provider within the next 24 hours because infection should be treated promptly. If you have redness, swelling, or severe pain in the breast and are unable to reach your health-care provider, a trip to the nearest emergency department is warranted.

If an abnormality is found on your mammogram, you should see your health-care provider right away to make a plan for further evaluation. Exams and Tests Diagnosis of breast cancer usually is comprised of several steps, including examination of the breast, mammography, possibly ultrasonography or MRI, and, finally, biopsy. Biopsy is the only definitive way to diagnose breast cancer. Examination of the Breast
• •

A complete breast examination includes visual inspection and careful palpation (feeling) of the breasts, the armpits, and the areas around your collarbone. During that exam, your health-care provider may palpate a lump or just feel a thickening.

Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.

23

Here's what you should look for:
• •

Breasts that are their usual size, shape, and color. Breasts that are evenly shaped without visible distortion or swelling.

If you see any of the following changes, bring them to your doctor's attention:
• •

Dimpling, puckering, or bulging of the skin. A nipple that has changed position or become inverted (pushed inward instead of sticking out). Redness, soreness, rash, or swelling.

Raise your arms and look for the same changes. While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).

Feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together. Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage.

Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4. 24

Mammography
• •

Mammograms are x-rays of the breast that may help define the nature of a lump. Mammograms are also recommended for screening to find early cancer. Usually, it is possible to tell from the mammogram whether a lump in the breast is breast cancer, but no test is 100% reliable. Mammograms are thought to miss as many as 1015% of breast cancers. A false-positive mammogram is one that suggests malignancy (cancer) when no malignancy is found on biopsy. A false-negative mammogram is one that appears normal when in fact cancer is present. A mammogram alone is often not enough to evaluate a lump. Your health-care provider will probably request additional tests. All breast lumps need to be clearly defined as benign or should be biopsied.

• • • •

25

A. Normal left mammogram with motion blur. Compression of the breast is necessary in order to minimize the chance of blurring or fuzziness that may hide a cancer. B. Normal left mammogram without motion blur. This is the same view of the same patient, performed with adequate breast compression that has immobilized the breast. The image is sharp and therefore cancer is easier to detect. Note: Image shown for illustrative purposes. Do not attempt to draw conclusions by comparing this image to others on the site. Only qualified radiologists should interpret images.

Biopsy

The only way to diagnose breast cancer with certainty is to biopsy the tissue in question. Biopsy means to take a very small piece of tissue from the body for examination and testing by a pathologist to determine if cancer is present. A number of biopsy techniques are available. Fine-needle aspiration consists of placing a needle into the breast and sucking out some cells to be examined by a pathologist. This technique is used most commonly when a fluid-filled mass is identified and cancer is not likely. Core-needle biopsy is performed with a special needle that takes a small piece of tissue for examination. Usually the needle is directed into the suspicious area with ultrasound or mammogram guidance. This technique is being used more and more because it is less invasive than surgical biopsy. It obtains only a sample of tissue rather than removing an entire lump. Occasionally, if the mass is easily felt, cells may be removed with a needle without additional guidance. Surgical biopsy is done by making an incision in the breast and removing the piece of tissue. Certain techniques allow removal of the entire lump. Regardless of how the biopsy is taken, the tissue will be reviewed by a pathologist. These are physicians who are specially trained in diagnosing diseases by looking at cells and tissues under a microscope. If a cancer is diagnosed on biopsy, the tissue will be tested for hormone receptors. Receptors are sites on the surface of tumor cells that bind to estrogen or progesterone. In general, the more receptors, the more sensitive the tumor will be to hormone therapy.

• •

Breast Cancer Treatment 26

Surgery is the mainstay of therapy for breast cancer. The choice of which type of surgery is based on a number of factors, including the size and location of the tumor, the type of tumor and the person's overall health and personal wishes. Breast-sparing surgery is often possible. The cancer is staged, using the information from surgery and from other tests. Staging is a classification that reflects the extent and spread of a tumor and has an impact on treatment decisions and also the prognosis for recovery.

Staging in breast cancer is based on the size of the tumor, which parts of the breast are involved, how many and which lymph nodes are affected, and whether the cancer has metastasized to another part of the body. Cancers may be referred to as invasive if they have spread to other tissues. Those that do not spread to other tissues are called noninvasive. Carcinoma in situ is a noninvasive cancer.

Breast cancer is staged from 0 to IV.
• • • • •

Stage 0 is noninvasive breast cancer, that is, carcinoma in situ with no affected lymph nodes or metastasis. This is the most favorable stage of breast cancer. Stage I is breast cancer that is less than 2 cm (3/4 in) in diameter and has not spread from the breast. Stage II is breast cancer that is fairly small in size but has spread to lymph nodes in the armpit OR cancer that is somewhat larger but has not spread to the lymph nodes. Stage III is breast cancer of a larger size, greater than 5 cm (2 in), with greater lymph node involvement, or of the inflammatory type. Stage IV is metastatic breast cancer: a tumor of any size or type that has metastasized to another part of the body. This is the least favorable stage

Medical Treatment Many women have treatment in addition to surgery, which may include radiation therapy, chemotherapy, or hormonal therapy. The decision about which additional treatments are needed is based upon the stage and type of cancer, the presence of hormonal and/or HER2/neu receptors, and patient health and preferences. Radiation therapy is used to kill tumor cells if there are any left after surgery.
• •

Radiation is a local treatment and therefore works only on tumor cells that are directly in its beam. Radiation is used most often in people who have undergone conservative surgery such as lumpectomy. Conservative surgery is designed to leave as much of the breast tissue in place as possible. Radiation therapy is usually given five days a week over five to six weeks. Each treatment takes only a few minutes. Radiation therapy is painless and has relatively few side effects. However, it can irritate the skin or cause a burn similar to a bad sunburn in the area.

• •

External Radiation The most common type of radiation is known as external beam. In this technique, a large machine called a linear accelerator delivers high-energy radiation to the affected area. The linear accelerator creates high-energy radiation to treat cancers, using electricity to form a 27

stream of fast-moving subatomic particles. You'll receive this form of radiation as an outpatient in daily sessions over five to seven weeks, depending on your particular situation.

Woman in position for external beam radiation treatment, from the front. Middle radiation beam is shown. A Bright yellow: breast being treated B Light yellow: beam in air, not touching woman C Opening of the linear accelerator D Arm holder supports woman's right arm

Woman in position for radiation treatment, from the side. Side radiation treatment beam is shown. A Bright yellow: breast being treated B Light yellow: beam in air, not touching woman C Opening of the linear accelerator D Arm holder

Cross-sectional view of a woman receiving radiation to the breast area A Middle radiation beam B Side radiation beam C Bright yellow: place where radiation is given to the breast D Rib cage/chest wall E Heart F Lungs G Backbone H Sternum/breastbone

28

As indicated in these photos, radiation to the whole breast is delivered from two different treatment fields. The two fields come from opposite directions, which face each other:
• •

One starts from the side of the breast and faces the middle of the chest (where the breastbone is). One starts in the middle of the chest and faces the side.

The radiation oncologist can maximize the amount of radiation delivered to the breast area and avoid or minimize radiation to other parts of the body by:
• • • •

treating the breast area with angled fields that skim across the chest, just catching the breast area, placing the back edges of the two fields as close to the breast area as possible, using special blocks in the head of the machine to avoid radiation to normal tissue, and placing special devices, called wedges, in the path of the beam to bend the dose of radiation away from normal tissues under the breast.

Woman lying on the table of a linear accelerator Photo courtesy of Varian Medical Systems, Inc. Partial-breast Radiation Most women with early-stage breast cancer are able to have breast-conserving surgery (lumpectomy) followed by radiation instead of mastectomy—with the same chances of a good long-term outcome. Lumpectomy removes the cancer. Then radiation is given to get rid of any cancer cells that might be left behind after the main cancer has been removed. The current standard of care is to treat the whole breast with radiation after lumpectomy. But another option is available: partial-breast radiation. It's also known as partial-breast irradiation (PBI) or limited-field radiation therapy. Researchers are studying partial-breast radiation to see how the benefits compare to whole-breast radiation. Partial-breast radiation was developed to reduce recurrence, shorten the length of time it takes to get radiation treatment, and limit the dose of radiation (and associated side effects) to surrounding normal tissue. Partial-breast radiation also MAY be able to be given again— but only to another part of the breast—if a new breast cancer is diagnosed in the future. Wholebreast radiation usually can't be given again to the same breast. Background A number of studies on women with early-stage breast cancer have compared lumpectomy alone to lumpectomy and whole-breast radiation. The results showed that whole-breast radiation after lumpectomy reduces the risk of recurrence by about two thirds. The area that's very close to the site of the original cancer is the area that's at highest risk of recurrence. The risk of cancer coming back in a different part of the same breast is quite low. This is true whether you have lumpectomy alone or lumpectomy followed by whole-breast radiation. 29

Based on these findings, doctors created a new radiation approach: focus the radiation only on the area near where the cancer was. Treating an area smaller than the whole breast can be done in less time (one week versus six to seven weeks). The early results from the first small studies on partial-breast radiation look very promising. These results have led to the next step: comparing partial-breast radiation to whole-breast radiation, which is the current standard of care. The NSABP B-39 clinical trial, which is comparing these two treatments, is looking at:
• • •

overall survival (how long the women lived, with or without the cancer coming back) recurrence-free survival (how many women lived with the cancer never coming back) distant disease-free survival (how long the women lived before the cancer came back)

The study is also looking at quality of life issues, including fatigue, treatment-related side effects, and convenience of the treatments. How Does Partial-breast Radiation Work? There are different ways to deliver partial-breast radiation. It is usually given internally (from the inside). But it can also be given externally (from the outside) during or after surgery. In the past, the most common way to give partial-breast radiation was to put very tiny pieces of radioactive material called seeds into hollow tubes that were placed in the treatment area. Now the most popular methods are internal radiation using the MammoSite balloon device, and external radiation using small fields from a linear accelerator (a large machine that creates the radiation for treatment). Internal radiation delivered at the time of surgery, called intraoperative radiation, is done in relatively few treatment centers. Internal Partial-breast Radiation Internal radiation is also called brachytherapy. "Brachy" means slow delivery using radioactive seeds (compared to regular external beam radiation, which delivers radiation faster using a machine). There are two kinds of brachytherapy: multi-catheter brachytherapy and ballooncatheter brachytherapy. In multi-catheter brachytherapy tiny tubes (catheters) are sewn under your skin in the area where the cancer was. The ends of the tubes stick out through little holes in the skin. Tiny stitches hold the tubes in place. Radioactive seeds are then placed into the tubes just long enough to deliver the prescribed dose. If slow-delivery radiation seeds are used, the treatment can take a few days. During treatment, you stay in the hospital because there is radioactivity inside you. Special precautions are taken to keep you and everyone else safe. Your nurses, doctors, and visitors are allowed to be with you for only a short time while the radiation seeds are in the tubes. No one will be able to be very close to you. Once the treatment is done, the radioactive seeds, the stitches, and the tubes are removed. Then you can go home. If high-dose radioactive seeds are used, each seed might be left in for up to 10 minutes. Once treatment is done, the tubes are removed. In balloon-catheter brachytherapy (the MammoSite system), a special tube with a balloon on the end is used. The balloon is placed into the area where the cancer was. The tube comes out through a little hole in the skin. Stitches aren't needed because the balloon is filled with fluid to hold the balloon and tube snugly in place. The MammoSite can be inserted in an operating room or in a surgeon's office. The balloon stays in place about a week and a half. Careful planning is done to make sure that the balloon fits into the breast properly. During each treatment, a radioactive seed is placed into center of the balloon for about 5 to 10 minutes—just long enough to deliver the prescribed dose of radiation. A total of 10 treatments usually are 30

given over five days. That means two treatments per day, about six hours apart. When the final treatment is done, the balloon is removed through the small hole in the skin. Intraoperative Partial-breast Radiation Partial-breast radiation can be given during lumpectomy surgery, after the cancer has been removed. While the underlying breast tissue is still exposed, a single dose of radiation is given directly to the area where the cancer was. One way uses the linear accelerator to deliver electron beam radiation to the area where the cancer was. Radiation with electrons only goes a short distance and can be concentrated on the area at risk. Special techniques are used to protect the underlying tissue. The procedure takes about two minutes and then the surgery is completed as usual. The other technique is known as the high-dose rate remote afterloading intraoperative radiation technique. This procedure uses a small tube to deliver a high dose of radiation to the area where the cancer was. The tube is put into position and then connected to a computerized radiation machine. The procedure takes about 5 to 10 minutes. For safety reasons, all the doctors and nurses must leave the room while the radiation is delivered. But a special patient monitoring station is located outside the operating room so your doctors watch and check on you the whole time. Only a few treatment centers offer radiation during surgery. There are several reasons why:
• • •

Using intraoperative radiation for partial-breast radiation is very new. Only small studies with short follow-ups have been done so far. Intraoperative partial-breast radiation hasn't been compared to the standard of care: whole-breast radiation after lumpectomy. It's very expensive to have a radiation machine and proper shielding in an operating room. Most radiation therapy departments are far away from the operating rooms, so the equipment can't be shared or moved.

External Beam Partial-breast Radiation Only a few very small studies with very little follow-up have been done on giving partial-breast radiation externally after surgery. This treatment approach starts with a planning session (simulation). A special CAT scan of the breast is done and is used to map out small treatment fields for the area at risk. The type and distribution of radiation is designed to maximize the dose to the area that needs to be treated and avoid or minimize radiation to tissue near the area. The radiation is delivered with a linear accelerator, twice a day for one week. External radiation therapy consists of beams of high-energy radiation directed to • the affected area. It is painless, and the treatments are usually given once a day over • a period of weeks. The area for radiation therapy is often marked with tiny tattoos • smaller than a freckle so that the treatment site is consistent throughout the therapy • sessions. Internal radiation (sometimes called brachytherapy) involves small amounts of • radioactive material placed into the tissue where the cancer has been detected. This • can be delivered by radioactive seeds or wires or by radioactive material placed into a • body cavity. Brachytherapy allows delivery of higher doses of radiation over a shorter • period because it stays in a small area near the cancerous tissue.

What is brachytherapy and how is it used? Brachytherapy is one type of radiation therapy used to treat cancer. Radiation therapy is the use of a type of energy, called ionizing radiation, to kill cancer cells and shrink tumors. 31

Unlike external beam therapy (EBT), in which high-energy x-ray beams generated by a machine are directed at the tumor from outside the body, brachytherapy involves placing a radioactive material directly inside the body. Brachytherapy, also called internal radiation therapy, allows a physician to use a higher total dose of radiation to treat a smaller area and in a shorter time than is possible with external radiation treatment. Brachytherapy is used to treat cancers throughout the body, including the:
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Prostate - see the "Prostate Cancer" page Cervix Head and neck - see the "Head and Neck Cancer" page Ovary Breast - see the "Breast Cancer" page Gallbladder Uterus Vagina

Brachytherapy may be either temporary or permanent: In temporary brachytherapy, the radioactive material is placed inside or near a tumor for a specific amount of time and then withdrawn. Temporary brachytherapy can be administered at a low-dose rate (LDR) or high-dose rate (HDR). Low-dose rate brachytherapy is also used in the treatment of coronary artery disease to prevent restenosis after angioplasty. (For more information, see "Radiation of the Heart: A Novel Treatment for Coronary Artery Narrowing After Balloon Angioplasty.") Permanent brachytherapy, also called seed implantation, involves placing radioactive seeds or pellets (about the size of a grain of rice) in or near the tumor and leaving them there permanently. After several weeks or months, the radioactivity level of the implants eventually diminishes to nothing. The seeds then remain in the body, with no lasting effect on the patient.
• COMPLICATIONS OF RADIATION THERAPY These depend on the site of the body being treated but may include • Skin redness near the radiated site • Fatigue • Infertility from radiation of the reproductive organs • Nausea, vomiting, or loss of appetite • Hair loss and dry mouth (if therapy is directed to the head or neck) • Diarrhea when the bowel is treated

Chemotherapy consists of the administration of medications that kill cancer cells or stop them from growing. In breast cancer, three different chemotherapy strategies may be used: 1. Adjuvant chemotherapy is given to people who have had curative treatment for their breast cancer, such as surgery and radiation. It is given to reduce the possibility that the cancer will return. 2. Presurgical chemotherapy is given to shrink a large tumor and/or to kill stray cancer cells. This increases the chances that surgery will get rid of the cancer completely. 3. Therapeutic chemotherapy is routinely administered to women with breast cancer that has spread beyond the confines of the breast or local area. Most chemotherapy agents are given through an IV line, but some are given as pills. 32

Chemotherapy is usually given in "cycles." Each cycle includes a period of intensive treatment lasting a few days or weeks followed by a week or two of recovery. Most people with breast cancer receive at least two, more often four, cycles of chemotherapy to begin with. Tests are then repeated to see what effect the therapy has had on the cancer. Chemotherapy differs from radiation in that it treats the entire body and thus may target stray tumor cells that may have migrated from the breast area. The side effects of chemotherapy are well known. Side effects depend on which drugs are used. Many of these drugs have side effects that include loss of hair, nausea and vomiting, loss of appetite, fatigue, and low blood cell counts. Low blood counts may cause patients to be more susceptible to infections, to feel sick and tired, or to bleed more easily than usual. Medications are available to treat or prevent many of these side effects.

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Hormonal therapy may be given because breast cancers (especially those that have ample estrogen or progesterone receptors) are frequently sensitive to changes in hormones. Hormonal therapy may be given to prevent recurrence of a tumor or for treatment of existing disease.
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In some cases, it is beneficial to suppress a woman's natural hormones with drugs; in others, it is beneficial to add hormones. In premenopausal women, ovarian ablation (removal of the hormonal effects of the ovary) may be useful. This can be accomplished with medications that block the ovaries' ability to produce estrogens or by surgically removing the ovaries, or less commonly with radiation. Until recently, tamoxifen (Nolvadex), an antiestrogen (a drug that blocks the effect of estrogen), has been the most commonly prescribed hormone treatment. It is used both for breast cancer prevention and for treatment. Fulvestrant (Faslodex) is another drug that acts via the estrogen receptor, but instead of blocking it, this drug eliminates it. It can be effective if the breast cancer is no longer responding to tamoxifen. Fulvestrant is only given to women who are already in menopause and is approved for use in women with advanced breast cancer. Toremifene (Fareston) is another anti-estrogen drug closely related to tamoxifen. Aromatase inhibitors, which block the effect of a key hormone affecting the tumor, may be more effective than tamoxifen in the adjuvant setting. The drugs anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femera) have a different set of side effects and risks than tamoxifen. Aromatase inhibitors are rapidly moving into first line hormonal therapy regimens. In addition, they are frequently used after two or more years of tamoxifen therapy. Megace (megestrol acetate) is a drug similar to progesterone which may also be used as hormonal therapy.

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Monoclonal antibodies are antibodies against proteins in or around a cancer cell. Antibodies recognize an "invader"—in this case, a cancer cell—and attack it.

Trastuzumab (Herceptin) is an antibody against the HER-2 protein, a protein responsible for cancer cell growth in many women with breast cancer (about 15-25% of breast cancers). Adding treatment with trastuzumab to chemotherapy given after surgery has been shown to lower the recurrence rate and death rate in women with HER2/neupositive early breast cancers. Using trastuzumab along with chemotherapy has become standard adjuvant treatment for these women.

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Lapatinib (Tykerb) is another drug that targets the HER2/neu protein and may be given combined with chemotherapy. It is used in women with HER2-positive breast cancer that is no longer helped by chemotherapy and trastuzumab. Another monoclonal antibody, Bevacixumab (Avastin) has been shown to have activity in the treatment of breast cancer and is used in combination with chemotherapy. This drug targets the ability of cancers cells to form new blood vessels.

Surgery Surgery is generally the first step after the diagnosis of breast cancer. The type of surgery is dependent upon the size and type of tumor and the patient's health and preferences.

Lumpectomy involves removal of the cancerous tissue and a surrounding area of normal tissue. This is not considered curative and should almost always be done in association with other therapy such as radiation therapy with or without chemotherapy or hormonal therapy. At the time of lumpectomy, the axillary lymph nodes (the glands in the armpit) need to be evaluated for the spread of cancer. This can be done by either removing the lymph nodes or by sentinel node biopsy (biopsy of the closest lymph node to the tumor). If a sentinel node biopsy is done at the time of lumpectomy, it may allow the surgeon to remove only some of the lymph nodes. In this procedure, a dye is injected into the area of the tumor. The path of the substance is then followed as it travels to the lymph nodes. The first node reached is the sentinel node. This node is considered most important to biopsy when evaluating the spread of the tumor. If the sentinel node biopsy is positive, the surgeon will usually remove of all of the lymph nodes found in the axilla (armpit). Simple mastectomy removes the entire breast but no other structures. If the cancer is invasive, this surgery alone will not cure it. It is a common treatment for DCIS, a noninvasive type of breast cancer. Modified radical mastectomy removes the breast and the axillary (underarm) lymph nodes but does not remove the underlying muscle of the chest wall. Although additional chemotherapy or hormonal therapy is almost always offered, surgery alone is considered adequate to control the disease if it has not metastasized. Radical mastectomy involves removal of the breast and the underlying chest wall muscles, as well as the underarm contents. This surgery is no longer done because current therapies are less disfiguring and have fewer complications.

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Mastectomy Overview Mastectomy is an operation in which the entire breast, usually including the nipple and the areola, is removed. Mastectomy is usually performed as a treatment of breast cancer. In general, women with breast cancer can decide whether to be treated with a lumpectomy or a mastectomy. A lumpectomy is the removal of the cancerous breast tissue as well as a surrounding rim of healthy breast tissue. A lumpectomy is a breast-conserving surgery that is usually followed by radiation therapy (high-dose x-rays or other high-energy rays to kill cancer cells). A woman may decide to have a mastectomy versus a lumpectomy based on the following:

If the tumor is big and, after the lumpectomy, very little breast tissue would remain 34

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If she does not want to undergo radiation therapy after the surgery If she believes she will have less anxiety about a recurrence of breast cancer with a mastectomy

If the woman has tumors in more than one quadrant of the breast, most cancer doctors recommend a mastectomy. Historically, a mastectomy for breast cancer included an axillary lymph node dissection (removal of many of the axillary lymph nodes). Over the last decade, the approach has changed slightly in that many women can undergo a sentinel lymph node biopsy (removal of the first few lymph nodes draining the tissue of the breast) rather than an axillary lymph node dissection. The nomenclature is such that a modified radical and a radical mastectomy include an axillary lymph node dissection as part of the overall procedure. With the adoption of sentinel lymph node biopsy in the treatment of early breast cancer, the nomenclature for mastectomy has also changed. Depending on the characteristics of the tumor, the breast, and the patient, the surgeon may choose one of the following types of mastectomies:

Simple or total mastectomy: The surgeon removes the entire breast tissue but does not remove the muscle tissue under the breast. This mastectomy can be combined with a sentinel lymph node biopsy in any case of an early invasive cancer and in some cases of ductal carcinoma in-situ when a mastectomy is chosen as the treatment option. Any of these can also be combined with an axillary lymph node dissection (which by convention turns the total mastectomy into a "modified radical mastectomy"). There are several subtypes of simple or total mastectomy depending on how much skin is removed.
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Traditional: The surgeon removes an ellipse of skin that includes the skin of the nipple/areolar complex. This is the most commonly performed mastectomy. If the woman doesn't want immediate reconstruction or is not offered immediate reconstruction, the end result is a flat chest with a scar about 8 inches in length, usually oriented transversely. Skin-sparing: In addition to the breast tissue as noted, the only skin removed is that of the nipple and areola, usually through a circular incision around the areola. If the breast is large, the surgeon may have to make a "keyhole" incision (one that includes a straight incision in one direction, generally down) to allow removal of the breast tissue. Nipple-sparing: The surgeon makes an incision around the nipple but leaves the areola intact. Again, in order to remove all of the breast tissue, the incision will need to be bigger than what is achieved with removal of the nipple. This is often an S-shaped incision. Total skin-sparing: The surgeon removes the breast tissue but leaves all the skin (including the skin of the nipple and areola) behind. The incision can be place in the outer part of the breast, in the inframammary fold or around the areola.

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In general, if leaving the skin of the areola and or nipple, some surgeons recommend that the woman have a tumor that is less than 2 centimeters in size and that is more than 2 centimeters away from the nipple. The skin-sparing mastectomies are ideal for patients undergoing prophylactic mastectomy. The skin-sparing, nipple-sparing, and total skin-sparing mastectomies are generally done in combination with immediate breast reconstruction. The benefit of these procedures is that more of the breast skin envelope is preserved to make it easier to recreate the breast. No randomized trial has been undertaken to evaluate if there is an increased risk of local (in the breast skin or on the muscle) recurrence with the skin-sparing techniques. Most surgeons estimate that preserving more skin increases the risk of local recurrence of the tumor by 1% or 2 % over 20 years (from 3%-5% for traditional to 5%-7% for skin-sparing).

Modified radical mastectomy: This combines a simple or total mastectomy, including the skin of the nipple and the areola, and includes removal of most of the lymph nodes in the armpit (axillary nodes) using a 6- to 8-inch incision. A woman undergoing a modified radical mastectomy can have immediate or delayed breast reconstruction. 35

Radical mastectomy: The surgeon removes the entire breast tissue, all the lymph nodes in the armpit, and the muscles of the chest wall (pectoral muscles) that lie under the affected breast. Radical mastectomy was common in the past; however, it is rarely performed now.

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