Breast Cancer (aka BR CA

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Etiology Heredity or genetics o Fam Hx of ovarian cancer (esp. if involved family member had this, was premenopausal, had bilateral BR CA and is a first degree relative) o First degree relative increases women¶s risk of BR CA 1.5X to 3X - Sex hormones: act as tumour promoters if initiating agents have induced malignant changes - Environmental factors ± e.g. radiation exposure - Modifiable factors ± e.g. body mass, physical activity & ETOH - Increasing age ± increases the risk of develop breast ca o Incidence under 25 y.o. is very LOW and GRADUAL INCREASE ± but AFTER 60 y.o. DRAMATIC INCREASE - Combined hormone replacement therapy (estrogen & progesterone) ± increase risk & risk of having a larger more advanced BR CA at diagnosis - Link may exist btwn recent oral contraceptive use & increased risk for women < 35 y.o. - Culture: white women higher incidence than non-whites BRCA1 & BRCA2 gene - A tumour suppressor gene that inhibits tumour development when functioning normally - Mutations have 40-80% lifetime chance of developing BR CA - Also, at high risk for developing ovarian ca - Routine screening for genetic abnormalities of a strong family hx of BR CA is NOT needed - Prophylactic bilateral oophorectomy can decrease the risk of both BR and ovarian ca - Women with high risk of developing BR CA ± undergo prophylactic bilateral mastectomy --SX REDUCES risk by 90% MEN - Predisposing risk factors include state of hyperestrogenism - Family hx of BR CA - Radiation exposure - Arise from epithelial lining of the ducts or epithelium of lobules - Most arise from the ducts & are invasive - Cancer growth rate can range from slow to rapid Factors that affect prognosis: - size - axillary nodes involved (more nodes involved, the worse the prognosis) - tumour differentiation - human epideral growth factor receptor 2 (HER-2) status ( overexpressed in ca) - & estrogen and progesterone receptor status. Noninvasive BR CA - Intraductal ca includes ductal carcinoma in situ (DCIS) and lobular insitu (LCIS) - DCIS tends to be unilateral and most likely to progress to invasive BR CA if left untx - No treatment is necessary for LCIS ± Tamoxifen can be given as chemotherapeutic agent Paget¶s Disease - Rare breast malignancy characterized by a persistent lesion of the nipple and areola with or without a palpable mass - Clinical Manifestation: Itching, burning, and bloody nipple discharge with superficial erosion and ulceration - Tx: simple or modified radical mastectomy - Prognosis is good when ca confined to nipple Inflammatory Breast Cancer - MOST MALIGNANT form of all, rare - Aggressive and fast-growing ca

Heredity Link

Pathophysiology

SLND associated with lower morbidity rates & greater accuracy as compared with COMPLETE axillary node dissection .Assessments of axillary lymph node status. then.Mistaken for an infection.If SLNs NEGATIVE ± NO further SX required .More nodes involved ± GREATER risk of recurrence 4+ nodes involved ± greatest risk Lymphatic mapping & sentinel lymph node dissection (SLND) help surgeon identify the lymph node(s) that drain(s) first from the tumour site (sentinel node) . principally those of the axilla . . tumour size. even if small CXR ± can pinpoint chest metastasis .If SLNs POSTIVE ± COMPLETE axillary dissection .Small %age cause nipple discharge . BR CA is characteristically  Hard  Irregular shaped  Poorly delineated  Nonmobile  Nontender . intraoperatively. it is determined in which sentinel lymph nodes (SLNs) the radioisotope or blue dye is located . feels warm & thickened appearance that is described as resembling an orange peel (peau d¶orange) .Occurs most often in UOQ b/c location of most of the glandular tissue .The MORE WELL differentiated the tumour ± the LESS aggressive .Even in node-negative BR CA.Metastases occur early and widely .clear or bloody .Nipple retraction may occur .Radioisotopes or blue dye is injected into the tumour site.Tx: radiation.Metastases primarily occur through the lymphatic chains.Peau d¶orange .If palpable.Detected as a single lump or mammographic abnormality in the breast . chemotherapy & hormone therapy is more likely to be used in Sx .Recurrence is the main complication  Recurrence is local or regional or distant .POORLY differentiated tumours ± MORE aggressive Estrogen & progesterone receptor status . are caused by ca cells blocking lymph channels . estrogen & progesterone receptor status and cell proliferation Hx including risk factors Physical examination including breast and lymphatics Mammography (+) ± detects tumour Ultrasonography (+) ± detects tumour & distinguish between fluid-filled cyst or solid mass Biopsy ± fine needle aspiration & excisional biopsy provide histologic cells MRI (if indicated) ± detect tumour.Clinical Manifestations Complications Diagnostic Studies (Very long explanation of SLND) Skin of the breast looks red. possibility of distant metastasis Table 53-4 Common Sites of BR CA Recurrence & Metastasis SITE Local Recurrence Skin Regional Recurrence Lymph nodes Distant Metastasis Skeletal Spinal Cord Brain Pulmonary (including lung nodules and pleural effusions) Liver Bone marrow .Nodes are then sent for a frozen-section pathologicalanalysis.

Pregnancy hx (nulliparity or 1st full-term pregnancy after 30 y.Adjuvant radiotherapy .Breast conservation (lumpectomy) with sentinel lymph node biopsy and dissection. and/or axillary lymph node dissection .Hyperestrogenism & testicular atrophy ( ) .25-30% of metastasis BR CA produces excessive HER-2 . late menopause) .Modified radical mastectomy (may include reconstruction) Radiation Therapy . abdomen. ovarian. or CRC . platelet count Ca 2+ & PO4-LFTs Chest radiograph Bone scan CT Scan of chest.High-dose brachytherapy . pelvis (if indicated) Surgery .Chemotherapy for recurrent disease .Positive mammography hx .Hormone therapy (see table below) .Biological and targeted therapy Therapeutic regimen is often dictated by the clinical stage classification of the cancer Table 53-6 Hormone therapy for BR CA MECHANISM OF ACTION EXAMPLES Blocks estrogen receptors Tomoxifen (Nolvadex) Destroys estrogen receptors Fulvestrant (Faslodex) Prevents production of estrogen by inhibiting Anastrozole (Arimidex) aromatase Letrozole (Femara) Exemestane (Aromasin) SINGLE MOST POWERFUL PROGNOSTIC FACTOR R/T LOCAL RECURRENCE OR METASTASIS AFTER PRIMARY THERAPY IS STILL THE PRESENCE OR ABSENCE OF MALIGNANT CELLS IN AXILLARY LYMPH NODES SUBJECTIVE DATA: Important Health Information Past health hx: .Primary radiotherapy .Adjuvant radiotherapy .Palliative radiotherapy Chemotherapy .Menstrual hx (early menarch.Dietary habits & hx of using and use of ETOH - Collaborative Care NURSING MGMNT (BR CA) Nursing Assessment .Benign breast disorders with atypical changes .Family hx of BR CA .Associated with aggressive tumour growth Staging Workup CBC.Previous endometrial.Ploidy status correlates with tumour aggressiveness  Diploid tumours ± lower risk of recurrence  Aneuploid tumours ± higher risk of recurrence HER-2 receptor status ± overexpression of this receptor has been associated with greater risk for recurrence & poorer prognosis .o) .

Sensitivity to an individual¶s need for information is essential . possibly fixated to fascia or chest wall.use of hormones (esp. and BMI (moderate diets or lifestyles that produce normal BMI better outcomes) Medications: .General: axillary & supraclavicular lymphadenopathy .Respiratory: pleural effusions (metastasis) . lymphoma or thyroid radiation) SYMPTOMS . as postmenopausal hormone replacement therapy & oral contraceptives. nipple inversion or retraction. infertility tx SX or other treatments: . nonmobile breast lump most often in UPPER.Women may exhibit signs of distress or tension. infiltration or dimpling (later stage) . jaundice.unilateral nipple discharge (clear. sleep disturbances & restlessness.Uneventful postop course with only moderate pain experienced ALND or mastectomy . induration. maintain Nursing Implementation . erosion.change in breast contour. peripheral edema (metastasis) . arm or bone pain (possible indicator of metastasis) .Placed in semi-fowler¶s position with the arm on the affected side elevated on a pillow . size or symmetry . wt. back. erythema. milky or bloody) .exposure to excessive radiation (e. OUTER sector.anorexia (possible indicator or metastasis) . ascites . discreet nodules at mastectomy site. clients and family need to be taught how to manage drainage tubes at home Post-op .g. with progressive increases in activity encouraged . increased muscle tension.Flexing and extending fingers should begin in recovery room.Information of arm exercise pertain to ALND & lumpectomy or total mastectomy . irregular. whenever she focuses on decision to be made .palpable change found on self-examination .headache.anxiety regarding threat to self-esteem OBJECTIVE DATA .Reproductive: hard.Since time between diagnosis of BR CA and selection of treatment plan is a difficult period --.appropriate nursing interventions include:  Exploring woman¶s usual decision-making patterns  Helping woman accurately evaluate the advantages and disadvantages of the options  Providing information relevant to the decision  Supporting the client once the decision is made . edema (peau d¶orange).psychological stress .GI: hepatomegaly.Provided with sufficient information to ensure informed consent .Level of usual physical activity.g. 53-8 are designed to prevent contractures and muscle shortening. tachycardia.Exercises fig.Teaching in preoperative phase include instructions in:  Turning  C & DB  A review of post-op exercises  Pain management plan  Explanation of recovery period from time of SX until discharge Breast Conservation therapy .Integumentary: firm. e.Drains are often left in place and clients discharged home with them .Therefore.

and cellulitis and progressive fibrosis can result Not always preventable. fluid accumulates in the arm. inflammation and obstruction resulting from the excision or radion of lymph nodes When the axillary nodes cannot return lymph fluid to the central circulation. even while the person is sleeping BP readings. seroma. hematoma. same nurse work with woman so progress can be monitored and problems can be identified Affected arm SHOULD NEVER be dependent. generally an ALND is recommended Lymphedema Accumulation of lymph in soft tissue with swelling. diffuse calcifications in more than one quandrant and central location of tumour near the nipple ADVANTAGES ± preserves breast. impaired motor function in the arm and numbness and parestheisa of the fingers result. pinprick or sunburn  If trauma to the arm occurs ± area should be washed with soap & water  Topical antibiotic ointment & bandaged or other sterile dressing applied Client must understand that she is at risk for developing lymphedema for REST of LIFE Axillary node dissection ALND involves the removal of 12 to 20 nodes Recently. masses and calcifications that are multifocal. infection Long-term: sensory CLIENT ISSUES Loss of breast Incision Body image Need for prosthesis . pain. If one or more sentinel lymph nodes contain malignant cells. ending with a boost to the tumour bed Evidence of systemic disease chemotherapy may be given before radiation therapy Contraindications ± small breast size in relation to the tumour size to yield an acceptable cosmetic result.- NURSING MANAGEMENT: BR augmentation & reduction - muscle tone and improve lymph & blood circulation Goal of all exercise is a gradual return to full ROM within 4-6 weeks Post-op discomfort minimized by administering analgesics about 30 minutes before initiating exercises When showering appropriate. including nipple DISADVANTAGE ± increased cost of SX and radiation and possible SE (side effects) of radiation - Table 53-8 Surgical Procedures for BR CA PROCEDURES DESCRIPTION Modified radical mastectomy Removal of breast. radiation therapy is delivered to the entire breast. but it can be controlled after SX or radiation Breast Conservation SX Involves the removal of the entire tumour along with a margin of normal tissue Following Sx. and injections should not be done on the affected arm Woman must be instructed to protect the arm on the operative side from even minor trauma ± e. flow of warm water over the involved shoulder often soothing and reduces jt stiffness Whenever possible. axillary lymph node dissection SE Chest wall tightens Phantom breast sensations Arm swelling POTENTIAL COMPLICATIONS Short-term: skin flap necrosis. SLND has replaced ALND for clients who do not have malignant cells identified in their sentinel nodes. causing obstructive pressure on the veins and venous return Manifestation: heaviness.g. venipuntures. masses that are multicentric. preserve pectoralis muscle.

infection LT: capsular contractions. skin. wound separation. radiation therapy Breast soreness Breast edema Skin reactions Arm swelling Sensory changes in breast and arm Fatigue Discomfort Chest wall tightens Tissue expansion & breast implants Musculocutaneous flap procedure Expander used to slowly stretch tissue. sentinel lymph node dissection (SLND) and/or ALND. infection LT: fibrosis. *rib fractures ST: skin flap necrosis. abdominal hernia. seroma. skin flap necrosis. muscle weakness. symmetry Prolonged postoperative recovery . hematoma Impaired arm mobility Prolonged tx Impaired arm mobility Change in texture & sensitivity of breast Body image Prolonged physician visits to expand implants Additional SXs for nipple construction.(ALND) Sensory changes Breast conservation surgery with radiation therapy Wide excision of tumour. saline gradually injected into reservoir over weeks to months Insertion of implant under musculofascial layer of chest wall Musculocutaneous flap (muscle. *hematoma. displacement of implant ST: delayed wound healing. infection. lymphedema. seroma. blood supply) is transposed from latissimus dorsi to transverse rectus abdominis to chest wall Pain r/t 2 surgical sties and extensive surgery loss. hematoma. pneumonitis. lymphedema ST: moist desquamation. myositis.