BREAST CANCER

1. INTRODUCTION AND EPIDEMIOLOGY

A1. DEFINITION

Breast cancer is cancer that develops in breast cells. Typically, the cancer forms in either the
lobules or the ducts of the breast. Lobules are the glands that produce milk, and ducts are the
pathways that bring the milk from the glands to the nipple. Cancer can also occur in the fatty
tissue or the fibrous connective tissue within your breast.

A2. TYPES

 Ductal Carcinoma in Situ

o Ductal carcinoma in situ (DCIS) is characterized by the proliferation of malignant
cells inside the milk ducts without invasion into the surrounding tissue. Unlike
invasive breast cancer, DCIS does not metastasize and a woman generally does
not die of DCIS unless it develops into invasive breast cancer. DCIS can develop
into invasive breast cancer if left untreated. The best estimates are that 14% to
53% of untreated DCIS progresses to invasive breast cancer over a period of 10
years or more. However, the natural history of DCIS is not well understood, and it
is currently not possible to accurately predict which women with DCIS will go on
to develop invasive breast cancer (ACS, 2015). DCIS is frequently manifested on
a mammogram with the appearance of calcifications and is considered breast
cancer stage 0.
 Infiltrating ductal carcinoma—the most common histologic type of breast cancer—
accounts for 80% of all cases. The tumors arise from the duct system and invade the
surrounding tissues. They often form a solid irregular mass in the breast.
 Infiltrating lobular carcinoma accounts for 10% to 15% of breast cancers. The tumors
arise from the lobular epithelium and typically occur as an area of ill-defined thickening in
the breast. They are often multicentric and can be bilateral.
 Medullary carcinoma accounts for about 5% of breast cancers, and it tends to be
diagnosed more often in women younger than 50 years. The tumors grow in a capsule
inside a duct. They can become large and may be mistaken for a fibroadenoma. The
prognosis is often favorable.
 Mucinous carcinoma accounts for about 3% of breast cancers and often presents in
women who are postmenopausal and are 75 years and older. A mucin producer, the
tumor is also slow growing; thus, the prognosis is more favorable than in many other
types.
 Tubular ductal carcinoma accounts for about 2% of breast cancers. Because axillary
metastases are uncommon with this histology, prognosis is usually excellent.
Micropapillary invasive ductal carcinoma is a rare type of aggressive ductal cancer
characterized by a high rate of axillary node metastasis and skin involvement.
  Inflammatory carcinoma is a rare (1% to 3%) and aggressive type of breast cancer that
has unique symptoms. The cancer is characterized by diffuse edema and erythema of
the skin, often
 referred to as peau d’orange (resembling an orange peel). This is caused by malignant
cells blocking the lymph channels in the skin. An associated mass may or may not be
present; if there is a mass, it is often a large area of indiscrete thickening. Inflammatory
carcinoma can be confused with an infection because of its presentation. The disease
can spread to other parts of the body rapidly. Chemotherapy often plays an initial role in
controlling disease progression, but radiation and surgery may also follow.
 Paget disease of the breast accounts for 1% of diagnosed cases of breast cancer
(Grossman & Porth, 2014). Symptoms typically include a scaly, erythematous, pruritic
lesion of the nipple. Paget disease often represents DCIS of the nipple but may have an
invasive component. If no lump can be felt in the breast tissue and the biopsy shows
DCIS without invasion, the prognosis is very favorable.

A3. IMAGE

A4. EPIDEMIOLOGY
Current statistics indicate that over a lifetime (birth to death), a woman’s risk of developing
breast cancer is about 12%, or one in eight. Currently, about 231,840 new cases of invasive
breast cancer are diagnosed in women each year. Risk of developing breast cancer increases
with increasing age. About two of three invasive breast cancers are found in women 55 years or
older. About 5% to 10% of breast cancer cases are thought to be hereditary, resulting directly
from gene defects (cell mutations) inherited from a biologic parent (ACS, 2015).

Female breast cancer incidence rates vary substantially by race and ethnicity. Higher death
rates in African Americans have been attributed to later stage at diagnosis and poorer stage-
specific survival. Research suggests that racial disparities in cancer mortality are driven in large
part by differences in socioeconomic status (ACS, 2013).

2. RISK FACTOR

There is no single, specific cause of breast cancer. A combination of genetic, hormonal, and
possibly environmental factors may increase the risk of its development (see Table 58-3). More
than 80% of all cases of breast cancer are sporadic, meaning that patients have no known
family history of the disease. The remaining cases are either familial (there is a family history of
breast cancer, but it is not passed on genetically) or genetically acquired. There is no evidence
that smoking, silicone breast implants, the use of antiperspirants, underwire bras, or abortion
(induced or spontaneous) increases the risk of the disease. There is some evidence that long-
term smoking, starting before first pregnancy, and night shift work may increase the risk for
breast cancer (ACS, 2015).
As stated previously, breast cancer can be genetically inherited, resulting in significant risk.
Approximately 5% to 10% of breast cancer cases have been linked to specific genetic
mutations. Factors that may indicate a genetic link include multiple first-degree relatives with
early- onset breast cancer, breast and ovarian cancer in the same family, male breast cancer,
and Ashkenazi Jewish background. BRCA1 and BRCA2 are tumor suppressor genes that
normally function to identify damaged deoxyribonucleic acid (DNA) and thereby restrain
abnormal cell growth (Yarbo, Wujcik, & Gobel, 2013). Mutations in these genes on chromosome
17 are responsible for the majority of hereditary breast cancer in the United States. BRCA
mutations in women have been associated with an overall risk of breast cancer up to 65%
(ACS, 2015). Currently, women who are BRCA positive are counseled to start screening,
typically using mammography, once a year and then MRI 6 months after the yearly
mammography by 25 years of age, or 5 to 10 years earlier than their youngest affected family
member. Mutations in the PALB2 gene confer similar risk. Males who carry the BRCA2 mutation
may have a lifetime risk of 6% to 7% of developing breast cancer (Jain & Gradishar, 2014).
3. PATHOPHYSIOLOGY OF THE DISEASE

4. CLINICAL MANIFESTATION
Breast cancers can occur anywhere in the breast but are usually found in the upper
outer quadrant, where the most breast tissue is located. In general, the lesions are
nontender, fixed rather than mobile, and hard with irregular borders. Complaints of
diffuse breast pain and tenderness with menstruation are usually associated with benign
breast disease. With the increased use of mammography, more women are seeking
treatment at earlier stages of the disease. These women often have no signs or
symptoms other than a mammographic abnormality. Some women with advanced
disease seek initial treatment after ignoring symptoms. Advanced signs may include skin
dimpling, nipple retraction, or skin ulceration.

5. NURSING DIAGNOSIS
 Deficient knowledge about the planned surgical treatments
 Anxiety related to the diagnosis of cancer
  Fear related to specific treatments and body image changes
 Risk for defensive or ineffective coping related to the diagnosis of breast cancer and
related treatment options
 Decisional conflict related to treatment options
6. MANAGEMENT
Patients who undergo SLNB in conjunction with breast conservation treatments are
generally discharged the same day. Patients who undergo SLNB with total mastectomy
usually stay in the hospital overnight, possibly longer if breast reconstruction is being
performed. The patient must be informed that although frozen-section analysis is highly
accurate, false-negative results can occur. A negative sentinel lymph node on frozen-
section analysis may show metastatic disease on subsequent analysis, indicating that
ALND is still necessary. The patient should also be reassured that the radioisotope and
blue dye are generally safe. The nurse informs patients that they may notice a blue-
green discoloration in the urine or stool for the first 24 hours as the blue dye is excreted.
The incidence of lymphedema, decreased arm mobility, and seroma formation
(collection of serous fluid) in the axilla is generally low, but the patient should be
prepared for these possibilities. Women who have SLNB alone have neuropathic
sensations similar to those who undergo ALND, although the prevalence and severity of
these sensations and the resulting distress are lower with SLNB (Chung & Giuliano,
2014). The nurse must not overlook the psychosocial needs of the patient who has
undergone SLNB. Although SLNB is a less invasive procedure than ALND and results in
a shorter recovery period, a patient who has undergone SLNB also has many difficult
issues surrounding her breast cancer diagnosis and treatment. The nurse must listen,
provide emotional support, and refer the patient to appropriate specialists when
indicated.

Name of Drugs

 Tamoxifen
 Raloxifene

Generic: Tamoxifen Generic: Raloxine

Brand: Nolvadex
Therapeutic Effects: reduces the risk
of breast cancer coming back by 40% to
50% in postmenopausal women and by 30%
to 50% in premenopausal women. reduce the
risk of a new cancer developing in the
other breast by about 50% shrink large,
hormone-receptor-positive breast
cancers before surgery.
Side and Adverse Effects: Tamoxifen's
Brand: Evista
Therapeutic Effects: produces estrogen-
like effects on bone, reducing the resorption
of bone and increasing bone mineral density
in postmenopausal women, thus slowing the
rate of bone loss.
 Side and Adverse Effects: hot
selective estrogen activation effects can
cause some serious side effects, including
blood clots, stroke, and endometrial cancer.
Nursing Implication:
Assessment & Drug Effects
 Monitor therapeutic effectiveness. An
objective response may require 4–10
wk of therapy, longer if there is bone
metastasis.
 Administer analgesics for pain relief as
necessitated by bone and tumor pain or
local disease flair. Reassure patient that
this discomfort frequently signals a
good tumor response.
 Be aware that local swelling and
marked erythema over preexisting
lesions or the development of new
lesions may signal soft-tissue disease
response to tamoxifen. These
symptoms rapidly subside.
 Lab tests: Assess CBC, including
platelet counts, periodically. Transient
leukopenia and thrombocytopenia
3
(50,000–100,000/mm ) without
hemorrhagic tendency have been
reported. Monitor serum calcium
periodically.
flashes (more common in the first 6
months of raloxifene therapy)
 leg cramps.
 swelling of the hands, feet, ankles, or
lower legs.
 flu-like syndrome.
 joint pain.
 sweating.
 difficulty falling asleep or staying
asleep.
Nursing Implication:
Assessment & Drug Effects
 Lab tests: Periodically monitor bone
density, liver function, and plasma
lipids; with concurrent oral
anticoagulants, carefully monitor PT
and INR.
 Monitor carefully for and immediately
report S&S of thromboembolic events.
 Do not give drug concurrently with
cholestyramine; however, if
unavoidable, space the two drugs as
widely as possible.
Patient & Family Education
 Contact physician immediately if
unexplained calf pain or tenderness
occurs.
 Avoid prolonged restriction of
movement during travel.
 Drug does not prevent and may
induce hot flashes.
 Do not take drug with other estrogen-
containing drugs.
 Tell prescriber if you are taking drugs
to lower your cholesterol.
Patient & Family Education  Do not breast feed while taking this
drug.
 Do not change established dose
schedule. .
 Report to physician occurrence of
marked weakness, sleepiness, mental
confusion, edema, dyspnea, blurred
vision.
 Understand the possibility of drug-
induced menstrual irregularities before
starting treatment.
 Avoid prolonged sun exposure,
especially if skin is unprotected. Apply
sunscreen lotions (SPF 12 or greater)
to all exposed skin surfaces.
 Avoid OTC drugs unless specifically
prescribed by the physician; particularly
OTC pain medicines.
 Report onset of tenderness or redness
in an extremity.
 Do not breast feed while taking this
drug without consulting physician.

 DIAGNOSTIC TESTS
 Staging
Staging involves classifying the cancer by the extent of the disease in the body. It is
based on whether the cancer is invasive or noninvasive, the size of the tumor, how many
lymph nodes are involved, and if it has spread to other parts of the body. The stage of a
cancer is one of the most important factors in determining prognosis and treatment
options. The most common system used to describe the stages of breast cancer is the
American Joint Committee on Cancer (AJCC) TNM (tumor, nodes, metastasis) system.
Other factors considered in staging include hormone receptors and genetic mutations.
Other diagnostic tests may be performed before or after surgery to help in the staging of
the disease. The extent of testing often depends on the clinical presentation of the
 disease and may include chest x-rays, computed tomography (CT) scan, MRI scan,
positron emission tomography (PET) scan, bone scans, and blood work (complete blood
count, comprehensive metabolic panel, and tumor markers.
 Prognosis
Several different factors must be taken into consideration when determining the
prognosis of a patient with breast cancer. Two of the most important factors are tumor
size and whether the tumor has spread to the lymph nodes under the arm (axilla).
In general, the smaller the tumor appears, the better the prognosis. A tumor starts with a
genetic alteration in a single cell and takes time to divide and double in size. A
carcinoma may double in size 30 times to become 1 cm or larger, at which point it
becomes clinically apparent. Doubling time varies, but breast tumors are often present
for several years before they become palpable. Nurses can reassure patients that once
breast cancer is diagnosed, they have a safe period of several weeks to make decisions
regarding treatment; however, a lengthy delay is not advisable.
Prognosis also depends on the extent of spread of the breast cancer. The 5-year
survival rate is approximately 88% for a stage I breast cancer and 15% for a stage IV
breast cancer (ACS, 2015). The most common route of regional spread is to the axillary
lymph nodes. Other sites of lymphatic spread include the internal mammary and
supraclavicular nodes. Distant metastasis can affect any organ, but the most common
sites are bone, lung, liver, pleura, adrenals, skin, and brain (ACS, 2015).
In addition to the type of breast cancer and the stage, other factors may help determine
prognosis. Excessive number of copies of certain genes (amplification) or excessive
amounts of their protein product (overexpression) may represent a poorer prognosis.
The HER-2/neu (also known as ERBB2) oncogene is the classic example; approximately
25% of invasive breast cancers, which typically involve the more aggressive tumors,
have amplification or overexpression of this gene (Press & Ma, 2015). The proliferative
rate or rapidity in growth rate (S-phase fraction) and DNA content (ploidy) of a tumor are
factors that are also associated with overall survival rate.

6.3 MEDICAL PROCEDURE

Current management takes into account (1) assurance of an accurate diagnosis, (2)
assessment of DCIS size and grade, and (3) careful margin evaluation. The pathologist
analyzes the piece of breast tissue removed to determine the type and grade of the DCIS or
how abnormal the cells look when compared with normal breast cells and how fast they are
growing. Grade III (high-grade DCIS) cells tend to grow more quickly than grade I (low-grade)
and grade II (moderate-grade) cells and look much different from normal breast cells. Accurate
grading of DCIS is critical, because high nuclear grade and the presence of necrosis (the
premature death of cells in living tissue) are highly predictive of the inability to achieve adequate
margins or borders of healthy tissue around the cancer, of local recurrence, and of the
probability of missed areas of invasion. The pros and cons of irradiating patients with DCIS who
are treated conservatively should be carefully weighed on a case-by-case basis, considering
recent trials have shown that radiation has a beneficial effect on distant recurrence, breast
cancer–specific mortality, and overall survival. Breast conservation (treatment of a breast
cancer without the loss of the breast) can be curative for well-defined subsets of women with
DCIS (ACS, 2015).

6.4 SURGICAL MANAGEMENT

 Modified Radical Mastectomy

Modified radical mastectomy is performed to treat invasive breast cancer. The
procedure involves removal of breast tissue, including the nipple–areola complex. In
addition, a portion of the axillary lymph nodes are also removed in axillary lymph
node dissection (ALND). If immediate breast reconstruction is desired, the patient is
referred to a plastic surgeon prior to the mastectomy so that she has the opportunity
to explore all available options. In modified radical mastectomy, the pectoralis major
and pectoralis minor muscles are left intact, unlike in radical mastectomy, in which
the muscles are removed.
 Total Mastectomy
Like modified radical mastectomy, total mastectomy (i.e., simple mastectomy) also
involves removal of the breast and nipple–areola complex but does not include
ALND. Total mastectomy may be performed in patients with noninvasive breast
cancer (e.g., DCIS), which does not have a tendency to spread to the lymph nodes.
It may also be performed prophylactically in patients who are at high risk for breast
cancer (e.g., LCIS, BRCA mutation). A total mastectomy may also be performed in
conjunction with sentinel lymph node biopsy (SLNB) for patients with invasive breast
cancer.
 Breast Conservation Treatment
The goal of breast conservation treatment (i.e., lumpectomy, wide excision, partial or
segmental mastectomy, quadrantectomy) is to excise the tumor in the breast
completely and obtain clear margins while achieving an acceptable cosmetic result. If
the procedure is being performed to treat a noninvasive breast cancer, lymph node
removal is not necessary. For an invasive breast cancer, lymph node removal (SLNB
or ALND) is indicated. The lymph nodes are removed through a separate
semicircular incision in the axilla.
 Sentinel Lymph Node Biopsy
The status of the lymph nodes is the most important prognostic factor in breast cancer.
The SLNB is a less invasive alternative to ALND and is considered a standard of care for
the treatment of early-stage breast cancer. ALND is associated with potential morbidity,
 including lymphedema, cellulitis, decreased arm mobility, and sensory changes. Studies
suggest that SLNB is highly accurate and is associated with a local recurrence rate
similar to that of ALND (Chung & Giuliano, 2014). The sentinel lymph node, which is the
first node (or nodes) in the lymphatic basin that receives drainage from the primary
tumor in the breast, is identified by injecting a radioisotope and/or blue dye into the
breast; the radioisotope or dye then travels via the lymphatic pathways to the node. In
SLNB, the surgeon uses a handheld probe to locate the sentinel lymph node, excises it,
and sends it for pathologic analysis, which is often performed immediately during the
surgery using frozen-section analysis. If the sentinel lymph node is positive, the surgeon
can proceed with an immediate ALND, thus sparing the patient a return trip to the
operating room and additional anesthesia. (The patient could also return for additional
surgery at a later time.) If the sentinel lymph node is negative, a standard ALND is not
needed, thus sparing the patient the possible complications of the procedure. After the
procedure is complete, all specimens are sent to pathology for more thorough analysis.

NURSING DIAGNOSIS

1. Deficient knowledge 2. Anxiety related to the 3. Fear related to specific

about the planned surgical
treatments
Independent: Assess
patient’s level of
understanding.
Rationale: Facilitates
planning of preoperative
teaching program, identifies
content needs.
Dependent: Preoperative
instructions: NPO time,
shower or skin preparation,
which routine medications to
take and hold, prophylactic
diagnosis of cancer
Validate source of fear.
Provide accurate factual
information. Rationale:
Identification of specific fear
helps patient deal realistically
with it. Patient may have
misinterpreted preoperative
information or have
misinformation regarding
surgery. Fears regarding
previous experiences of self
or family may be resolved.
Administer medication as
prescribe such as IV anti-
anxiety agents. Rationale:
May be provided in the
outpatient admitting or
treatments and body image
changes
Assess meaning of loss or
change to patient and SO,
including future expectations
and impact of cultural or
religious beliefs. Rationale:
The extent of response is
more related to the value or
importance the patient places
in the part or function than
the actual value or
importance. This
necessitates support to work
through to optimal resolution.
Encourage family interaction
with each other and with
rehabilitation team.
Rationale: A good
conversation provides
antibiotics, or anticoagulants,
anesthesia premedication.
Rationale: Helps reduce the
possibility of postoperative
complications and promotes
a rapid return to normal body
function. Note: In some
instances, liquids and
medications are allowed up
to 2 hr before scheduled
procedure.
Collaborative: Inform patient
or SO about itinerary,
physician/SO
communications.
Rationale: Logistical
information about operating
room (OR) schedule and
locations (recovery room,
postoperative room
assignment), as well as
where and when the surgeon
will communicate with SO
relieves stress and mis-
communications, preventing
confusion and doubt over
patient’s well-being.
preoperative holding area to
reduce nervousness and
provide comfort. Note:
Respiratory depression and/or
bradycardia may occur,
necessitating prompt
intervention.
Collaborative: Refers to
counselling. Rationale: This
will help him decrease
anxiety.
ongoing support for patient
and family.
Collaborative: Refer to
physical and occupational
therapy, vocational
counselor, psychiatric
counseling, clinical specialist
psychiatric nurse, social
services, and psychologist,
as needed. Rationale: These
are helpful in identifying
ways/devices to regain and
maintain independence.
Patient may need further
assistance to resolve
persistent emotional
problems.

REFERENCES:
1. Brunner & Suddarth's Textbook of Medical-Surgical Nursing
14th edition
2. http://www.robholland.com/Nursing/Drug_Guide/data/monogr
aphframes/R002.html#:~:text=Nursing
%20Implications&text=Contact%20physician%20immediately
%20if%20unexplained,with%20other%20estrogen
%2Dcontaining%20drugs.
3. http://www.robholland.com/Nursing/Drug_Guide/data/monogr
aphframes/T004.html#:~:text=Nursing
%20Implications&text=An%20objective%20response%20may
%20require,signals%20a%20good%20tumor%20response.
4. https://www.mayoclinic.org/diseases-conditions/breast-
cancer/symptoms-causes/syc-20352470
5. https://www.healthline.com/health/breast-cancer