BREAST CANCER

- is a disease in which cells in the breast grow out of control.

-It is second only to lung cancer as the leading cause of death from cancer in
women.

ETIOLOGY
-not completely understood

RISK FACTORS
- Female
- Age ≥ 50 yr
- Hormone use
- Family history
- Genetic factors
- Personal history of breast cancer, colon cancer, endometrial cancer, ovarian
cancer
- Early menarche (before age 12), late menopause (after age 55)
- First full-term pregnancy after age 30, nulliparity
- Benign breast disease with atypical epithelial hyperplasia, lobular carcinoma
in situ
- Dense breast tissue
- Weight gain and obesity after menopause
- Exposure to ionizing radiation
- Alcohol consumption
- Physical inactivity

PATHOPHYSIOLOGY
- The main components of the breast are lobules and ducts. In general, breast
cancer arises from the epithelial lining of the ducts or from the epithelium of
the lobules.
- Breast cancers may be in situ or invasive.
Metastatic breast cancer is breast cancer that has spread to other organs, with the
most common sites being bone, liver, lung, and brain. Factors that affect cancer
prognosis are tumor size, axillary node involvement, tumor differentiation, estrogen
and progesterone receptor status, and human epidermal growth factor receptor 2
(HER-2) status.

TYPES
A. NON-INVASIVE
❏ Ductal Carcinoma in Situ (DCIS)
- It is characterized by the proliferation of malignant cells inside the milk ducts
without invasion into the surrounding tissue.
- DCIS is frequently manifested on a mammogram with the appearance of
calcifications and is considered breast cancer stage 0.

❏ Lobular Carcinoma In Situ (LCIS)

- It is an area (or areas) of abnormal cell growth that increases a person's risk
of developing invasive breast cancer later on in life.
- Despite the fact that its name includes the term “carcinoma,” LCIS is not a true
breast cancer.

B. INVASIVE CANCER
❏ 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.

❏ Infiltrating Lobular Carcinoma

- It 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.

❏ Medullary Carcinoma
- It accounts for about 5% of breast cancers.
 - The tumors grow in a capsule inside a duct.

❏ Mucinous Carcinoma
- It accounts for about 3% of breast cancers.
- A mucin producer, the tumor is also slow growing.

❏ Tubular Ductal Carcinoma

- It accounts for about 2% of breast cancers.
- Because axillary metastases are uncommon with this histology, prognosis is
usually excellent.

❏ Inflammatory Carcinoma
- It 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).

❏ Paget Disease
- It accounts for 1% of diagnosed cases of breast cancer.
- Symptoms typically include a scaly, erythematous, pruritic lesion of the nipple.

CLINICAL MANIFESTATIONS
● Breast cancers can occur anywhere in the breast but are usually found in the
upper outer quadrant, where the most breast tissue is located.
Some warning signs of breast cancer are—

● New lump in the breast or underarm (axillary).

● Thickening or swelling of part of the breast.
● Irritation or dimpling of breast skin.
● Redness or flaky skin in the nipple area or the breast.
● Pulling in of the nipple or pain in the nipple area.
● Nipple discharge other than breast milk, including blood.
● Any change in the size or the shape of the breast.
● Pain in any area of the breast.

Assessment and Diagnostic Findings

● Techniques to determine the diagnosis of breast cancer include various types
of biopsy.
❖ Breast ultrasound. A machine that uses sound waves to make detailed
pictures, called sonograms, of areas inside the breast.
❖ Diagnostic mammogram. This is a more detailed X-ray of the breast.
❖ Magnetic resonance imaging (MRI). The MRI scan will make detailed
pictures of areas inside the breast.
 ❖ Biopsy. This is a test that removes tissue or fluid from the breast to be looked
at under a microscope and do more testing.
● Tumor staging and analysis of additional prognostic factors are used to
determine the prognosis and optimal treatment regimen

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
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)

Pathologic Factors Associated With Favorable Prognosis for Breast Cancer

● Noninvasive tumors or invasive tumors <1 cm
● Negative axillary lymph nodes Estrogen receptor (ER) and progesterone
receptor (PR) proteins
● Well-differentiated tumors
● Low expression of HER-2/neu oncogene (also known as ERBB2)
● No vascular or lymphatic invasion
● Diploid tumors with low S-phase fraction

Surgical Management
● The main goal of surgery is to gain local control of the disease.

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).
● 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 SLNB is a less invasive alternative to ALND and is considered a standard
of care for the treatment of early-stage breast cancer.
● In SLNB, the surgeon uses a handheld probe to locate the sentinel lymph
node, excise it, and send 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 Management
● The patient must be informed that although frozen-section analysis is highly
accurate, false-negative results can occur.
● 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 nurse must not overlook the psychosocial needs of the patient who has
undergone SLNB.
Postoperative Nursing Interventions
RELIEVING PAIN AND DISCOMFORT
● all patients must be carefully assessed, because individual patients can have
varying degrees of pain.
● All patients are discharged home with analgesic medication (e.g., oxycodone
and acetaminophen [Percocet]) and are encouraged to take it if needed.
● Alternative methods of pain management, such as taking warm showers (if
permitted by the surgeon) and using distraction methods (e.g., guided
imagery), may also be helpful.
MANAGING POSTOPERATIVE SENSATIONS
● Common sensations include tenderness, soreness, numbness, tightness,
pulling, and twinges. These sensations may occur along the chest wall, in the
axilla, and along the inside aspect of the upper arm.
● After mastectomy, some patients experience phantom sensations and report
a feeling that the breast or nipple is still present. Sensations usually persist for
several months and then begin to diminish, although some may persist for as
long as 5 years and possibly longer.
● Patients should be reassured that this is a normal part of healing and that
these sensations are not indicative of a problem.
PROMOTING POSITIVE BODY IMAGE
● Patients who have undergone mastectomy may find it difficult to view the
surgical site for the first time.
● Ideally, the patient sees the incision for the first time when she is with the
nurse or another health care provider who is available for support. The nurse
first assesses the patient’s readiness and provides gentle encouragement.
● If the patient has not had immediate reconstruction, providing her with a
temporary breast form or soft padding to place in her bra on discharge can
help alleviate feelings of embarrassment or self-consciousness.
PROMOTING POSITIVE ADJUSTMENT AND COPING
● Providing ongoing assessment of how the patient is coping with her diagnosis
of breast cancer and her surgical treatment is important in determining her
overall adjustment.
 ● Assisting the patient in identifying and mobilizing her support systems can be
beneficial to her well-being.
● Encouraging the patient to discuss issues and concerns with other patients
who have had breast cancer may help her to understand that her feelings are
normal and that other women who have had breast cancer can provide
invaluable support and understanding.
● The patient may also have considerable anxiety about the treatments that will
follow surgery (i.e., chemotherapy and radiation) and their implications.

IMPROVING SEXUAL FUNCTION

● Encouraging the patient to openly discuss how she feels about herself and
about possible reasons for a decrease in libido (e.g., fatigue, anxiety, self-
consciousness) may help clarify issues for her.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

● Lymphedema is a complication characterized by a chronic swelling of an
extremity due to interrupted lymphatic circulation.
● The swelling is due to the accumulation of protein-rich fluid in the interstitial
space and is a somewhat common postoperative complication after ALND.
● Risk factors for lymphedema in mixed-age groups include ALND,
concomitant radiation therapy, increased age, presence of a concomitant
infection, pre-existing cardiovascular conditions, and obesity (McLaughlin,
2014).
● Hematoma or Seroma Formation. Hematoma formation (collection of blood
inside a cavity) may occur after either mastectomy or breast conservation and
usually develops within the first 12 hours after surgery.
● The surgeon should be notified immediately if there is gross swelling or
increased bloody output from the drain.
● Infection. Patients are taught to monitor for signs and symptoms of infection
(redness, warmth around incision, tenderness, foul-smelling drainage,
temperature greater than 40°C [100.4°F], chills) and to contact the surgeon or
nurse for evaluation.
● Treatment consists of oral or IV antibiotics (for more severe infections) for 1
or 2 weeks. Cultures are taken of any foul-smelling discharge.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy

cancer cells. There are several different types of radiation therapy:

● External-beam radiation therapy. This is the most common type of

radiation treatment and is given from a machine outside the body. This
includes whole breast radiation therapy and partial breast radiation
 therapy, as well as accelerated breast radiation therapy, which can be
several days instead of several weeks.
● Intra-operative radiation therapy. This is when radiation treatment is
given using a probe in the operating room.
● Brachytherapy. This type of radiation therapy is given by placing
radioactive sources into the tumor.

Radiation therapy may be given after or before surgery:

● Adjuvant radiation therapy is given after surgery. Most commonly, it is

given after a lumpectomy, and sometimes, chemotherapy.
● Neoadjuvant radiation therapy is radiation therapy given before surgery
to shrink a large tumor, which makes it easier to remove. This approach is
uncommon and is usually only considered when a tumor cannot be
removed with surgery.

Therapies using medication

● Systemic therapy is the use of medication to destroy cancer cells.

● Common ways to give systemic therapies include an intravenous (IV) tube
placed into a vein using a needle, an injection into a muscle or under the
skin, or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for breast cancer include:

Chemotherapy

- Chemotherapy is the use of drugs to destroy cancer cells, usually by

keeping the cancer cells from growing, dividing, and making more cells.

-A chemotherapy regimen, or schedule, usually consists of a combination

of drugs given in a specific number of cycles over a set period of time.

Side Effects:
 ● Common physical side effects of chemotherapy for breast cancer may
include nausea, vomiting, bone marrow suppression, taste changes,
alopecia (hair loss), mucositis, neuropathy, skin changes, and fatigue. A
weight gain of more than 10 pounds occurs in about half of all patients.
Women who are premenopausal may also experience temporary or
permanent amenorrhea.

Hormonal therapy

● Hormonal therapy, also called endocrine therapy, is an effective treatment for

most tumors that test positive for either estrogen or progesterone receptors
(called ER positive or PR positive).
● Hormonal therapy may be given before surgery to shrink a tumor, make
surgery easier, and/or lower the risk of recurrence. This is called neoadjuvant
hormonal therapy. It may also be given solely after surgery to reduce the risk
of recurrence. This is called adjuvant hormonal therapy.

Targeted therapy

● Targeted therapy is a treatment that targets the cancer’s specific genes,

proteins, or the tissue environment that contributes to cancer growth and
survival. These treatments are very focused and work differently than
chemotherapy.
● Trastuzumab (Herceptin) is a monoclonal antibody that binds specifically to
the HER-2/neu protein. TTrastuzumab targets and inactivates the HER-
2/neu protein, thus slowing tumor growth.
● Unlike chemotherapy, trastuzumab spares the normal cells and has limited
adverse reactions, which may include fever, chills, nausea, vomiting,
diarrhea, and headache.

Immunotherapy

● Immunotherapy, also called biologic therapy, is designed to boost the body's

natural defenses to fight the cancer. It uses materials made either by the body
or in a laboratory to improve, target, or restore immune system function. The
following drugs are used for advanced or metastatic breast cancer.

● Atezolizumab (Tecentriq). The FDA approved a combination of

atezolizumab plus protein-bound paclitaxel for locally advanced triple-
negative breast cancer that cannot be removed with surgery and
metastatic triple-negative breast cancer.
 ● Pembrolizumab (Keytruda). This is a type of immunotherapy that is
approved by the FDA to treat metastatic cancer or cancer that cannot
be treated with surgery.

Treatment of Recurrent and Metastatic Breast Cancer

● Despite the advances made in the treatment of breast cancer, it may recur
locally (on the chest wall or in the conserved breast), regionally (in the
remaining lymph nodes), or systemically (in distant organs).
● Treatment includes hormonal therapy, chemotherapy, and targeted
therapy.
● Surgery or radiation may be indicated in select situations. Women who are
premenopausal and who have hormonally dependent tumors may
eliminate the production of estrogen by the ovaries through oophorectomy
(removal of the ovaries) or suppression of estrogen production by
medications such as leuprolide (Lupron) or goserelin (Zoladex).
● Patients with advanced breast cancer are monitored closely for signs of
disease progression. Baseline studies are obtained at the time of
recurrence. These may include complete blood count; comprehensive
metabolic panel; tumor markers (i.e., carcinoembryonic antigen, cancer
antigen 15-3); bone scan; CT of the chest, abdomen, and pelvis; and MRI
of symptomatic areas. Additional x-rays may be performed to evaluate
areas of pain or abnormal areas seen on bone scan (e.g., long bones,
pelvis).

Nursing Management

● Nurses play an important role in not only educating patients and managing
their symptoms but also in providing emotional support.
● The nurse can help the patient identify coping strategies and set priorities
to optimize quality of life.
● Referrals to support groups, as well as psychiatry or psychiatric clinical
nurse specialist, social work, and complementary medicine programs (e.g.,
guided imagery, meditation, yoga), should be made as indicated.
● Nurses can also be instrumental in providing palliative care, if indicated.
The highest priorities include alleviating pain and providing comfort
measures. Referrals to hospice and home health care should be initiated
as necessary