Breast Cancer
• Current statistics indicate that over an entire
lifetime (from birth to death), a woman’s risk of
developing breast cancer is one in eight
• Combination of early detection and improved
treatment modalities had an effect on over-all
survival
Types of Breast Cancer
A. Ductal Carcinoma in Situ (DCIS)
- characterized by the proliferation of malignant
cells inside the milk ducts without invasion into
surrounding tissue
B. Invasive Cancer
Types of Invasive Breast Cancer
1. Infiltrating Ductal carcinoma
- most common histologic type of breast cancer
- Tumors arise from the duct system and invade
the surrounding tissues
- Tumors form a solid irregular mass in the
breast
2. Infiltrating Lobular Carcinoma
- Tumors arise from the lobular
epithelium and typically occur as an area of ill-
defined thickening of the breast.
3. Medullary carcinoma
-Tumors grow in capsule inside a duct
-with fast-growth rate and favorable prognosis
4. Mucinous Carcinoma
- Tumor is slow-growing
- prognosis is more favorable
5. Tubular Ductal carcinoma
- axillary metestasis is uncommon. Frequently
associated with infiltrating type.
Tubular cell type dominates
6. Inflammatory carcinoma
-Characterized by diffuse edema and
brawny erythema of the skin, often referred to a
peau d’ orange which resembles an orange peel.
5. Paget’s Disease
- symptoms typically include a scaly,
erythematous, pruritic lesion of the nipple
- Often represents ductal carcinoma in situ of the
nipple but may have an invasive component.
Risk Factors
• Genetics
Associated with a gene on chromosome 17. This
gene is mutated in families with early-onset
breast cancer and ovarian cancer
• Breast cancer in mother, sister or daughter
(especially bilateral or premenauposal
• Female Gender
Menstrual history :
early menarch under age 12,
late menopause after age 50
nulliparous history or late first pregnancy
• Increasing Age
-First child after 30
Mean and median age of women with breast
cancer is between 60 to 61 years
• Hormonal- controversial
• Environmental
• History of Benign proliferative breast disease
• High Fat diet – re lease free radicals that may
contribute to cancer
-Diets that are considered as free-radical
scavengers or antioxidants reducesthe risk for
cancer
- Vitamins A, E and C, folic acid
• Alcohol Intake
Increases the risk slightly
* No single specific cause of Breast Cancer
Protective Factors
• Physical activity most especially in post
menauposal women ; moderate exercise can be
beneficial- rfeduces estrogen level or a decrease
in fat consumption and abesity
• Breastfeeding
-Prevents the return of menstruation, thereby
decreasing exposure to endogenous estrogen
-Women who breastfeed for at least 6
consecutive months have reduced risks
• Completed a full-term pregnancy before 30 years
of age
- Women who had multiple pregnancies
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 Progesterone is a protective hormone that
inhibits the stimulatory effect of estrogen
Preventive Strategies
• Long-term surveillance
- Clinical breast examinations :
1. Yearly mammography
-Most reliable means of detecting breast
cancer before a mass can be palpated
-Mammography should begin at age 40
2. Ultrasound
3. MRI
• Chemoprevention
1. tamoxifen
2. Raloxifene
• Prophylactic Mastectomy
-Sometime referred to as « risk-reducing »
mastectomy
-removal of the breast tissue
• Self-examination
-It is a useful technique since many patients do
detect their own cancer and women mosre often
feel in control and proactive in performing BSE
-Beginning at age 20
Clinical Manifestations:
1. Lesions usually are found in the upper outer
quadrant of the breast ; usually painless
2. Nontender, fixed and hard lesions with irregular
borders
3. Skin dimpling – late sign
4. Nipple retraction
5. Skin Ulceration
6. Enlargement of the axillary or supraclavicular
lymph nodes may indicate metastasis
7. Nipple discaharge- spontaneous, may be bloody,
clear or serous
8. Breast symmetry- change in the size or shape of
the breast or abnormal contours. As woman
changes positions, compare one breast to
another.
9. Non-invasive breast cancer rarely presents a
palpable mass ; usually presents as
microcalcifications found on mammography.
Assessment and Diagnostic Findings:
1. Biopsy
a. Fine-needle aspiration cytology
Uses thin needle and syringe to collect
tissue or to drain lump after using a local anesthetic.
Normal cyst fluid appears straw-
colored or greenish. Fluid will be sent for cytology if
appears to be suspicious (clear or bloody), otherwise it
will be discarded.
b. Large-needle (core needle) biopsy
- removes a core of tissue with a large cutting
needle
c. Open biopsy
- consists of either incisional biopsy or
excisional biopsy.
Incisional- incision is made and only a portion of
the breast abnormality is removed for histologic
evaluation
Excisional- done through an incision in the skin,
but with the intent to remove the entire abnormality, not
simply a sample.
2. Ultrasonography – performed to differentiate cystic
from solid lesions.
- may reveal features highly suggestive of
malignancy such as irregular margins on a new solid
mass.
3. Mammography
When a suspicious abnormality is identified by
mammography alone and cannot be palpated by the
physician, the lesions should be biopsied by a
computerized stereotactic guided core needle technique.
Under mammographic guidance, a biopsy needle can be
inserted into the lesion and a core of tissue for histologic
examination or cells for cytology can then be examined
- calcifications are the most easily recognized
mammographic abnormality
-The most common findings associated
with carcinoma of the breast are clustered
polymorphic microcalcifications
4. Nipple discaharge Cytology
Secretions are smeared on a slide, fixed and
submitted for cytologic examination. There is a high rate
of false-negative test results with this method.
5. Tumor staging and analysis of additional prognostic
factors
6. Biomarkers
-Estrogen and progesterone receptors evaluates
the cancer cells from tissue biopsy to determine receptors
sites
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 - if estrogen-receptor positive, results are more
than 10 fmol/mg protein Not Clinically Malignant
Mammogram, UTZ

7. Laboratory tests
No abnormality Appears
a. Proliferation/ S phase- cell kinetic study that Cystic
malignant
or solid mass but
shows percent of cells in S phase in a Aspirate not suggestive of
tumor and gives as indication of malignancy
proliferative capacity. Non-bloody
Biopsy or
fluid Biopsy
b. DNA ploidy- measurement of DNA content of reexamine after
Completely next menses or 1-
a tumor, interpreted as favorable or
resolves 4 months
infavorable
c. Her-2/neu- oncogene that has been Reexamine
(Persistence)
demostrated in 15-30 of breast cancers.
EXCISION
Found by many investigators to be (Recurrence)
EXCISION
associated with poorer survival,
(Non (Resoultion)
especially node negative tumors. May Recurrence) ROUTINE FF-UP
affect treatment decisions. ROUTINE FF-UP
d. CEA Carcinoembryonic antigen
and CA 15-3 or CA27-29 may be used as
markers for recurrent breast cancer but
are not helpful in diagnosing early
lesions

Evaluation of Basses in Post Menopausal woman

Evaluation of Basses in Post

Menopausal woman
Multiple Nodules

Solitary mass Dominant mass

Not Clinically Clinically
Malignant Malignant
Mammogram

Mammogram, Ultrasound Biopsy

Preoperative evaluation
and counseling

Definitive Procedure

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Staging
STAGE

0 DCIS, LCIS or Paget’s disease of the nipple with no invasion

1 Tumors that are 2 cm or less with no involvement of axillary lymph nodes

2A -no tumor is located in the breast (T0), but cancer cells are found in 1–3 axillary (under the
arm) lymph nodes (N1) and have not spread to distant sites (M0); or
-tumor is less than 2 cm in diameter (T1) and cancer cells have spread to 1–3 axillary lymph
nodes (N1), but not to distant sites (M0); or
-tumor is larger than 2 cm and less than 5 cm in diameter (T2) and cancer cells have not
spread to axillary nodes (N0) or to distant sites (M0).
2B -tumor is larger than 2 cm and less than 5 cm in diameter (T2) and cancer cells have spread
to 1–3 axillary lymph nodes (N1), but not to distant sites (M0); or
tumor is larger than 5 cm and does not grow into the chest wall (T3) and cancer cells have
not spread to lymph nodes (N0) or to distant sites (M0).
3A -tumor is less than 5 cm in diameter (T0–T2) and cancer cells have spread to 4 to 9 axillary
lymph nodes (N2), but not to distant sites (M0); or
-tumor is larger than 5 cm (T3) and cancer cells have spread to 1 to 9 axillary nodes (N0–N2)
or to internal mammary nodes, but not to distant sites (M0).
3B -the tumor has grown into the chest wall or the skin (T4) and cancer cells may have spread to
as many as 9 axillary nodes (N0–N2), but not to distant sites (M0).

3c -tumor of any size (T0–T4) and cancer cells that have spread to 10 or more axillary lymph
nodes, or to 1 or more other regional lymph nodes, or to internal mammary lymph nodes
(enlarging these nodes) on the same side as the tumor (N3), but not to distant sites (M0). I
4 tumor of any size (T0-T4) and cancer cells that may have spread to nearby lymph nodes (N0-
N3) and have spread to a distant site (M1). Common sites of metastasis include the bones,
liver, lungs, brain, and distant lymph nodes.

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Management:
1. Surgery
a. Modified radical mastectomy
- performed to treat invasive breast
cancer.
- removal of the entire breast tissue,
including the nipple-areola complex
- a portion of theaxillary lymph nodes
are also removed in the axillary lymph node disection
(ALND)
b. Total Mastectomy
- performed in patients with non-invasive breast
cancer.
- involve the removal of the breast and the
nipple-areola complex but does not include the ALND.
c. Breast Conservation Treatment
- to excise the tumor in the breast completely and
obtain clear margins while achieving and acceptable
cosmetic result.
- Eg. Lumpectomy
2. Radiation Therapy
o adjuvant therapy to decrease incidence of
local recurrence for invasive type
o may be used after mastectomy in patients
with large tumors that involve the chest wall
and/or many positive axillary lymph nodes.
o radiation directed to the breast, chest wall and
remaining lymph nodes
o -usually 5 treatments per week for 6 to 7
weeks
o -adverse effect : mild fatigue, sore throat, dry
cough, nausea, anorexia ; later, skin will look
and feel sunburned
3. Adjuvant Systemic Therapy
A. Chemotherapy
-usually begins 4 weeks after surgery
-treatments are given every 3-4 weeks for 6-9
months
- Indications for chemotherapy :
o Large tumors
o Positive lymph nodes
o Premenopausal women
o Poor prognostic factors
- Main drugs :cyclophosphamide (Cytoxan),
methotrexate (mexate), 5-fluorouracil (5-FU),
doxorubicin (Adriamycin)
B. Hormonal Therapy
o -Antiestrogens (eg. Tamoxifen) bind
estrogen receptors, thereby blocking the
effects of estrogen
o Adjuvant systemic therapy after surgery
o Given for at least 5 years ; oral
administration once or twice per day
o Raloxifene is an estrogen-like drug
(estrogen receptor modulator)with some
bone and heart protective benefits.
o Estrogens such as diethyl stilbestrol or
ethinyl estradiol are given in high doses
to suppress FSH and LH and may
decrease endogenous estrogen
production
o Corticosteroids suppress estrogen/
progesterone secretion from the
adrenals
Nursing Diagnosis and Management:
1. Anxiety
- Provide opportunities for the client to express
her thoughts and feelings
2. Decisional Conflict
- Provide an opportunity for the client to ask
questions
- Focus on immediate concerns and provide up-
to-date written materials for the client to review
3. Anticipatory grieving
- Listen attentively to expression of grief and
watch for non-verbal cues.
4. Risk for infection
o Assess surgical dressings for bleeding,
drainage and odor.
o Assess drainage systems for patency and
adequate suction; note color and amount of
drainage.
o Use sterile technique to change dressings
and IV tubing.
o Encourage the patient to eat a protein-rich
diet.
o Teach the client on caring of the drainage
system.
o Teach on what to watch out that may
indicate symptoms of infection.
o Explain that she may experience scaling,
flaking, dryness, itching, rash or dry
desquamation of the involved skin,
particularly after radiation therapy.
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 o Tell the client to avoid deodorants and
talcum powder on the affected side until the
incision is completely healed.
5. Risk for disturbed body image
o Encourage the client to express her thoughts
and feelings.
o Assess how the client views her body.
o Include significant others, if possible when
discussing plan of care.
o Increase patient’s understanding about her
condition and what lies ahead.
o Encourage to look at her incision site
whenever she is ready.
o If the client is interested in breast
reconstruction, provide written materials and
encourage her to talk with a plastic surgeon
and with women who had reconstruction.

Home care and teaching:

1. Continue to perform breast self-examination.
2. Develop a postoperative excercise program in
consultation with the physician and physical
therapist.
3. Teach signs of metastsis to the lungs, liver and
bones and the importance of promptly reporting
these signs and symptoms to the physician.
4. 4. Review medications and the schedule of
follow-up visits for care and treatment.
5. 5. Refer to support groups.
6. 6. Discuss options for reconstructive surgery and
that of using a prosthesis.