Breast Cancer

Medical Management
1. Chemotherapy
Chemotherapy uses drugs to destroy cancer cells. Chemotherapy is sometimes given
before surgery in women with larger breast tumors. Chemotherapy is also used in women whose
cancer has already spread to other parts of the body.
Standard Chemotherapy Regimens Include:
 AT: Adriamycin and Taxotere
 AC ± T: Adriamycin and Cytoxan with or without Taxol or Taxotere
 CMF: Cytoxan, Methotrexate, and Fluorouracil
 CEF: Cytoxan, Ellence, and Fluorouracil
 FAC: Fluorouracil, Adriamycin, and Cyrtoxan
 CAF: Cytoxan, Adriamycin, and Fluorouracil
(The FAC and CAF regimens use the same medications but use different doses and
frequencies)
 TAC: Taxotere, Adriamycin, and Cytoxan
 GET: Gemzar, Ellence, and Taxol
Common Drugs Include
 docetaxel (Taxotere)
 paclitaxel (Taxol)
 doxorubicin
 epirubicin (Ellence)
 pegylated liposomal doxorubicin (doxil)
 capecitabine (Xeloda)
 carboplatin
 cisplatin
 cyclophosphamide
 eribulin (Halaven)
 fluorouracil (5-FU)
 Gemcitabine (Gemzar)
 Ixabepilone (ixempra)
 Methotrexate (rheumatrex, trexall)
 Protein-bound paclitaxel (abraxane)
 Vinorelbine (navelbine)
2. Hormonal Therapy
Hormonal therapy is prescribed to women with ER-positive breast cancer to block certain
hormones that fuel cancer growth. An example of hormonal therapy is the drug Tamoxifen. This
drug blocks the effects of estrogen, which can help breast cancer cells survive and grow. Most
women with estrogen-sensitive breast cancer benefit from this drug.
Another class of hormonal therapy medicines called aromatase inhibitors such as
exemestane (Aromasin), have been shown to work just as well or even better than tamoxifen in
postmenopausal women with breast cancer. Aromatase inhibitors block estrogen from being
made.
Types of Hormonal Therapy:
 Tamoxifen – is a drug that blocks estrogen from binding to breast cancer cells. It is
effective for lowering the risk of recurrence in the breast that had cancer, the risk of
developing cancer in the other breast, and the risk of distant recurrence.
 Aromatase Inhibitors (AIs) - AIs decrease the amount of estrogen made in tissues other
than the ovaries in post-menopausal women by blocking the aromatase enzyme. This
enzyme changes weak male hormones called androgens into estrogen when the ovaries
have stopped making estrogen during menopause. These drugs include anastrozole
(Arimidex), exemestane (Aromasin), and letrozole (Femara). Only women who have
gone through menopause or who take medicines to stop the ovaries from making estrogen
can take AIs. Treatment with AIs, either as the first hormonal therapy taken or after
treatment with tamoxifen, may be more effective than taking only tamoxifen to reduce
the risk of recurrence in post-menopausal women.
 Ovarian Suppression or Ablation - Ovarian suppression is the use of drugs to stop the
ovaries from producing estrogen. Ovarian ablation is the use of surgery to remove the
ovaries. For ovarian suppression, gonadotropin or luteinizing releasing hormone (GnRH
or LHRH) agonist drugs are used to stop the ovaries from making estrogen, causing
temporary menopause. Goserelin (Zoladex) and leuprolide (Eligard, Lupron) are types of
these drugs.


3. Radiation Therapy
Radiation therapy is an adjuvant treatment for most women who have undergone
lumpectomy and for some women who have mastectomy surgery. In these cases the purpose of
radiation is to reduce the chance that the cancer will recur.
This radiation is very effective in killing cancer cells that may remain after surgery or
recur where the tumor was removed.
Radiation therapy can be delivered either external beam radiotherapy or brachytherapy
(internal radiotherapy).
 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 operation room.
 Brachytherapy – this type of radiation therapy is given by placing radioactive
sources into the tumor.
Adjuvant radiation therapy – is given after surgery. Most commonly, it is given after a
lumpectomy, and sometimes, chemotherapy. Patients who have a mastectomy may or may not
need radiation therapy, depending on the features of the tumor.
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.
4. 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. This type of treatment blocks the growth and spread of
cancer cells and limits damage to healthy cells.
 Trastuzumab - This drug is approved as a therapy for non-metastatic HER2-positive
breast cancer. Given in patients with stage I to stage III breast cancer.
 Pertuzumab (Perjeta) - This drug is approved for stage II and stage III breast cancer in
combination with trastuzumab and chemotherapy.
 Neratinib (Nerlynx) - This oral drug is approved as a treatment for higher-risk HER2-
positive, early-stage breast cancer. It is taken for a year, starting after patients have
finished 1 year of trastuzumab.
5. 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.
 Pembrolizumab (Keytruda) - This is a type of immunotherapy that is approved by the
FDA to treat both high-risk, early-stage, triple-negative breast cancer and metastatic
cancer or cancer that cannot be treated with surgery. Pembrolizumab is approved to treat
people with high-risk, early-stage, triple-negative breast cancer in combination with
chemotherapy before surgery.
 Dostarlimab (Jemperli) - This type of immunotherapy is approved by the FDA to treat
recurrent or metastatic breast cancers that have dMMR and have progressed during or
after previous treatment.
Surgical Management
(Mainstay for non metastasis disease)
(The main goal of surgery is to gain local control of the disease. )
1. Lumpectomy
This is also referred to as breast-conserving therapy. The surgeon removes cancerous area
and a surrounding margin of normal tissue. A second incision may be made in order to remove
the lymph nodes.
2. Mastectomy
A mastectomy is the surgical removal of the breast, non-protruding breast tissue, the
lymph nodes in the armpits and some pectoral muscle.
Breast construction surgery may be conducted after the removal of the breast.
Partial or Segmental Mastectomy
Simple or Total Mastectomy
o Best treatment and cosmetic result
o Performed in patient with noninvasive breast cancer which does not have a
tendency to spread to the lymph nodes.
Modified Radical Mastectomy
o Performed to treat invasive breast cancer. The procedure involves removal
of breast tissue, including the nipple-areola complex and a portion of
axillary lymph nodes. (in modified radical mastectomy, the pectoralis
minor muscles are left intact, unlike in radical mastectomy, in which the
muscles are removed.
3. Sentinel Lymph Node Biopsy
In a sentinel lymph node biopsy (also called a sentinel node biopsy or SNB), the surgeon
finds and removes 1 to 3 or more lymph nodes from under the arm that receive lymph drainage
from the breast. This procedure helps avoid removing a large number of lymph nodes with an
axillary lymph node dissection for patients whose sentinel lymph nodes are mostly free of
cancer.
4. Axillary Lymph Node Dissection
In an axillary lymph node dissection, the surgeon removes many lymph nodes from under
the arm. These are then examined for cancer cells by a pathologist. The actual number of lymph
nodes removed varies from person to person.
5. Reconstructive Surgery
 This is surgery to recreate a breast using either tissue taken from another part of the body
or synthetic implants. Reconstruction is usually performed by a plastic surgeon. A person may be
able to have a reconstruction at the same time as the mastectomy, called immediate
reconstruction. They may also have it at some point in the future, called delayed reconstruction.
 Reconstruction with implants
 Reconstruction with a tissue flap
 Transverse Rectus Abdominis Muscle (TRAM) Flap
 Latissimus Dorsi Flap
 Deep inferior epigastric perforation (DIEP) reconstruction
 Gluteal Free Flap
 Reconstruction of the nipple and areola

Nursing Management (Surgical)

 Discuss the importance of hand washing and wound care.
 Discuss the postoperative drainage device and its management after going home.
 Assess the pain tolerance and administer analgesics as prescribed.
 Encourage expressing thoughts and feelings about the body changes.
 Assess the interest in spiritual/religious support and refer if appropriate.
 Provide a list of educational resources about chemotherapy and breast reconstruction.
 Discuss the possibility of attending a breast cancer support group.
 Refer to social services for a consultation about the changed family roles during her
recovery and treatment.

Nursing Management (Chemotherapy)

 Instruct patient on ways to prevent infection including hand washing, proper skin care,
avoiding foods with high microorganism content and offering information on smoking
cessation assistance using educational videos and instructional pamphlets.
 Instruct patient in ways to minimize risk of bleeding:
a. Avoid taking aspirin and other nonsteroidal anti-inflammatory agents (e.g. ibuprofen) on a
regular basis
b. Use an electric rather than a straight-edge razor
c. Floss and brush teeth gently
d. Use caution when ambulating to prevent falls or bumps and do not walk barefoot.
 Instruct patient to control any bleeding by applying firm, prolonged pressure to the area if
possible. Demonstrate on peripheral extremity and request a return demonstration.
 Eat several small meals per day instead of 3 large ones
Encourage patient to eat dry foods, such as toast and crackers) or sip cold carbonated beverages
if nausea is present. Take deep, slow breaths when nauseated.
 Provide instructions related to care of a central venous catheter (Groshong):
a. Change dressing if present according to protocol using aseptic technique
b. Observe exit site for changes in appearance, redness, swelling, and unusual drainage
c. Flush catheter according to protocol to maintain patency
d. Replace injection cap as directed
Tape catheter securely to the chest wall to prevent accidental dislodgment
f. Notify physician if unable to flush catheter, if signs and symptoms of infection occur at exit
site, or if catheter appears to be leaking. Observe return demonstration on mock catheter model
Observe for and notify physician if any of the following occur:
 Redness, swelling, or change in appearance of insertion site
 Unusual drainage from exit site
 Increasing abdominal pain
 Chills or fever
 Increased abdominal distention between treatments
 Persistent nausea or vomiting
 Dyspnea
 Allow time for questions, clarification, and return demonstration of procedures.
 Use active listening and acceptance to help patient express emotions such as crying, guilt,
and anger (within appropriate limits).
 Thoroughly explain rationale for, side effects of, and importance of taking medications
prescribed. Inform patient of pertinent food and drug interactions. Reinforce physician's
explanation of planned chemotherapy schedule.
 Discuss with patient any difficulties he/she might have adhering to the schedule and
assist in planning ways to overcome these.
 Implement measures to improve patient compliance
a. Include significant others in teaching sessions
 b. Encourage questions and allow time for reinforcement and clarification of information
provided
 c. Provide written instructions regarding ways to maintain nutritional status, future
appointments with health care provider and laboratory, medications prescribed, and signs
and symptoms to report.

Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea,
anorexia.
Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting,
alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and depression.
Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide
psychological support to the patient throughout the diagnostic and treatment process.
Involve the patient in planning and treatment.
Describe surgical procedures to alleviate fear.
Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue.
Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy.
Administer I.V. fluids and hyperalimentation as indicated.
Help patient identify and use support persons or family or community.
Suggest to the patient the psychological interventions may be necessary for anxiety, depression,
or sexual problems.
Teach all women the recommended cancer-screening procedures.