Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph

Nursing Management of Breast Cancer

Introductory Statement:
A woman who finds a breast mass or a lump will probably first suspect of cancer, though
8 out of 10 lumps are benign. Breast cancer is the most common cancer in women. In the US one
in every eight women will develop breast cancer in her lifetime (American Cancer Society). With
the advancement in technology, breast cancer is easily detected.
Nurses have a responsibility to educate his/her client, family and to a greater scope the
public about breast cancer, early detection and prevention. It is also of prime importance to
understand the flight of clients having the disease, therefore compassionate care should be
communicated through gentle and humane care.

Learning Outcomes:
At the end of the lesson, the student will be able to:
!. Identify the methods of breast cancer prevention and screening.
2. Identify the risk factors of breast cancer.
3. Trace the concept map of cancer of the breast
4. Apply the nursing process in the care of a client with cancer
5. Plan and Implement health education in a post mastectomy client.

Assessment of Breast Disorders

Improved survival is an outcome of early detection, accurate diagnosis, and timely
treatment. The American Cancer Society (ACS), the National Cancer Institute 9NCI), and the
National Comprehensive Cancer Network (NCCN) emphasized the guidelines for screening and
mandate its implementation to older women, women with serious health problems and women
with increased risk. The Philippine Cancer Society is one agency in collaboration in the early
detection of breast cancer (Borromeo, et al. 2014).

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Prevention and Screening of Breast Cancer:
1. Breast Self Examination (BSE) should start from age 20, done monthly 7 to 10 days from
the first day menstruation or 2-3 days from the last day of menstruation.
For post menopausal or post hysterectomy women, BSE should be done each month on
the same date (example: first day of the month or on her birth date)
2. Clinical Breast Examination – at least every three years for women between ages 20-30
and every year for women beginning at age 40
3. Mammogram involving the x-ray of the breast
Digital mammography – is a new technique n which x-ray images are digitally coded into
a computer.
4. Magnetic Resonance Imaging (MRI) is recommended as a sensitive screening tool for
women at high risk for breast cancer, women whose result of mammography or UTZ is
suspicious for malignancy
5. Biopsy thru the fine needle aspiration (FNA) is a definitive diagnosis for a suspicious
area. The specimen is subjected foe biopsy.

Did you know that in the Philippines, BSE, aspiration, and open biopsy are the most
effective strategies in detecting breast malignancies.

Risk Factors Associated with Cancer

Udan (2017) supports the findings of research that show a close association of several
factors with the development cancer which includes the following:

1. Age : 50 years and above and with increasing of incidence after 60

2. Menarche before age 11
3. Menopause after age 50
4. Family history of breast cancer for the first degree relative (mother, sister,
daughter).
5. Nulliparity or birth of first child after age 30.
6. History of uterine cancer
7. Link with obesity, diabetes and hypertension
8. Presence of benign breast disease
9. Excessive caffeine intake
10. Microwaving with plastic
11. Exposure to ionizing radiation

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BENIGN BREAST DISORDERS
MASTALGIA

Mastalgia is also known as breast pain, which is the most common breast related
complaint in women. Cyclic mastalgia (most common form of mastalgia) occurring that
coincides with the menstrual cycle characterized by diffuse breast tenderness or heaviness. It is
accompanied by pain that may last 2-3 days or more or most of the month. There is an
association with the pain with the hormonal insensitivity. The symptoms often decrease with
menopause.
Method of diagnosis is mammography to exclude cancer and to provide information on the
etiology of mastalgia.

The discomforts brought about by Mastalgia may be relieved by:

1. Caffeine and dietary fat reduction
2. Taking of vitamins E, A, and B complex and gamma linoleic acid (evening primrose oil)
3. Continuous use of support bra
4. Ice compress
5. Analgesics and anti-inflammatory drugs
6. Oral contraceptives and danazol (Danocrine)
Androgenic side effects of Danazol: acne, edema, hirsutism

FIBROCYSTIC CHANGES OF THE BREAST

Fibrocystic changes in the breast is a benign condition characterized by changes in the
breast tissue. Such changes include the development of excess fibrous tissue, hyperplasia of the
epithelial lining and mammary ducts, proliferation of mammary ducts and cyst formation. These
changes produce pain by irritation from edema in the connective tissue and by fibrosis from
pinching the nerves.
Fibrocystic changes has no association with hormonal influence. There are masses or
nodularities that appear in both breasts usually found in the upper, outer quadrants and usually
occurring bilaterally.
It is most frequently the most occurring breast disorder in women between 35 and 50
years of age but often begins at an early age of 20. Fibrocystic changes has a close association
with the heightened responsiveness of the breast to circulating hormones (Estrogen and
progesterone). It commonly occurs in women with:

1. Premenstrual abnormalities
2. Nulliparous women

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 3. Women with history of spontaneous abortion
4. Nonusers of oral contraceptives
5. Women with early menarche and menopause

Manifestations of Fibrocystic breast changes include the following:

1. One or more palpable lumps that are round, well delineated and freely movable
within the breast
2. Breast tenderness
3. Lump increases in size and tenderness before menstruation
4. Cyst may enlarge or shrink rapidly
5. Nipple discharges (milky, watery- milky, yellow or green).

Management:
1. Aspiration
2. Surgical biopsy for frequent cyst
Excisional biopsy if:
● no fluid is found on aspiration
●fluid that is found is hemorrhagic
●after aspiration, a residual mass remains
3. Biopsy for women with high risk for breast cancer
4. For pain
a. Caffeine and dietary fat reduction
b. Taking of vitamins E, A, and B complex and gamma linoleic acid (evening
primrose oil)
c. Continuous use of support bra
d. Ice compress
e. Analgesics and anti-inflammatory drugs
f. Oral contraceptives and danazol (Danocrine)

FIBROADENOMA
Fibroadenoma are firm, round, movable benign tumors. They can occur from puberty to
menopause with a peak incidence of 30 years of age. These masses are non tender and are
sometimes biopsied or removed for definitive diagnosis (Hinkle & Cheever, 2018).

Fibroadenoma are firm, round, movable benign tumors. They can occur from puberty to
menopause with a peak incidence of 30 years of age. These masses are non tender and are
sometimes biopsied or removed for definitive diagnosis (Hinkle & Cheever, 2018).

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Breast Cancer
Breast cancer is a major health concern in the United States. Current statistics indicate
that over a lifetime (birth death) a woman’s risk to developing cancer is about 12% or one in
eight (Hinkle & Cheever, 2018).
Female breast cancer incidence rates vary substantially by race and ethnicity. Higher death
rates in African-Americans have been attributed to late stage at diagnosis and poorer stage-
specific survival. In Asia, the Philippines has the highest reported incidence of breast cancer. It
is the most common cancer which is prevalent in the 35-to 40 year old group of Filipino women.
Etiology and Risk Factors
Although the is not completely understood, number of factors are thought to relate to the
cause of breast cancer. The following contribute to the development of breast cancer:
1. Heredity or genetics:
Women with BRCA 1 mutations have 40-80% chance to develop breast cancer
2. Hormonal regulation of the breast
Sex hormones (estrogen and progesterone) act as tumor promoters to stimulate breast
cancer growth
3. Modifiable risk factors :
● weight gain during adulthood
●sedentary life style
●dietary fat intake
●obesity
●alcohol intake
●combined hormone replacement therapy (estrogen and progesterone)
●oral contraceptive therapy
4. Environmental factors: radiation exposure
5. Family history (first degree relative –mother, daughter, sister

According to recent local study, four risk factors for breast cancer have been found to be
prevalent in Filipino women(Borromeo, 2014):
1. Passive smoking
2. First degree family history,
3. Consumption of scalding hot food
4. . Increased age at first pregnancy
The study also identified protective factors against breast cancer namely:

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 1. Inverted cigarette smoking
2. Consumption of canned meat, patis and bagoong

Pathophysiology:
Breast cancers are malignant tumors that typically begin on the ductal lobular epithelial
cells of the breast and spread via the lymphatic system to the axillary lymph nodes. The tumor
may the metastasize to distant regions of the body, including the lungs, liver, bone and brain.
The finding of breast cancer in the axillary lymph nodes is an indicator of the tumor’s ability for
potential distant spread and it is not merely contiguous growth into the adjacent region of the
breast. Most cancer of the breast are adenocarcinoma located in the upper outer quadrant of
the breast (Black, et al.,2009)

Classic symptoms that define breast cancer:

1. Firm, painless, nontender, nonmobile mass
2. Solitary, irregularly shaped mass
3. Adherence to muscle skin causing a dimpling effect
4. Involvement of upper outer quadrant or central nipple portion of the breast
5. Asymmetry of the breast
6. Orange peel skin
7. Retraction of the nipple
8. Abnormal discharge from the nipple

Types of Breast Cancer

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Noninvasive breast cancer
1. Ductal carcinoma in situ (DCIS) tends to be unilateral and most likely to progress if
not treated
Management: Excision, Mastectomy with breast reconstruction, breast conserving
treatment (Lumpectomy), Radiation therapy and Tamoxifen (Novaldex)
2. Lobularcarcinoma in situ (lCIS)
Management: Tamoxifen (Novaldex)

Inflammatory Breast Cancer

Management:
1. Excision of mass or lump

Stages of Breast Cancer

1. Stage 1. Tumor size is up to 2cm
2. Stage II. Tumor size is up to 5cm with axillary node involvement
3. Stage III. Tumor size is more than 5cm with axillary and neck lymph node
involvement
4. Stage IV. Metastasis to distant organs (LLBB)

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Management

1. Surgical Management: The extent of the surgical intervention is determined by

the clinical presentation and by the possibility of resecting the tumor with clean
margins. The goal is to preserve the breast because there is no clear evidence that
a mastectomy is more beneficial than a lumpectomy plus radiation therapy.
• Breast preserving procedure are selected for stage 1 and stage II breast
cancers. Such conservative surgical approaches may be appropriate, depending on
the size of the primary tumor. Clients with small invasive cancers usually require
a wide local excision under local or general anesthesia. Partial mastectomy
involves the removal of the tumor plus a 1 -2 cm margin of normal tissue
(lumpectomy).

•Mastectomy is the treatment of choice when the following apply:

1. The tumor involves the nipple-areola complex.
2. The tumor is larger than 7cm.
3. The tumor exhibits extensive intraductal disease involving multiple
quadrants of the breast,
4. The woman can not comply with radiation therapy.

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 • Lumpectomy is removal of the lump and surrounding breast tissue.
• Simple mastectomy is surgical removal of the breast only.
• Radical mastectomy is the removal the breast, muscle layer down to
chest wall, and axillary lymph nodes.
• Modified radical mastectomy is an en bloc removal of the breast,
axillary lymph nodes and over lying skin, with the muscles left intact.

Nursing Management of the Surgical Client

Preoperative care
Assessment. The preoperative time, before the biopsy for breast cancer and before a woman
knows whether she has cancer in the breast or not, is extremely stressful, constituting a
psychological emergency. Once the diagnosis is established, the woman can return to the
routines of her life. But if the biopsy result is positive, she now begins to mobilize her
resources to plan for next step. Overtly or covertly, Fear, anxiety and even denial may be
felt by the client for several days to weeks. With this she needed more to recover from the
diagnosis. Psychological preparations is needed in this phase. Begin emotional support and
to continue in the postoperative period. The surgeon explains about the procedure,
including the risk, possible complication including altered body image.
A written consent for the surgery is of prime importance as an evidence that the client is
voluntarily submitting herself for surgery.
Physiological preparations include Chest X ray, routine laboratory blood examinations
(CBC, blood typing), urine examination and ECG. A cardiopulmonary clearance should be
granted by the internist prior to the surgery. Routine vital signs monitoring is required.
Preventive teachings by the nurse should be considered: turning, coughing and deep
breathing exercises should be done by the client preoperatively as this will be the exercises
that she will do immediately after the surgery. These exercises will prevent respiratory
complications. Remember that a restrictive surgical dressing may decrease chest
expansion. In addition, the essentials of postoperative care, wound care, hand care are
discussed prior to admission to the hospital.
Nothing per orem (NPO) should be observed at least 6-8 hours prior to the operation.
However, Intravenous fluids will be started on the day of the surgery, unless earlier
indicated.

Post Operative Care

*Position the client on her back or on the unaffected side.
*Deep breathing and coughing, turning should be done once the client is awake from anesthesia.

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*Jackson Pratt drain or hemovac drain may be in place to drain fluids that accumulate when lymph
nodes are removed.

Source: https://my.clevelandclinic.org/health/articles/21104-how-to-care-for-your- jackson-pratt-drain

*Note signs of bleeding on dressing and reinforce pressure dressing as needed.

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*Encourage early range of motion exercises to prevent contractures and edema.

*Use unaffected arm only to provide IV fluids and take blood pressure.
* Discharge Instructions:
1. Use caution when lifting heavy objects with arm on affected side.
2. Avoid injury and infection on affected side. Wear rubber gloves when washing dishes
and garden gloves when working outside
3. Do not allow procedures (blood pressure taking or venipuncture) on the affected side.
4. Refer client to support groups for psychological support.
5. Diet should be rich in vitamins and minerals.
6. Take prescribed meds.
7. Report for signs of wound infection (pain, swelling, redness, foul smelling discharge,
fever.
8. Follow up schedule.

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