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FEATURE ARTICLE

Cutaneous Metastatic Breast Cancer

Downloaded on 08 13 2018. Single-user license only. Copyright 2018 by the Oncology Nursing Society. For permission to post online, reprint, adapt, or reuse, please email pubpermissions@ons.org

Susan Moore, RN, MSN, APN-NP, AOCN ®

reast cancer is the most Pathophysiology

B commonly diagnosed
cancer in women and the
second leading cause of cancer
Breast cancer is the most commonly diagnosed cancer in
women and the second leading cause of cancer deaths
among women in the United States. Many women diag-
Cutaneous metastatic skin le-
sions are extensions of tumors to
deaths among women in the the skin, preferentially occurring
United States. Estimates for nosed with breast cancer will achieve a cure with surgery in the skin overlying or proximal
2002 indicate that nearly followed by adjuvant chemotherapy, hormonal therapy, or to the primary tumor. Most com-
203,500 new cases of breast can- monly, breast cancer metastasis to
cer will be diagnosed and 39,600
radiation therapy; however, some breast cancer survivors the skin occurs via direct exten-
women will die from the disease will develop locally recurrent disease. Skin metastases are sion or through vascular or lym-
(Jemal, Thomas, Murray, & one of the most distressing presentations of locally recur- phatic channels. Other mecha-
Thun, 2002). Many women di- nisms include iatrogenic implan-
rent breast cancer. The purpose of this article is to in- tation of malignant cells follow-
agnosed with breast cancer will
achieve a cure through surgery crease oncology nurses’ understanding of the pathophysi- ing a surgical procedure, such as
followed by adjuvant chemo- ology of cutaneous metastases, facilitate recognition of mastectomy or reconstruction.
therapy, hormonal therapy, or the various presentations of cutaneous metastatic breast The appearance of cutaneous me-
radiation therapy (RT). Some tastases in breast cancer is gener-
breast cancer survivors will de- cancer, discuss management of both the underlying dis- ally a late sign, although cutane-
velop locally recurrent disease ease process and skin lesions, and identify issues of psy- ous metastases may be the pre-
defined as “any reappearance of chosocial support for patients and families throughout the senting sign of an undiagnosed,
cancer in the ipsilateral breast, asymptomatic breast cancer. Cu-
chest wall, or skin overlying the
continuum of illness. taneous metastases of breast can-
chest wall after initial therapy” cer generally are found on the
(Recht, Come, Troyan, & Sadowsky, 2000, The skin is a common site for the spread of chest, abdomen, and scalp; less frequently on
p. 731). internal malignancies, and nearly half of ob- the back, upper arms, and lower abdomen; and
One of the most distressing presentations served skin metastases in patients with can- rarely on the buttocks, perianal region, lower
of locally recurrent breast cancer is the ap- cer are because of progression of breast can- extremities, and eyelids (Schwartz, 1995).
pearance of cutaneous metastases. After cer (Crosby, 1998). Cutaneous metastases can Several types of cutaneous metastases are
melanoma, breast cancer is the most com- occur following breast-conserving treatment unique to breast cancer. Carcinoma erysipe-
mon cancer to metastasize to the skin (Mor- (BCT), which consists of lumpectomy fol- latoides is found generally in patients with in-
denti, Peris, Fargnoli, Cerroni, & Chimenti, lowed by RT or mastectomy, even if postsur- flammatory breast cancer and is the most
2000). The presence of skin metastases is a gical RT was delivered to the chest wall. Lo- common situation in which skin metastasis is
daily, visible reminder of the disease. Dis- cal recurrence in the skin of the treated breast the presenting sign of the underlying cancer.
ruption of the integumentary barrier can be- is rare following BCT and dependent on many The lesions generally are rash-like, warm, ten-
come infected and result in open, bleeding variables, such as nodal status or tumor size. der, and erythematous, they often are elevated
wounds that are difficult to control. The In a study of 1,624 patients who underwent above the skin surface, and they usually have
purpose of this article is to increase oncol- BCT, skin recurrence without parenchymal a distinctive leading edge (see Figure 1). The
ogy nurses’ understanding of the patho- involvement was observed in 1.1% of patients
physiology of cutaneous metastases, facili- (Gage et al., 1998). Local recurrence after
tate recognition of the various presenta- mastectomy has a reported incidence of 6% Submitted January 2002. Accepted for pub-
tions of cutaneous metastatic breast cancer, (Roses, 1999). Approximately 90% of local lication March 6, 2002. (Mention of specific
discuss management of both the underly- recurrences appear within five years follow- products and opinions related to those prod-
ing disease process and skin lesions, and ing mastectomy and nearly 100% occur by ucts do not indicate or imply endorsement by
identify issues of psychosocial support for 10 years, although recurrences as long as 50 the Clinical Journal of Oncology Nursing or
patients and their families throughout the years after initial diagnosis have been reported the Oncology Nursing Society.)
continuum of illness. (Recht et al., 2000). Digital Object Identifier: 10.1188/02.CJON.255-260

CLINICAL JOURNAL OF ONCOLOGY NURSING • VOLUME 6, NUMBER 5 • CUTANEOUS METASTATIC BREAST CANCER 255

Note the medial leading edge of the lesion. Pa-
tient has a saline breast implant.
FIGURE 1. CARCINOMA ERYSIPELATOIDES
entire breast may be involved with dense,
firm tissue. Carcinoma erysipelatoides
typically occurs through lymphatic dissem-
ination throughout the thickness of the der-
mis and subcutaneous tissue. Carcinoma
telangiectaticum is distinctive in its mul-
tiple pruritic, hemorrhagic nodules, plaques,
or papules on the skin that usually are con-
tiguous with the surgical site and dissemi-
nated through superficial lymphatics and
blood vessels of the dermis (see Figure 2).
Carcinoma en cuirasse generally dissemi-
nates along tissue spaces and only to a mi-
nor degree through the lymphatics. It ini-
tially appears as infiltrated hard papules or
firm nodules overlying a smooth, shiny
skin surface. Nodules may converge to
form a woody, well-defined area that often
encompasses the affected half of the chest
wall and, on rare occasions, may involve
the entire chest wall (see Figure 3). En
cuirasse is a French term that refers to the
resemblance of the condition to a metal
breastplate of a suit of armor (Schwartz,
1995).
Presentation of Disease
Cutaneous metastases have a variety of
presentations ranging from small, firm,
flesh-colored nodules just under the surface
Cutaneous metastases began at the mastectomy
scar. Patient has a saline breast implant.
FIGURE 2. CARCINOMA TELANGIECTATICUM
256
of the skin of the chest wall to large, fungat-
ing lesions. Patients may be asymptomatic
and the nodules may be discovered only on
close clinical examination, or the nodules
may be found by patients themselves. The
following signs and symptoms may or may
not be present in any combination: warmth,
pruritus, erythema, pain, stinging, macular
rash, and thickening or hardening. The size
of the lesion(s) has little to do with present-
ing symptoms; small, rash-like metastases
may create more symptoms, (e.g., pruritus, Woody indurated lesions involving the entire
stinging) than large sites. Inspection of the right side of the chest wall
lumpectomy or mastectomy scar is impor-
tant during examination. Cutaneous me- FIGURE 3. CARCINOMA EN CUIRASSE
tastases often develop immediately adjacent
to the scar and may be subtle in early pre-
sentation. Both visual inspection and Cutaneous metastatic breast cancer often
manual palpation of the chest wall, includ- presents synchronously with distant me-
ing the inframammary creases, should be in- tastases and is considered to be a marker for
cluded in any examination. Occasionally, distant metastatic disease (Chapman &
cutaneous metastases may appear on the Goodman, 2000; Roses, 1999). For that rea-
eyelid, often presenting as painless, firm son, the diagnosis of cutaneous metastases
swellings. Scalp lesions often appear in clus- should be followed up with a full restaging
ters. Regardless of the location of the cuta- to rule out other metastases before defini-
neous metastases, they may be solitary, few, tive treatment. Evidence at this time does not
or multiple in number; firm or rubbery; indicate that systemic therapy in conjunc-
freely movable or fixed; flesh-colored or tion with local treatment can prolong dis-
pink, red, or inflamed; or nodular, indurated, ease-free or overall survival. Therefore, rec-
thickened and fibrotic, or raised (Schwartz, ommendations for treatment of local recur-
1995). rence are as follows. If no evidence of dis-
tant metastases exists, local treatment re-
Medical Management duces morbidity for many women and may
increase survival time, especially for women
Cutaneous metastatic breast lesions can with favorable prognostic factors. Patients
mimic a variety of benign and malignant with concurrent or prior distant metastases
skin conditions, as well as cutaneous me- should be given appropriate systemic
tastases of other visceral cancers. All sus-
picious or indeterminate skin lesions
should be assessed by biopsy with histo-
pathologic and immunohistologic findings
reported to the attending surgeon or medi-
cal oncologist. Cutaneous metastases rarely
appear as solitary lesions. Rather, the usual
presentation is a rash or multiple nodules,
thus precluding surgical resection of the
suspected abnormality (see Figure 4). Cu-
taneous metastases can be evaluated by a
fine needle aspiration biopsy (FNAB) or a
(a) Presentation with discrete nodules
punch biopsy easily performed in a
surgeon’s office. Although FNAB can pro-
vide material for cytologic diagnosis of ma-
lignant cells, one drawback is that insuffi-
cient cellular material may be available to
perform hormone receptor (estrogen and
progesterone), Her2-neu, and any addi-
tional specialized testing that may be
needed to make treatment decisions. Her2-
neu status rarely changes from that reported
at the initial diagnosis, but up to 20% of
estrogen receptor content between primary (b) Early presentation as fine rash
and metastatic lesions may change (Ellis,
Hayes, & Lippman, 2000). FIGURE 4. CARCINOMA TELANGIECTATICUM
SEPTEMBER/OCTOBER 2002 • VOLUME 6, NUMBER 5 • CLINICAL JOURNAL OF ONCOLOGY NURSING
therapy and local treatment, such as RT, for
persistent local symptoms (Winer, Morrow,
Osborne, & Harris, 2001).
Treatment Decisions
Computerized tomographic scans of the
chest, abdomen, pelvis, and brain, as well
as a bone scan, serum chemistry panel, and
tumor markers should be assessed before
making treatment decisions. If restaging ex-
aminations do not reveal the presence of
other metastatic sites, in the rare instance
where a single, small, well-vascularized cu-
taneous metastasis exists, surgical excision
can be considered (Clive, Gardiner, & Leo-
nard, 1999). These situations will be rare
because most often multiple skin nodules
will be present at diagnosis of recurrence or
they will appear shortly thereafter. How-
ever, for most women, the immediate ques-
tion is whether surgery is an option. When
cutaneous metastases are confined to the
breast, simple mastectomy may be an op-
tion, although relapse often occurs on the
chest wall following salvage mastectomy
(Recht et al., 2000).
External beam RT is an option for con-
trol of local metastases. Women who under-
went mastectomy at their original diagnosis
and did not receive locoregional RT should
be assessed by a radiation oncologist for
therapy, although recurrences in the mastec-
tomy scar may be more difficult to eradicate
than other chest wall recurrences. Women
who had BCT most likely received RT post-
surgery. Retreatment of previously irradi-
ated sites using limited volumes with lim-
ited radiation doses will not achieve a cure
but may result in an acceptable level of pal-
liation (Recht et al., 2000). Further RT may
not be an option in previously irradiated ar-
eas, but evaluation by a radiation oncolo-
gist may be considered. Inflammatory car-
cinoma and carcinoma en cuirasse generally
are resistant to local therapy.
Evaluation of the immunohistochemical
assays from the biopsy will help direct treat-
ment. Cutaneous metastases that have arisen
from hormone receptor positive breast can-
cers are treated initially with hormonal
therapy. Women who were estrogen recep-
tor (ER) or progesterone receptor (PR) posi-
tive at diagnosis most likely received five
years of adjuvant therapy with tamoxifen. If
tamoxifen therapy still is continuing, it
should be discontinued at the time of meta-
static diagnosis. At discontinuation of tam-
oxifen therapy or if adjuvant tamoxifen
therapy was completed or discontinued prior
to completion of five years of therapy,
therapy with an aromatase inhibitor in post-
menopausal women should be considered
CLINICAL JOURNAL OF ONCOLOGY NURSING • VOLUME 6, NUMBER 5 • CUTANEOUS METASTATIC BREAST CANCER
and continued as long as a response occurs.
Women who are ER or PR negative do not
respond to aromatase inhibitors and will not
have this option of hormonal manipulation.
Other systemic or local therapies, therefore,
are indicated (Ellis et al., 2000).
Chemotherapy can be used when hor-
monal manipulation is not an option, when
metastases have proven refractory to hor-
mone therapy, when aggressive concurrent
pulmonary or hepatic lesions are present, or
when cutaneous metastases are large or pro-
gressing rapidly. Options for chemotherapy
include, among others, anthracycline-con-
taining regimens, methotrexate/5-fluoroura-
cil, methotrexate/5-fluorouracil/cyclophos-
phamide, taxanes, and gemcitabine. An oral
version of 5-fluorouracil, capecitabine
(Xeloda®, Roche Laboratories Inc., Nutley,
NJ), also has shown some efficacy, with an
average response rate of about 10% in meta-
static breast cancer overall (Smorenburg,
Bontenbal, & Verweij, 2001). Women who
received adjuvant chemotherapy may re-
spond again when metastatic disease occurs,
although, as with any chemotherapy, ques-
tions of drug resistance and patient tolerance
to further chemotherapy must be addressed.
A monoclonal antibody, trastuzumab (Her-
ceptin®, Genentech, Inc., South San Fran-
cisco, CA), is approved by the U.S. Food
and Drug Administration (FDA) for meta-
static breast cancer in women whose tumors
overexpress the Her2-neu protein and can
be used as a single agent or in combination
with certain other chemotherapy agents
(Rosen, Sepp-Lorenzino, & Lippman,
2000).
Investigational Therapies
Research into new therapies for breast
cancer, including cutaneous metastases,
holds promise for more effective treatment
for these often-resistant metastatic sites. In-
vestigational agents currently in clinical trial
include (a) photodynamic therapy (PDT)
using porfimer sodium (PhotoFrin®, Axcan
Pharma, Inc., Birmingham, AL), (b) milte-
fosine (Miltex®, Asta Medica, Frankfort,
Germany), and (c) antiangiogenesis agents.
PDT has been FDA approved for treat-
ment of bronchogenic and esophageal can-
cers and is currently in clinical trials for
treatment of superficial and cutaneous
metastatic cancers. As opposed to systemic
therapy, PDT causes minimal damage to
healthy tissues. PhotoFrin is selectively
concentrated and retained in malignant cells
but cleared more rapidly from healthy cells.
Nonthermal laser therapy administered to
the affected area 40–50 hours after
PhotoFrin administration results in prefer-
ential uptake of the laser treatment by can-
cer cells. Patients undergoing PDT must
follow strict guidelines for prevention of
photosensitivity reactions (Bruce, 2001).
Miltefosine is a cytostatic protein kinase
C inhibitor that is used as a topical agent.
Local application of the solution was tested
in a double-blind, placebo-controlled, multi-
center, phase III trial and was an effective
palliative treatment option for cutaneous
metastases from breast cancer. The response
rate was 33.3% for miltefosine compared
with 3.7% for placebo (Leonard et al.,
2001). Skin reactions included burning,
itching, local pain, erythema, skin dryness,
or desquamation. Of note, all grade 3–4 skin
reactions in the miltefosine group occurred
in previously irradiated areas. Miltefosine is
not available currently in the United States;
named-patient compassionate use can be re-
quested through the manufacturer.
Research into the mechanisms of angio-
genesis has shown that nearly 20 proteins
now are known to activate endothelial cell
growth, including vascular endothelial
growth factor (VEGF). Anti-VEGF, com-
bined with oral chemotherapy, is currently
in phase III clinical trials for metastatic
breast cancer. Early data analysis was com-
pleted recently for a phase II, dose-escala-
tion, clinical trial of bevacizumab (Avas-
tin™, Genentech, Inc.). It demonstrated ob-
jective clinical responses or disease stabili-
zation rates ranging from 5.6%–12.2% de-
pendent on dose in patients with progres-
sive, previously treated metastatic breast
cancer (Cobleigh et al., 2001) (see Figure 5).
Implications for Practice
Metastatic breast cancer, regardless of the
metastatic site, is incurable, and the thera-
peutic goals should be attainment of a clini-
cally meaningful remission, maintenance of
quality of life (QOL), and prolongation of
survival. When cutaneous metastases result
in disruption of the integument, nursing care
focuses first on containment and treatment
of infection. Little research has been con-
ducted to evaluate the best method for treat-
ing metastatic skin lesions. Open skin me-
tastases often can be managed for long peri-
ods of time with a combination of good topi-
cal and systemic therapy. If the overlying
skin is intact, no wound management is nec-
essary. When the skin no longer is intact,
good wound management techniques will be
needed to treat or prevent infection, drain-
age, or odor.
The goal in treating metastatic wounds is
palliation. Metastatic wounds do not heal in
the same manner as surgical or trauma
wounds to healthy skin. In addition, cutane-
257

(a) Prior to receiving investigational agent plus
capecitabine
(b) Six weeks later receiving two infusions of in-
vestigational agent plus capecitabine
FIGURE 5. RESPONSE TO INVESTIGATIONAL
ANTIANGIOGENESIS AGENT PLUS CAPECITABINE
ous metastases may occur in skin that has
been irradiated previously, thus altering the
ability of the skin to heal. In metastatic
wounds, the function of the platelets is taken
over by tumor cells, thus creating more fri-
able wounds with increased oozing of blood.
Leukocytes in the wound bed are reduced,
and exudate is increased because of hyper-
permeability, partially mediated by tumor
secretion of vascular permeability factor.
Lastly, malignant wounds are unable to con-
tract as healing occurs, thus resulting in a
large, nonresolving wound deficit. The re-
sult of these various factors is a wound that
drains, may never fully close, and is subject
to opportunistic infection (see Figure 6).
The patient had received extensive chest wall ra-
diation therapy for control of skin metastases.
Wound occurred following removal of a trau-
matically ruptured saline implant after the devel-
opment of skin metastases.
FIGURE 6. NONHEALING WOUND DEFICIT
258
Drainage from large metastatic wounds
may be contained with a surgical wound or
ostomy drainage device that can be con-
cealed under clothing. Other methods in-
clude absorbent wound dressings, such as
those used for pressure ulcers, such as
Polymem® (Ferris Industries, Burr Ridge,
IL). Polymem contains a cleanser, moistur-
izer, and starch copolymer that absorbs up
to 10 times its weight in exudate (Ferris In-
dustries, 1998). Avoid using tape to secure
dressings to the skin to reduce the risk of Example of cutaneous metastases with necrotic
breakdown in adjacent skin. Dressings ap- core
plied to wounds on the chest wall can be
held in place using a pair of mesh panties FIGURE 7. CARCINOMA ERYSIPELATOIDES,
with the crotch cut out; a soft sleep bra that INFLAMMATORY BREAST CANCER
has hooks in the front; or a loose-fitting tube
top. The dressing binder should be changed
and washed daily. Malignant wounds that dressing, are intended for lightly exudating
ooze blood often can be contained with he- wounds. In wounds with heavy exudate, vis-
mostatic agents, such as Gelfoam® (Phar- cous exudate may become trapped under the
macia, North Peapack, NJ) or similar prod- dressing, leading to maceration and inflam-
ucts. mation of the surrounding skin. If used as a
Wounds that remain open but have little skin contact layer on heavily exudating
exudate can be packed with dry, sterile wounds, a secondary absorbent pad should
gauze and covered with one of the non- be used over the Telfa pad (Kendall Com-
adherent methods previously mentioned. If pany, 2000). Products ordinarily used for
the gauze tends to adhere to the wound bed, skin impaired by pressure or venous statis
using a layer of petroleum-impregnated ulcers can be used with some success in cu-
gauze as the first layer in the wound bed will taneous metastatic wounds. If patients are
prevent unintentional debridement when the not hypersensitive to iodine, Iodosorb® gel
dressing is removed. Patients with non- or an Iodoflex® pad (HealthPoint, Ft Worth,
draining wounds need to be reminded to re- TX) provides slow release of iodine in the
move the dressings daily, inspect the wound wound bed. Iodoflex pads also absorb sig-
bed after bathing, and apply new dressings nificant amounts of exudate. Both products
to prevent infection. help control the odor often found in infected
Infection is a common problem in cuta- wounds, but neither is effective in cleaning
neous metastatic skin lesions. Tumor masses dry wounds (HealthPoint, 1999). A less-ex-
grow rapidly and often grow faster than the pensive method of applying iodine to an in-
blood supply to the surface of the lesion, fected wound is the use of povidone-iodine
thus creating necrosis at the surface (see Fig- 10% solution (Betadine®, Purdue Frederick
ure 7). A necrotic core because of hypoxia Company, Norwalk, CT) for wound irriga-
or metabolite toxicity at the tumor bed also tion.
may occur (Bauer, Gerlach, & Doughty, Once wounds have been managed effec-
2000). Anaerobic organisms frequently tively, symptoms secondary to cutaneous
grow out of control in necrotic tissue, re-
sulting in foul-smelling exudate. This infec-
tion may spread to the surrounding or un-
derlying tissue and, in severe cases, result
in systemic infection or sepsis. Prevention
of infection past the surface of the wound is
important. Debridement presents problems
because of the failure of the underlying skin
to heal following surgical intervention. One
method that has been used with varying de-
grees of success in odorous wounds is the
application of metronidazole gel
(MetroGel®, Galderma Laboratories, Ft.
Worth, TX) to the wound surface and cov- Example of lymphedema in patient’s left upper
ering the wound with a nonadherent dress- extremity
ing, such as a Telfa® pad (Kendall Company,
Mansfield, MA). Telfa pads have a low ab- FIGURE 8. CARCINOMA ERYSIPELATOIDES,
sorbent capacity and, if used as the only INFLAMMATORY BREAST CANCER
SEPTEMBER/OCTOBER 2002 • VOLUME 6, NUMBER 5 • CLINICAL JOURNAL OF ONCOLOGY NURSING
metastases must be addressed. The most
common subjective symptoms of women
with cutaneous lesions are pruritus and pain.
Systemic medications, such as diphenhy-
dramine or hydroxyzine, often are effective
against pruritus. Patients using these medi-
cations should be warned that drowsiness is
a common side effect and should be cautious
if their work or leisure activities involve
driving or operating work or sporting equip-
ment. Itching caused by nonexudative, in-
tact lesions sometimes can be relieved by
liberal use of lanolin-containing skin lotions
or creams.
Pain at cutaneous metastatic lesion sites
is the result of multiple factors. Skin lesions
on the side where an axillary node dissec-
tion or axillary radiation was given may be
complicated by upper extremity lymphe-
dema that often results in a deep, aching pain
(see Figure 8). Lymphedema management
by knowledgeable physical or occupational
therapists or nurses should be initiated if
patients are not receiving such care already.
Some measures used by lymphedema thera-
pists, such as bandaging or compression
sleeves, may not be options when open skin
lesions are present on the affected arm.
However, continued use of techniques, such
as manual lymph drainage and elevation of
the affected arm, may afford some relief of
both the swelling and pain. When nerve dis-
ruption occurs, neuropathic pain may be
present. Distinguished by shooting, burning
pain or tingling, neuropathic pain is one of
the more difficult types of pain to treat. Use
of gabapentin (Neurontin®, Pfizer, New
York, NY) has provided effective palliation
in some cases of neuropathic pain (Jensen
& Larson, 2001; Ripamonti & Dickerson,
2001). The pain from open wounds often is
characterized as a burning, stinging pain.
Use of an occlusive dressing designed for
wound containment may help to relieve this
type of pain until some degree of healing
can take place.
One area where nurses can play a key role
in the care of women with cutaneous meta-
static breast cancer is in addressing the psy-
chosocial concerns that arise from this dev-
astating diagnosis. Confirmation of meta-
static skin lesions carries a poor prognosis
and often accompanies the discovery of dis-
tant metastases. On average, survival from
the diagnosis of breast cutaneous metastases
to death is 31 months (Crosby, 1998). In
view of the change in disease status from
curable to incurable, issues such as accept-
ing the prognosis and end-of-life concerns
now must be addressed by patients, signifi-
cant others, families, and friends.
Other psychosocial needs include dealing
with changes in body image, especially if
CLINICAL JOURNAL OF ONCOLOGY NURSING • VOLUME 6, NUMBER 5 • CUTANEOUS METASTATIC BREAST CANCER
the skin lesions are in areas visible to others
or involve draining odorous wounds. Sexu-
ality can become an issue when women are
self-conscious about the appearance of their
skin or need to wear dressings continuously
to contain drainage. Many women who dealt
effectively with body image changes at the
time of their mastectomy find themselves
unable to accept their appearance when
metastatic skin lesions appear. They may
withdraw from their sexual partners, feel-
ing that they are unattractive or unhealthy.
Their partners may worry about causing
pain or bleeding. Counseling both parties,
alone and together, may help them to resolve
these issues and encourage intimacy.
When treating and supporting women
with cutaneous metastatic breast cancer, im-
provement in QOL is achieved most often
by judicious use of local and systemic thera-
pies with equally important goals of achiev-
ing an objective tumor response and mini-
mizing treatment-related toxicities (Ellis et
al., 2000). Effective palliative care of cuta-
neous metastatic breast cancer can have a
positive impact on QOL. When breast can-
cer recurs, women may feel they have lost
what little control they had over their dis-
ease and may begin to lose hope. Metastasis
confined to the skin often is indolent, and
patients can be maintained with tolerable
treatment regimens for a number of years.
Counseling goals for patients and families
can include understanding the treatment
plan and goals, recognizing improvements
in control of metastatic disease, and accept-
ing palliative therapy. If chemotherapy or
hormonal or radiation therapy are part of the
treatment plan, educating patients on the
side effects of therapy and how to manage
them will help them achieve a restored sense
of control. Support for family members can
be accommodated by being included in edu-
cational sessions, attending family support
groups, and, when necessary, providing
hands-on care.
Sadly, cure of metastatic cancer remains
an elusive target, and current therapies do
not offer dramatic survival benefits. Nurses
caring for women with cutaneous metastatic
breast cancer should remain focused on
management of treatment-related symp-
toms, supporting QOL, and patient and fam-
ily education to assure quality care. Nursing
research related to the care of metastatic skin
wounds, supportive care for women with
long-term, indolent skin metastasis, and
management of toxicities related to new and
investigational treatment modalities is
needed to develop baseline best practice or
evidence-based clinical guidelines.
Author Contact: Susan Moore, RN, MSN,
APN-NP, AOCN®, can be reached at Susan_
H_Moore@rush.edu.
References
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Rapid Recap
Cutaneous Metastatic Breast Cancer
• Any breast cancer survivor who reports a rash or skin nodules, especially in the upper torso, should be assessed for the
development of cutaneous metastatic breast cancer.
• A diagnosis of cutaneous metastatic breast cancer usually heralds or accompanies the development of distant me-
tastases.
• Skin metastases without the presence of distant metastases often are indolent and can be controlled for long periods of
time with relatively tolerable treatment regimens.
• Good wound care to control drainage and prevent infection contributes to good quality of life for women with cutane-
ous metastatic breast cancer.
• Education and appropriate counseling can help women cope with incurable metastatic disease and the lifestyle changes
that can occur as a result of skin metastases.
• Consider referring patients for clinical trials of investigational agents when standard therapy fails to control skin me-
tastases.

260 SEPTEMBER/OCTOBER 2002 • VOLUME 6, NUMBER 5 • CLINICAL JOURNAL OF ONCOLOGY NURSING