THE NCLEX CHANNEL

{ Breast Cancer }

Session Objectives:
• Objective 1: Identify risk factors and hallmark signs associated with breast
cancer.
• Objective 2: Review how breast cancer is diagnosed, including medical
management for a breast cancer diagnosis.
• Objective 3: Explore nursing management for a client diagnosed with
breast cancer.

Points of Emphasis:
Risk Factors

• Age:
o Over 50
o Increased breast density
o Atypical hyperplasia
• Alcohol Consumption
o Two or more alcoholic drinks per day
• Weight
o Body Mass index of 31.1 or greater
o Sedentary lifestyle and inadequate intake of fruits and vegetables
• Genetics
o Strongest predictive risk factor
o First degree (parents, siblings, offspring)
o BRCA 1 or BRCA 2 (BReast CAncer gene)
o Ashkenazi Jewish heritage
o Self or family history and diagnosis of breast, ovarian, prostate,
pancreatic, endometrial, colon, or melanoma cancer
• Hormonal
o Estrogen-based hormonal therapy for 5 years or longer
o Experiencing menarche before the age of 12
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o Menopause after age 50
• Radiation Exposure
o Chest/breast to ionizing radiation
o Increase risk if exposure occurs during ages 10 to 30
o Hodgkin lymphoma treatment

Hallmark Signs

• Skin irritation: redness, scaliness, or thickening of the breast tissue or

nipples.
• Swelling or dimpling of the breast, nipple, or underarm area. The dimpling
or pitting resembles an orange peel (peau d’orange) in late stage breast
cancer.
• A palpable lump or mass in the breast tissue or underarm area.
• Nipple pain, inversion (inward turning of the nipple), or discharge
(unrelated to breastfeeding and production of breastmilk).
• Men present with a hard, painless, mass with or without gynecomastia
(enlargement of breast tissue in men). Men typically do not seek treatment
when there is a mass (they don’t think about breast cancer) and
diagnosis/treatment is delayed, which causes a slightly lower survival rate.

Screenings

Mammograms: Single most effective method of early detection. Detects up to

90% of breast cancer in asymptomatic women. More accurate in postmenopausal
women as the breast tissue is less dense.
• Choice to start mammography imaging at the age of 40.
• Annual mammograms at the age of 45.
• Every other year at the age of 55.
• High-risk clients may begin at age 25.
• BI RADs reporting system is used into six categories.
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o Category 0 is inconclusive and another mammogram needs to be
completed.
o Category 1 and 2 are negative and benign.
o Category 3 is considered probably benign, but a follow-up 6-month
mammogram is recommended.
o Category 4 or higher is considered suspicious for malignancy.
o Category 5 is considered highly suggestive of malignancy.
o Category 6 is only used for findings on a mammogram that have
already been shown to be cancer by a previous biopsy.
Mammograms may be used in this way to see how well the cancer is
responding to treatment.

Breast self-awareness: Most women detect abnormalities in the breast during

bathing and getting dressed, not during monthly breast self-exams. The American
Cancer Society no longer recommends that all women perform monthly breast
self-exams as an effective screening tool for early detection. Women should be
aware of their body and changes in their breast and underarm areas. Breast self-
awareness is more effective than completing monthly breast self-exams. Women
should report any abnormal findings or changes.

Clinical breast exams (CBEs): Performed manually by a trained health care

professional. These are recommended for all clients with the BRCA 1/2 gene
mutation or other gene identifiers and performed at more frequent intervals.

Magnetic resonance imaging (MRI): Begin at the age of 30 for those clients that
have a high risk of developing breast cancer. This includes BRCA 1/2 or other gene
markers, radiation to the chest area, lifetime risk factor from a risk model of 15%
to 20%, and history of breast cancer.

Diagnosis
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• Diagnostic mammograms are performed that are more definitive with
clearer images of the breast tissue and are different from the screening
type of imagery.
• Ultrasounds are used with soundwaves that bounce off tissue to detect
fluid filled sacs (usually benign) or solid masses (malignancy).
• MRIs are also used for the screening of high-risk clients and diagnosis of
suspicious findings.
• Biopsies are indicated with a BI RADS category 4 or higher. A fine needle,
core (thick needle) or tissue (surgical removal) biopsy can be performed.

Categories
Noninvasive is where the cancer cells stays enclosed in the ducts or lobules and
have not invaded the surrounding breast tissue. These cancer names end in “-in
situ,” meaning in its original place/position, and account for about 20% of breast
cancer cases.
• Ductal carcinoma in situ (DCIS): Early form.
• Lobular carcinoma in situ (LCIS): Rare, prophylactic treatment including
tamoxifen, raloxifene or prophylactic mastectomy is recommended.

Invasive accounts for about 80% of breast cancer. This is where the cancer is no
longer confined to the ducts and the cancer cells spread to the surrounding breast
tissue or metastasis.
• Infiltrating ductal carcinoma: Most common.
• Inflammatory breast cancer (IBC): Rare and highly aggressive.
• The most common sites of metastasis are bone, lung, brain, and liver.

Medical Management

Tissue Analysis
• Hormone receptor test
o Estrogen receptor positive or negative (ER+ or ER−).
o Progesterone receptor positive or negative (PR+ or PR−).
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o Clients respond to hormonal treatment if ER+ or PR+.
• HER2 Testing
o HER2+ or HER2−
o Clients respond to target therapy with HER2+ (more aggressive).

Stages
• Stage 0 to IV
• Determined by the size of the tumor, involvement of lymph nodes, and
metastasis
• Localized → surgery and radiation
• Spread beyond the breast and axilla → hormonal therapy, chemotherapy
and biological therapies.

Surgery
The type of surgery implemented is determined by the size of tumor, stage, size
of breasts, age of client, and psychosocial impact on the client.
• Breast sparing (lumpectomy): Removal of the tumor in the breast.
• Partial mastectomy: Removal of part of the breast.
• Total mastectomy: Removal of the whole breast.
• Sentinel lymph node biopsy: Lymph node involvement and removal. With
any of these surgical procedures, the surgeon will perform a sentinel lymph
node biopsy, which is minimally invasive using a radioactive dye to see if
the lymph nodes take up the dye or give off any radiation. Any lymph nodes
involved will be removed during the surgical procedure.

Radiation
• External radiation destroys cancer cells with high-energy rays given 5 days a
week for up to 6 weeks.
• Brachytherapy involves target radiation implants given twice a day for 5
days.

Hormone therapy
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• Selective estrogen receptor modulators tamoxifen, raloxifene, and
toremifene selectively block estrogen in the breasts. Tamoxifen is the only
one approved for premenopausal women. Hormonal therapies can provide
prophylactic measures. In 2017, the FDA approved medications to prevent
breast cancer in clients that have a 20% to 25% increase risk. Research
findings show a 38% decrease in the risk of getting breast cancer when
taking the selective estrogen receptor modulators.
• LR-RH agonists: Goserelin and leuprolide block ovarian production of
estrogen.
• Aromatase inhibitors: Anastrozole, letrozole, and exemestane prevent
conversion of estrogen.
• Estrogen receptor down-regulator fulvestrant is involved in degradation of
estrogen receptors.

Chemotherapy
• Doxorubicin, docetaxel, cyclophosphamide, and methotrexate.
• Four to six cycles lasting 2 to 3 weeks in length. Total treatment time is 3 to
6 months.

Target Therapy
• These specifically target cancer cell growth, viability, and invasion.
• Trastuzumab (specifically targets HER2), lapatinib, pertuzumab, everolimus,
and T-DM1.
• These medications can cause serious side effects. A part of safe nursing
care is knowing the information about these medications when the client is
receiving them.

Postoperative Care
Drains are commonly placed during surgery. Jackson-Pratt (JP) drains are used
and resemble a “bulb or grenade.” The bulb can be depressed to create suction
and collect fluid from the surgical site to promote healing.
• Maintain lymph circulation and prevent lymphedema.
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o Avoid tight clothing, jewelry, and carrying handbag/purse on affected
extremity.
o Avoid injections, blood tests, and blood pressure measurements on
the affected extremity.
o Avoid detergents, perfumes, and deodorants on affected extremity.
o Protect affected extremity from burns, cuts, trauma, and infection.
This includes sunburns, aggressive manicures, cuticle cuts on
fingers/nails, and wearing gloves when gardening.
• Collaborate with interdisciplinary team including physical therapy.
o Physical therapy massage and exercises to promote circulation, range
of motion, and strength begins 1 to 2 days after surgery.
o Physical therapy wrap (elastic sleeve or cuff).
• Psychosocial
o Body image: Anxiety, difficulty expressing feelings, difficulty
expressing sexuality (physical and emotional love).
o Reach to Recovery program.
o Reconstruction:
 Tissue expansion and implants (most common)
 Autologous reconstruction (muscle flap; more natural look)
 Nipple recreation (2 to 6 months after reconstruction)
o Breast prosthesis:
 Adhere to chest or pocket in post-mastectomy bra
 Different materials (e.g., silicone gel, foam, or fiberfill)

References:
American Cancer Society. (2019). Cancer facts and figures. Retrieved from
https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-
figures/cancer-facts-figures-2019.html
Centers for Disease Control and Prevention. (2019). National Breast and Cervical
Cancer Early Detection Program (NBCCEDP). Retrieved from
http://www.cdc.gov/cancer/nbccedp/about.htm
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Ignatavicious, D. D., & Workman, M. L. (2016). Medical-surgical nursing:
Patient-centered collaborative care (8th ed.). St. Louis: Missouri. Elsevier.
[Vitasource Bookshelf Online]. Retrieved from
https://bookshelf.vitalsource.com/#/books/9780323392693/cfi/6/86!/4/2/6/2
@0:0
Komen, Susan G. (2019). Financial assistance. Retrieved from
https://ww5.komen.org/BreastCancer/FinancialResources.html

Murray, S., McKinney, E., Holub, K., & Jones, R. (2019). Foundations of maternal-
newborn and women’s health nursing (7th ed.). [VitalSource Bookshelf Online].
Retrieved from
https://bookshelf.vitalsource.com/#/books/9780323398947/cfi/6/228!/4/2/12
/16/6/4/2@0:69.2
National Comprehensive Cancer Network. (2019). Breast cancer screening and
diagnosis. Retrieved from http://www.nccn.org