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Breast Cancer

Katherine MacGillivray & Melissa Poirier

Objectives

Discuss breast cancer statistics in Canada and Nova Scotia.


Overview of the breasts anatomy and physiology.
Discuss risk factors for breast cancer and how to minimize those risks.
Discuss differences between benign, non-invasive and invasive breast
disease.
Brief overview of breast cancer in men.
Discuss types of lymph node involvement.
Discuss screening options for breast cancer.
Discuss diagnostic tests used for breast cancer.
Discuss grading & staging of breast cancer.
What are the treatment options for breast cancer?
Discuss complications and prognosis of breast cancer.
Discuss pre/postoperative nursing diagnosis and interventions .

Canadian Statistics for 2012


In Canada, 200 men & 23,000 women will be diagnosed
with breast cancer in 2012.
Of that, 50 men & 5100 women will succumb to the
disease.
Breast cancer accounts for 26% of new cancer cases in
Canadian women.
Approximately 62 Canadian women are diagnosed with
breast cancer daily.
Approximately 14 Canadian women die daily of breast
cancer.
1 in 9 women will develop breast cancer in their lifetime
and 1 in 29 will die from it.

Statistics in Nova Scotia for 2012


An estimated 740 women will be diagnosed with breast
cancer.
An estimated 160 women will die of breast cancer.
100 out of every 100,000 women of NS will be diagnosed
with breast cancer.
Of 100,000 deaths, 20 women will die as the result of
breast cancer.
In Nova Scotia, there is limited data available for breast
cancer in men. Men succumb to prostate, colorectal and
lung cancers.

Breast A & P
Male and female breast
develop at the same rate till
puberty.
Located between the 2nd & 6th
ribs.
Tail of Spence extends into the
axilla.
Coopers ligaments support
the breast to the chest wall.
Each breast contains 12-20
lobes.

Risk Factors

Personal Health History


Family Health History
Certain Genome Changes
Radiation Therapy to the Chest
Reproductive and Menstruation History
Race
Being Overweight or Obese after Menopause
Lack of Physical Activity
Alcohol Use
Smoking
Age

Minimizing Your Risk

Lose excess weight.


Be physically active.
Limit your intake of alcohol.
Breastfeed your baby.
Quit smoking.
Talk to your doctor about the risks and benefits of
hormone replacement therapy (HRT).
Reduce exposure to chemicals

Benign Proliferative Breast Disease


Atypical Hyperplasia
Benign
Abnormal proliferation of cells
Increased risk of breast cancer

Lobular Carcinoma in Situ

Benign
Proliferation of cells in the lobules
Unable to be diagnosed with a Mammogram
Increased risk of breast cancer

Lobular Carcinoma in Situ


Breast profile:
A Ducts
B Lobules
C Dilated section of
duct to hold milk
D Nipple
E Fat
F Pectoralis major
muscle
G Chest wall/rib cage
Enlargement
A Normal lobular cells
B Lobular cancer cells
C Basement membrane

Types of Breast Cancer:


Non-Invasive vs. Invasive
Non-Invasive Cancer
Ductal Carcinoma in Situ

Invasive Cancer

Infiltrating Ductal Carcinoma


Infiltrating Lobular Carcinoma
Medullary Carcinoma
Mucinous Carcinoma
Tubular Ductal Carcinoma
Inflammatory Carcinoma
Pagets Disease

Ductal Carcinoma in Situ


Breast profile:
A Ducts
B Lobules
C Dilated section of duct to
hold milk
D Nipple
E Fat
F Pectoralis major muscle
G Chest wall/rib cage
Enlargement
A Normal duct cells
B Ductal cancer cells
C Basement membrane
D Lumen (center of duct)

Non-Invasive (In Situ) Cell Growth


Subtypes

Non-invasive cancer is grouped into four subcategories,


based on how the cancer cells grow relative to each
other, within the center of the milk duct:
Solid
Cribriform
Papillary
Comedo

Solid:
There is wall-to wall cell growth

A - Cancer cells
B - Basement
membrane

Cribriform:
There are holes between groups of cancer cells, making it look
like Swiss cheese.

A - Cancer Cells
B - Basement membrane
C - Lumen (center of duct)

Papillary:
The cells grow in fingerlike projections, toward the inside of
the duct.

A - Cancer cells
B - Basement membrane
C - Lumen

Comedo:
There are areas of necrosis, which is debris from dead cancer cell; this
indicates that a tumor is growing so fast that some of the tumor will wither
and die because there is not enough blood to feed all of the cells.

A - Living cancer cells


B - Dying cancer cells
C - Cell debris (necrosis)
D - Basement
membrane
* Referred to as high
grade noninvasive
cancer- fast growing

Invasive Cancers
Most Common:
Infiltrating Ductal Carcinoma
Infiltrating Lobular Carcinoma

Invasive Ductal Carcinoma

Breast profile:
A ducts
B lobules
C dilated section of duct to hold
milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage

Enlargement:
A normal duct cells
B ductal cancer cells breaking
through the basement
membrane
C basement membrane

Invasive Lobular Carcinoma


Breast profile:
A ducts
B lobules
C dilated section of
duct to hold milk
D nipple
E fat
F pectoralis major
muscle
G chest wall/rib cage
Enlargement:
A normal cells
B lobular cancer cells
breaking through the
basement membrane
C basement
membrane

Other Invasive Carcinomas


Medullary Carcinoma
Mucinous Carcinoma
Tubular Ductal Carcinoma
Inflammatory Carcinoma
Pagets Disease

Men & Breast Cancer

Less than 1% of breast cancers happen to men in Canada;


however the number is increasing
Men over the age of 60 are most often diagnosed with
breast cancer
Risk factors, diagnosis, staging and treatment are the
same as in women
Risk factors include: mumps, radiation exposure &
decreased testosterone levels.
Most common is ductal carcinoma found in breast ducts
Symptoms include a small painless lump, discharge from
nipple, inverted nipple and skin ulceration
Adverse feelings related to manhood and sexuality,
having a womens disease

Lymph Node Involvement


Some breast cancers spread to the lymph nodes
under a woman's arm.
Microscopic examination:
Lymph node involvement = positive
Lymph node clear of cancer = negative

Connection between the number of lymph nodes


involved & aggressiveness of cancer's personality.
Knowing how many lymph nodes are involved will
help identify appropriate treatment.

Lymph Nodes
Three types of lymph node involvement
1. Minimal (or microscopic) lymph node involvement:
- Small number of cancer cells in lymph nodes.
2. Significant (or macroscopic) involvement:
-A particular lymph node or group of nodes has
become involved with the cancer. Can often
felt by hand or seen without a microscope.
3. Extra-capsular extension:
-A breast cancer tumor takes over a whole lymph
node and spills beyond the wall of the lymph
node into the surrounding fat.

Lymph Nodes
In most cases, the more extensive the lymph node
involvement, the more aggressive the cancer. But the
extent of disease within a particular lymph node is
less important than the total number of lymph nodes
affected. The more lymph nodes that are involved,
the more threatening the cancer may be.
Doctors use the following categories to describe the
overall level of lymph node involvement:

No lymph nodes involved


13 nodes involved
49 nodes involved
10 or more nodes involved.

Has Cancer Invaded Lymph or


Blood Vessels?

A blood vessels
B lymphatic channels
Enlargement
A Normal duct cell
B Cancer cells
C Basement membrane
D Lymphatic channel
E Blood vessel
F Breast tissue

Breast Cancer Tissue

Report to Physician ASAP

Screening

1.
2.

SBE (self-breast examination)


Mammography

Self Breast Examination


Self Breast Exams are an important way to find a
breast cancer early.
Not every cancer can be found this way, but it is
critical to become familiar with your breasts in
order to identify an abnormality
SBE should be done once a month approximately
1wk after your menstrual period

Self Breast Exam contd


Lumps
most women have lumps or lumpy areas in the breast that
may be the result of Fibroadenomas or Cysts
8 out of 10 lumps removed from the breast are benign
Upper/outer area(armpit) - most prominent lumps/bumps
Lower half - sandy/pebbly beach
Underneath nipple - collection of large grains
Other parts - lumpy bowl of oatmeal

Studies show that regular breast


self-exams, combined with an
annual exam by a doctor,
improves the chances of
detecting cancer early.

Steps to a Self Breast Exam:


Step 1
Look in the mirror, shoulders straight
and arms on your hips.
Look for size, shape, and colour of
breasts, is there any distortion or
swelling present
Changes to report: dimpling,
puckering, bulging of the skin,
change in nipple position, inverted
nipple, redness, soreness, rash or
swelling.

Step 2
Raise your arms
above your head
and look for the
same changes.

Step 3
Still standing at the mirror, look for any
discharge/fluid coming from your nipples.
Changes to report: any fluid coming out of 1 or
both nipples (unless you are lactating). Could
be watery, milky, yellow or bloody.

Step 4
Lie down on the bed and
palpate breasts using pads
of a few fingers.
Use a firm smooth touch
in a circular motion.
Cover entire breast
collar bone to top of
stomach, armpit to
sternum.
Make sure to follow a
pattern so to cover all
area of the breasts.

Step 5
Sit or stand and
palpate the breast in
the same manner as
step 4.
Changes to report:
lumps, bumps,
irregularities

Mammography
Breast imaging technique
Identifies non-palpable masses and diagnoses palpable
masses
Procedure takes approximately 15 minutes
Breast is compressed from top to bottom, and side to side
New and old mammograms are compared
Radiation exposure is equivalent to 1 hour in the sun
Canadian Cancer Society recommends women to have a
mammogram every 2 years between 50 & 69 years of age.
Women at high risk and under 50 should speak with the HCP
http://www.youtube.com/watch?v=Y-GmNmPeqHQ

EXPERT QUOTE
"The biggest misconception about mammography is that
it picks up every breast cancer. In fact, mammography
misses at least 10 percent of breast cancer. So if you feel a
lump that doesn't show up on a mammogram, bring it to
your doctor's attention. Get it evaluated."
Susan Orel, M.D.

Diagnosis for Breast Cancer

Procedures for tissue analysis:


Percutaneous Biopsy
Fine-Needle Aspiration
Core Needle Biopsy
Guided Core Biopsy

Surgical Biopsy
Excisional Biopsy
Incisional Biopsy

Needle Biopsy

Excisional Biopsy

Grading

Grade

Description

Low grade slow growing, less likely to spread

Moderate grade

High grade tend to grow quickly, more likely to spread

Staging
Stage Description
0

There are two kinds of stage 0 breast cancer:


Ductal carcinoma in situ (DCIS): Abnormal cells are in the lining of a milk duct and have
not spread outside the duct.
Lobular carcinoma in situ (LCIS): Abnormal cells are in the lining of a lobule.

Tumour is 2 cm or smaller and the cancer has not spread outside the breast.

Tumour is 2 to 5 cm, or cancer has spread to the lymph nodes, or both.

Cancer has spread to the lymph nodes and may have spread to nearby tissues such as
the muscle or skin.

Cancer has spread to distant parts of the body.

Treatment
Surgery
Chemotherapy
Radiation
Adjunctive Therapy
Alternative Therapy

Breast Sparing Surgery: Lumpectomy &


Partial Mastectomy

Lumpectomy vs. Mastectomy

Modified Radical Mastectomy

Radical Mastectomy

Total Mastectomy

TRAM Flap Reconstruction

Complications
Infection

Lymphedema

Hematoma/Seroma Formation

Allergic Reaction

Lymphedema
Lymphedema is the buildup of fluid in the arm.
About 10-20% of women
will develop this especially
if more than 10 lymph
nodes were removed.

Lymphedema

How to Prevent Lymphedema

Talk to HCP if experiencing symptoms of lymphedema


Keep skin and nails clean
Avoid blocking the flow of fluid through the body
Keep blood from pooling in affected limb
Exercise

Prognosis
Two most important factors when determining the
prognosis of breast cancer:
Size of tumour
Spread of tumour
Excessive number of copies of certain genes
Excessive amounts of the genes protein products

Preoperative Nursing Diagnosis

Deficient knowledge
Anxiety
Fear
Risk for ineffective coping
Decisional conflict

Preoperative Nursing Interventions

Provide education and preparation for surgical


treatments
Reduce fear and anxiety and improve coping ability
Promote decision-making ability

Postoperative Nursing Diagnoses


Acute pain
Disturbed sensory perception
Disturbed body image
Risk for impaired adjustment
Risk for ineffective coping for individual and family
Deficient knowledge
Risk for sexual dysfunction
Risk for infection

Postoperative Nursing Interventions

Relieving pain and discomfort


Managing postoperative sensations
Promoting a positive body image
Promote positive adjustment and coping
Improving sexual function
Monitor for complications

Case Study
Mrs. X, a 59 year old female with a family history of breast cancer
recently found a small palpable mass in the upper outer quadrant
of her left breast, she also noticed some slight dimpling upon a
breast self exam. When she notified her doctor, he preformed a
fine needle aspiration biopsy for tissue analysis. Mrs. Xs results
showed she had an infiltrating ductal carcinoma, which is an
invasive cancer. Mrs. Xs doctor staged her cancer as T1N1M0.
1.
2.
3.

How often and when should one perform a breast self


exam?
If Mrs. Xs breast cancer was genetically inherited, which
gene(s)would most likely have a mutation?
Interpret T1N1M0

Case Study Contd


Mrs. X was scheduled for a modified radical mastectomy (removal
of entire breast tissue, nipple areola complex and axillary lymph
nodes). She met with a plastic surgeon to explore the option of
breast reconstructive surgery but has decided to wait until after
her surgery to decide. Mrs. Xs mother and sister both have
undergone the same surgery and she has a very supportive
husband. Mrs. X confides in you, the RN, that she is still anxious
regarding her upcoming surgery.
1.
2.

What are some preoperative nursing interventions you


would do?
What are some postoperative nursing interventions you
would do?

References
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., &
Bare, B. G. (2010). Textbook of Canadian medicalsurgical nursing (2nd ed). Philadelphia, Pennsylvania:
Wolters Kluwer Health/Lippincott Williams & Wilkins.
www.breastcancer.org
www.cancer.ca
www.cancer.gov