Breast Cancer

Smriti Poudel
Lecturer

1
 Normal Breast

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 basement membrane (duct wall)
C lumen (center of duct)

2 © Mary K. Bryson
Illustration
 Breast Cancer (BC)
Introduction:

• Breast cancer is a malignant tumor that starts in the

cells of the breast.

• Breast cancer is the second most common cancer

among Nepalese women

3
Contd…

• Accounts for 6% of cancers in Nepal, higher in

women aged less than 50 years, compared to older
women in high-income countries.

• Early detection of breast cancer is the most

important method of reducing the mortality and
morbidity associated with breast cancer.

• Screening for breast cancer in developed countries

generally involves clinical examination and
mammogram. (Singh, 2009)

4
 Etiology and Risk Factors
• Etiology not known
Risk Factors

• Age and ethnicity

– Risk increases with age, although the rate of
increase slows after menopause.
– African American women under age 50 years have
a higher age-specific incidence of breast cancer than
that in Caucasian women.
5
• Ovarian and Hormonal Function:

– Early menarche and late menopause lead to an

increased total lifetime number of ovulatory
menstrual cycles and a corresponding 30% to 50%
increase in breast cancer risk.

– Women who experience natural menopause before

age 45 years has risk for BC that is half that of the
women whose menopause occurs after age 55
years.

6
Ovarian and Hormonal Function (Contd.)
– Oophorectomy before a woman reaches menopause
lowers her risk of breast cancer by approximately
two thirds.

– Both null parity and age over 30 years at first live

birth are associated with a nearly doubled risk of
subsequent breast cancer.

– The use of HRT has also demonstrated a small but

significant increase in risk for BC in women who used
it for more than 10 years.
7
 Risk Factors (Contd.)

• Benign Breast Disease:

– Non-proliferative lesions (such as cysts, mild
hyperplasia and fibroadenoma) do not increase the
risk of BC.

– Cellular atypia or atypical hyperplasia ( a proliferative

disease ) can undergo histologic change associated
with a higher risk of BC.

– Nearly 40% of women with a family history of BC and

atypical hyperplasia subsequently have BC.
8
Risk Factors (Contd.)

• Family History:

– The BC susceptibility gene BRCA1 and BRCA2

(chromosome 17) and the p53 tumor suppressor
gene have identified in fewer than 10% of all
women with BC.

9
Risk Factors (Contd.)

• Environmental and Dietary Factors:

– Receive radiation for the treatment of Hodgkin’s
disease, the increased incidence of BC have been
reported particularly when they were younger than
20 years.

– Alcohol intake is the best-established dietary risk

factor for BC. Moderate alcohol intake (two drinks
per day) increases the risk of breast cancer by
altering estrogen metabolism.

10
 Breast Cancer Risk Factors
that cannot be changed

Age
GENDER - All Reproductive
women are History
Family/Personal
at risk
History

Menstrual
Race History
Radiation
Genetic
Factors 11
Breast Cancer Risk Factors
that can be controlled
Obesity
All Not having
women
women are
are Family planning
Exercise children
at
at risk
risk

Breastfeeding
Breastfeeding
Birth Control
Birth Control
Hormone
Hormone Pills
Alcohol Replacement
Replacement
Therapy
Therapy 12
 Protective Factors
• Regular, vigorous exercise

• Breastfeeding

• Full-term pregnancy before the age of 30 years

13
 Types of Breast Cancer
• Carcinoma in Situ (Noninvasive): ductal and lobular
• Invasive Carcinoma
– Infiltrating ductal carcinoma
– Infiltrating lobular carcinoma
• Medullary Carcinoma
• Mucinous Cancer
• Tubular Ductal Cancer
• Inflammatory Cancer
• Paget’s Disease: disease of the breast is a rare form of
breast cancer. Paget's disease of the breast starts on the
nipple and extends to the dark circle of skin (areola)
around the nipple. 14
 Carcinoma in situ
• This disease is characterized by the proliferation of
malignant cells within the ducts and lobules,
without invasion into the surrounding tissue;
therefore, it is a noninvasive form of cancer and is
considered stage 0 breast cancer.

• There are two types of in situ carcinoma: ductal and

lobular.

15
 Ductal Carcinoma in situ (DCIS)

Ductal
cancer
cells

Normal
ductal
cell
16
Illustration © Mary K. Bryson
 DCIS

• Because DCIS has the capacity to progress to

invasive cancer, the most traditional treatment is
total or simple mastectomy (removal of the breast
only), with a cure rate of 98% to 99% .

17
 Lobular Carcinoma in Situ
• LCIS is characterized by proliferation of cells
within the breast lobules.

• LCIS is usually an incidental finding discovered on

pathologic evaluation of a breast biopsy for a
breast change noted during physical examination
or on screening mammography.

18
• Historically, treatment was bilateral total
mastectomy, but LCIS is a marker of increased
risk for the development of an invasive cancer
(rather than an actual malignancy).

19
 INVASIVE CARCINOMA
Infiltrating Ductal Carcinoma
• Infiltrating ductal carcinomas are the most common
histologic type of breast cancer and account for 75% of all
breast cancers.

• These tumors are notable because of their hardness on

palpation.

• They usually metastasize to the axillary nodes.

• Prognosis is poorer than for other cancer types.

20
 Infiltrating Lobular Carcinoma

• Infiltrating lobular carcinoma accounts for 5%

to 10% of breast cancers.

• These tumors typically occur as an area of ill-

defined thickening in the breast, as compared
with the infiltrating ductal types.

21
• Infiltrating ductal and infiltrating lobular
carcinomas usually spread to bone, lung, liver,
or brain, whereas lobular carcinomas may
metastasize to meningeal surfaces or other
unusual sites.

22
 Medullary Carcinoma
• Medullary carcinoma constitutes about 6% of
breast cancers and grows in a capsule inside a
duct.

• This type of tumor can become large, but the

prognosis is often favorable.

23
 Mucinous Cancer
• Mucinous cancer accounts for about 3% of
breast cancers.

• A mucin producer, it is also slow-growing and

thus has a more favorable prognosis than
many other types. Mucinous breast cancer
begins in the milk duct of the breast before
spreading to the tissues around the duct.

24
 Tubular Ductal Cancer
• Tubular ductal cancer accounts for only 2% of
cancers.

• Because axillary metastases are uncommon

with this histology, prognosis is usually
excellent.

25
 Invasive Ductal Carcinoma (IDC –
80% of breast cancer)

Ductal cancer cells

breaking through
the wall

• The cancer has spread to the

surrounding tissues
• Carcinoma refers to any cancer
that begins in the skin or other
tissues that cover internal
26
organs
Illustration © Mary K. Bryson
 Range of
Ductal Carcinoma in situ

Illustration © Mary K. Bryson

27
 Invasive Lobular Carcinoma (ILC)

Lobular cancer
cells breaking
through the
wall
28
Illustration © Mary K. Bryson
 Cancer Can also Invade Lymph or
Blood Vessels

Cancer cells
invade
lymph duct

Cancer cells
invade
blood vessel

29
Illustration © Mary K. Bryson
 Inflammatory Carcinoma
• Inflammatory carcinoma is a rare type of breast
cancer (1% to 2%) with symptoms different from
those of other breast cancers.

• The localized tumor is tender and painful, and the

skin over it is red and dusky.

• The breast is abnormally firm and enlarged.

30
• Often, edema and nipple retraction occur.

• These symptoms rapidly grow more severe.

• The disease can spread to other parts of the body

rapidly; chemotherapeutic agents play a major
role in attempting to control the progression of
this disease.

• Radiation and surgery are also used to control

spread.

31
Staging of BC

Stage I:
Tumors are less
than 2 cm in
diameter and
confined to
breast.

32
Staging of BC

Stage II:
Tumors are less
than 5 cm, or
tumors are smaller
with mobile
axillary lymph
node involvement.

33
Stage IIIa:
Tumors are greater
than 5 cm, or
tumors are
accompanied by
enlarged axillary
lymph nodes fixed
to one another or to
adjacent tissue.

34
Stage IIIb:
More advancd
lesions with
satellite nodules,
fixation to the skin
or chest wall,
ulceration, edema,
or with supra-
clavicular or
intraclavicular
nodal involvement.
35
Stage IV:
All tumors with
distant
metastases.

36
 Signs and Symptoms

Most common:
lump or
thickening in
breast. Often
painless

Discharge Redness or pitting

or of skin over the
bleeding breast, like the
skin of an orange

Change in color
Change in size or appearance
or
37
contours of of areola
breast
 Signs and Symptoms
• A spontaneous clear or bloody discharge from nipple, often
associated with a breast lump

• Retraction or indentation of nipple

• A change in the size or contours of breast

• Any flattening or indentation of the skin over breast

• Redness or pitting of the skin over breast, like the skin of

an orange
38
 Assessment and Diagnosis
• Health history
• Physical Examination:
– Breast examination
• Investigation:
– Blood test: complete blood count
– Chest X-ray
– Mammogram/ Galactography (mammography and an injection of
contrast material to create pictures of the inside of the breast’s milk
ducts)
– Ultrasound
– Biopsy
– MRI
– CT scan
– PET (Positron Emission Tomography ) scan 39
Breast Examination

40
 Mammography
• Two views are taken of each breast:
– a craniocaudal view
– a mediolateral oblique view
A baseline mammogram
should be obtained after
the age of 35 years
and by the age of 40.

41
 Management

• Surgery
• Chemotherapy
• Radiation therapy

42
43
 Modified Radical Mastectomy
• Modified radical mastectomy is removal of the
entire breast tissue, along with axillary lymph
nodes.

• The pectoralis major and pectoralis minor

muscles remain intact.

44
45
 Breast-Conserving Surgery
• Breast-conserving surgery consists of:
– lumpectomy,
– wide excision,
– partial or segmental mastectomy, or quadrantectomy
(resection of the involved breast quadrant)
– removal of the axillary nodes (axillary lymph node
dissection)for tumors with an invasive component,
followed by a course of radiation therapy to treat
residual, microscopic disease.

46
 Contraindications
Breast-conservation treatment includes both
surgery and radiation.
• First or second trimester of pregnancy
• Prior radiation to the breast or chest region
• History of collagen vascular disease
• Large tumor-to-breast ratio

47
 ROLE OF RADIOTHERAPY IN BREAST
CANCER

 Breast conservation
 Adjuvant radiotherapy
 Palliative radiotherapy

48
 ADJUVANT RADIOTHERAPY
Indications of Radiation therapy
 Patients with 4 or more positive lymph nodes
 Presence of extracapsular extension, positive or close
margins
 T3 tumors with positive lymph nodes, medial quadrant
tumors
 Any T4 tumors and pectoral fascia involvement

49
 RADIATION THERAPY
• With breast-conserving surgery, a course of external-
beam radiation therapy usually follows excision of the
tumor mass to decrease the chance of local recurrence
and to eradicate any residual microscopic cancer cells.

• Radiation typically begins about 6 weeks after the

surgery to allow the incision to heal.

• If systemic chemotherapy is indicated, radiation

therapy usually begins after completion of the
chemotherapy.
50
 Chemotherapy
• Chemotherapy regimens for breast cancer combine
several agents to increase tumor cell destruction and
to minimize medication resistance.

• The chemotherapeutic agents most often used in

combination are cyclophosphamide (Cytoxan) (C),
methotrexate (M), fluorouracil (F), and doxorubicin
(Adriamycin) (A).

51
Contd….

• The combination regimen of CMF or CAF is a

common treatment protocol.

• AC, ACT (AC given first followed by Taxotere), and

ATC, with all three agents given together, are other
regimens that may be used.

52
 Hormonal Therapy
• Hormonal therapy may include surgery to
remove endocrine glands (eg, ovaries,
pituitary, or adrenal glands) with the goal of
suppressing hormone secretion.

53
Contd….

• Tamoxifen is the primary hormonal agent used in

breast cancer treatment today.

• Anastrazole (Arimidex), letrozole (Femara),

leuprolide (Lupron), megestrol (Megace),
diethylstilbestrol (DES), fluoxymesterone
(Halotestin), and aminoglutethimide (Cytadren) are
other hormonal agents used to suppress hormone-
dependent tumors.

54
 Prosthesis
• Women should be encouraged to wear the
prosthesis because it provides a sense of
psychological restoration and wholeness.

• The prosthesis also assists the woman in resuming

proper posture, because it helps to balance the
weight of the remaining breast.

55
Contd….

• A temporary cotton fluff that can be worn

until the surgical incision is well healed (4 to 6
weeks).

• At that time, the woman can be fitted for a

prosthesis.

56
 POTENTIAL COMPLICATIONS

• Based on the assessment data, potential

complications may include the following:
– Lymphedema
– Hematoma formation
– Infection

57
Lymphedema

58
 Nursing Process
• Health history:
– Client response to diagnosis.
– Coping mechanism which is helpful to her
– Psychological and emotional support: does she
have and use?
– Partner, family members or friends to make
decision
– Most important areas of information she needs
– Client’s discomfort
59
 Nursing Diagnosis
Preoperative
• Deficient knowledge about breast cancer and
treatment options
• Anxiety related to cancer diagnosis
• Fear related to specific treatments, body image
changes, or possible death
• Risk for ineffective coping (individual or family) related
to the diagnosis of breast cancer and related treatment
options
• Decisional conflict related to treatment options
60
Postoperative
• Acute pain related to surgical procedure
• Impaired skin integrity due to surgical incision
• Risk for infection related to surgical incision and
presence of surgical drain
• Disturbed body image related to loss or
alteration of the breast related to the surgical
procedure

61
Contd….

• Risk for impaired adjustment related to the diagnosis

of cancer, surgical treatment, and fear of death

• Self-care deficit related to partial immobility of upper

extremity on operative side

• Disturbed sensory perception (kinesthesia) related to

sensations in affected arm, breast, or chest wall

62
Contd…..

• Risk for sexual dysfunction related to loss of body

part, change in self-image, and fear of partner’s
responses
• Deficient knowledge: drain management after breast
surgery
• Deficient knowledge: arm exercises to regain
mobility of affected extremity
• Deficient knowledge: hand and arm care after an
axillary lymph node dissection

63
 Goal
• Increased knowledge about the disease and its
treatment;
• Reduction of preoperative and postoperative fears,
anxiety, and emotional stress;
• Improvement of decision-making ability; pain
management;
• Maintenance of skin integrity;
• Improved self-concept;
• Improved sexual function; and
• The absence of complications.
64
 Preoperative Nursing Interventions
1. EXPLAINING BREAST CANCER AND TREATMENT
OPTIONS

• The patient confronting the diagnosis of breast

cancer reacts with fear, dread, and anxiety.

• Overwhelming emotional reactions: give time to

absorb the significance of the diagnosis and any
information that will help her to evaluate
treatment options.

65
Contd….

• Information about the surgery, the location and

extent of the tumor, and postoperative treatments
involving radiation therapy and chemotherapy.

• Discuss about the patient medications, the extent of

treatment, management of side effects, possible
reactions after treatment, frequency and duration of
treatment, and treatment goals.

66
REDUCING FEAR AND ANXIETY AND IMPROVING COPING
ABILITY

• Patients who have lost close relatives to breast cancer (or any
cancer) may have difficulty coping with the possible diagnosis of
breast cancer because memories of loss and death can emerge
during their own crisis.

• Fears and concerns are common and are discussed with the patient.

• If she will undergo a mastectomy, information about various

resources and options is provided.

• Such services include prostheses, reconstructive surgery, and

groups.

67
Contd….
• Discussion with a plastic surgeon about the various
options for reconstructive surgery can be a valuable
source of information and support.

• Anticipatory teaching and counseling of each stage of

process and procedure.

• Introduce patient to other members of oncology team.

• Promote preoperative physical, psychological, social,

and nutritional well-being.

68
 PROMOTING DECISION-MAKING ABILITY

• Careful guidance and supportive counseling.

• Also, encouraging the patient to take one step of the
treatment process at a time can be helpful.
• The advanced practice nurse or oncology social worker
can be helpful in discussing some of the personal issues
that may arise in relation to treatment.
• Some patients may need a mental health consultation
before surgery to assist them in coping with the
diagnosis and impending treatment.

69
 Postoperative Nursing Interventions

1. RELIEVING PAIN AND DISCOMFORT

•Ongoing nursing assessment of pain and discomfort.

•Moderate elevation of the involved extremity is one

means of relieving pain of arms and chest because it
decreases tension on the surgical incision, promotes
circulation, and prevents venous congestion in the
affected extremity.

70
Contd….

• Intravenous or intramuscular opioid analgesic agents

to manage pain in the initial postoperative phase.

• After the patient is taking fluids and food and the

anesthesia has cleared sufficiently (usually by the
next morning), oral analgesic agents can be effective
in relieving pain.

71
Contd…

• Patient teaching before discharge in managing

discomfort after surgery.

• Patients should be encouraged to take analgesic

agents (opioid or non-opioid analgesic medications
such as acetaminophen) before exercises or at
bedtime and also to take a warm shower twice daily
(usually allowed on the second postoperative day) to
alleviate the discomfort that comes from referred
muscle pain.

72
MAINTAINING SKIN INTEGRITY AND PREVENTING
INFECTION
• In the immediate postoperative period, the patient will
have a snug but not tight dressing or a surgical bra
packed with gauze over the surgical site and one or
more drainage tubes in place.

• Maintain the patency of the surgical drains to prevent

fluid from accumulating under the chest wall incision

• The dressings and drains should be inspected for

bleeding and the extent of drainage monitored
regularly.
73
Contd….

• If a hematoma develops, it usually occurs within the

first 12 hours after surgery; thus, monitoring the
incision is important.

• A hematoma could cause necrosis of the surgical

flaps rarely.

• If either of these complications occurs, the surgeon

should be notified, and the patient should have an
Ace wrap placed around the incision and an ice pack
applied.

74
Contd…

• Initially, the fluid in the surgical drain appears

bloody, but it gradually changes to a
serosanguinous(serous and blood) and then a serous
fluid during the next several days.

• The drain is usually left in place for 7 to 10 days and

is then removed after the output is less than 30 mL in
a 24-hour period.

75
Contd…

• The patient is discharged home with the drains in

place; therefore, teaching of the patient and family is
important to ensure correct management of the
drainage system.

• Explain the care of the incision, sensations to expect,

and the possible signs and symptoms of an infection.

76
Contd….

• Generally, the patient may shower on the second

postoperative day and wash the incision and drain
site with soap and water to prevent infection.

• A dry dressing should be applied to the incision each

day for 7 days.

77
Contd….

• After the incision is completely healed (usually 4 to 6

weeks), lotions or creams may be applied to the area
to increase skin elasticity.

• After the incision is fully healed, the patient may

again use deodorant on the affected side, although
many women note that they no longer perspire as
much as before the surgery.

78
 PROMOTING POSITIVE BODY IMAGE

• During teaching sessions, the nurse can address the

patient’s perception of the body image changes and
physical alteration of the breast.

• Privacy is necessary when assisting the woman to

view her incision fully for the first time and allows
the patient to express her feelings safely to the
nurse.

79
 Contd…..

• Asking the patient what she perceives, acknowledging

her feelings, and allowing her to express her emotions
are important nursing actions.

• Explaining that her feelings are a normal response to

breast cancer surgery may be reassuring to the
patient.

• Ideally, she will see the incision for the first time when
she is with the nurse or another health care provider
who is available for support.
80
 PROMOTING POSITIVE ADJUSTMENT AND
COPING
• Ongoing assessment of the patient’s concerns.

• Assisting the patient in identifying and mobilizing her

support systems is important.

• The patient’s spouse or partner may need guidance,

support, and education as well.

• Patient and spouse can benefit from breast foundation

or association or society ( social groups).
81
Contd….

• Answer questions and address her concerns about

the treatment options that may follow surgery.

• If a woman displays ineffective coping, counseling or

consultation with a mental health practitioner may
be indicated.

82
 PROMOTING PARTICIPATION IN CARE

• Ambulation is encouraged when the patient is free of

postanesthesia nausea and is tolerating fluids.

• The nurse supports the patient on the nonoperative

side.

• Exercises (hand, shoulder, arm, and respiratory) are

initiated on the second postoperative day, although
instruction occurs on the first postoperative day.

83
Exercise: Wall hand climbing
1. Stand facing the wall with feet
apart and toes as close to the
wall as possible.
2. With elbows slightly bent, place
the palms of the hand on the
wall at shoulder level.
3. By flexing the fingers, work the
hands up the wall until arms are
fully extended.
4. Then reverse the process,
working the hands down to the
starting point.
84
Exercise: Rod or broomstick lifting
1. Grasp a rod with both hands,
held about feet apart.
2. Keeping the arms straight,
raise the rod over the head.
3. Bend elbows to lower the rod
behind the head.
4. Reverse maneuver, raising
the rod above the head, then
return to the starting position.

85
Exercise: Rope turning

1. Tie a light rope to a doorknob.

2. Stand facing the door.
3. Take the free end of the rope in
the hand on the side of surgery.
4. Place the other hand on the hip.
5. With the rope-holding arm
extended and held away from the
body (nearly parallel with the
floor), turn the rope, making as
wide swings as possible.
6. Begin slowly at first; speed up
later.
86
Exercise: Pulley tugging

1. Toss a light rope over a shower

curtain rod or doorway curtain
rod.
2. Stand as nearly under the rope
as possible.
3. Grasp an end in each hand.
4. Extend the arms straight and
away from the body.
5. Pull the left arm up by tugging
down with the right arm, then the
right arm up and the left down in
a see-sawing motion.
87
Contd….

• The goals of the exercise regimen are to increase

circulation and muscle strength, prevent joint
stiffness and contractures, and restore full range of
motion.

• Hand exercises are also important for the same

reasons.

88
 IMPROVING SEXUAL FUNCTION
• Most breast surgery patients are physically allowed to
engage in sexual activity once discharged from the
hospital.

• However, any change in the patient’s body image and

self-esteem or the partner’s response may increase the
couple’s anxiety level and may affect sexual function.

• This affects the patient’s self-image, sexuality, and

acceptance.

89
Contd….

• Open discussion and clear communication about

how the patient sees herself and about possible
decreased libido related to fatigue, anxiety, or
nausea may help to clarify issues for her and her
partner.

• Encourage discussion about fears, needs, and desires

may reduce the couple’s stress.

90
Contd….

• If problems develop or persist, referral to a

psychosocial resource (psychologist, psychiatrist, or
psychiatric clinical nurse specialist, social worker, or
sex therapist) can be helpful for the woman and her
partner.

91
 MONITORING AND MANAGING
POTENTIAL COMPLICATIONS
1. Lymphedema
• Lymphedema can occur any time after an axillary
lymph node dissection.

• Lymphedema results if functioning lymphatic

channels are inadequate to ensure a return flow of
lymph fluid to the general circulation.

• After removal of axillary nodes, collateral or

auxiliary circulation must take over their function.
92
 PATIENT EDUCATION

Hand and Arm Care After Axillary Dissection

• Avoid blood pressures, injections, and blood draws in affected
extremity.

• Use sunscreen (higher than 15 SPF) for extended exposure to sun.

• Apply insect repellent to avoid bug bites.

• Wear gloves for gardening.

• Use cooking mitt for removing objects from oven.

• Avoid cutting cuticles; push them back during manicures.

93
Contd….

• Use electric razor for shaving armpit.

• Avoid lifting objects greater than 5–10 pounds.

• If a trauma or break in the skin occurs, wash the area

with soap and water, and apply an over-the-counter
antibacterial ointment (Bacitracin or Neosporin).

• Observe the area and extremity for 24 hours; if

redness, swelling, or a fever occurs, call the surgeon
or nurse.
94
Contd….

• If lymphedema occurs, the patient should contact

the surgeon or nurse as she may need a course of
antibiotics or specific exercises to decrease the
swelling.

• Emphasis should be placed on early intervention

because lymphedema can be manageable if treated
early; otherwise the swelling can become painful and
difficult to reverse.

95
 Management consists of:
• Arm elevation with the elbow above the shoulder
and the hand higher than the elbow, along with
specific exercises, such as hand pumps.

• A referral to a physical therapist or rehabilitation

specialist may be necessary for a custom-made
elastic sleeve, exercises, manual lymph drainage, or a
special pump to decrease swelling.

96
 Hematoma Formation

• Hematoma formation may occur after either

mastectomy or breast conservation.

• Monitor the surgical site for excessive swelling and

monitors the drainage device, if present.

• Gross swelling or output from the drain may indicate

hematoma formation, and the surgeon should be
notified promptly.

97
 Infection
• Infection follows breast surgery in about 1 in 100
patients.

• Infection can occur for a variety of reasons,

(diabetes, immune disorders, advanced age) and
exposure to pathogens.

98
 Continuing Care
• Assess for incision and drainage system, physical and
psychological status, adequacy of pain management,
and adherence to the exercise plan.

• The home care nurse reinforces previous teaching

and communicates important physiologic findings or
psychosocial issues to the patient’s primary care
provider, nurse, or surgeon.

99
Contd….

• Follow-up visits to the physician after diagnosis and

treatment.

• Visits every 3 months for 2 years, followed by every 6

months up to 5 years, may be then extended to
annual examinations, depending on the patient’s
progress and the physician’s preference.

100
Contd….

• A disease-free state for as long as possible is the

goal.

• Patients are also encouraged to do BSE on the

remaining breast (and operative side if breast-
conserving surgery was done) and the chest wall
(after mastectomy).

• Additional screening is done with annual

mammography.

101
 RECONSTRUCTIVE SURGERY
• Women may undergo reconstruction immediately (at
the time of mastectomy) or delay it (6 months to 1
year after surgery)

102
 Contraindications

• Locally advanced cancer,

• Metastasis, or

• Inflammatory breast cancer.

103
Contd….

• Reduction mammoplasty is performed to reduce the

size of the breast.

• Augmentation mammoplasty is performed to

increase the size of the breast.

• Some women desire surgery to reconstruct their

breasts after mastectomy

104
 REDUCTION MAMMOPLASTY
• Reduction mammoplasty is usually performed on
women who have breast hypertrophy (excessively
large breasts).

• If the enlargement occurs early in life, it is called

virginal breast hypertrophy.

• The condition is usually bilateral but may affect just

one breast.

105
106
 AUGMENTATION MAMMOPLASTY

• Augmentation mammoplasty is requested frequently

by women desiring larger or fuller breasts.

• It is performed through an incision along the

undermargin of the breast, in the axilla, or at the
border of the areola.

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Contd…..

• The breast is then elevated, and a pocket is formed

between the breast and the chest wall into which
various types of synthetic materials are inserted to
enlarge and uplift the breast.

• The subpectoral approach is preferred because it

interferes less with clinical breast examinations or
mammography than do subglandular implants.

• These procedures may be performed on an

outpatient basis with local anesthesia.
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Contd….

• Silicone implants were used in the past; however,

because of the reported systemic complications
associated with their use, they have been removed
from the market.

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 RECONSTRUCTIVE PROCEDURES
AFTER MASTECTOMY

• About 75% of women with breast cancer undergoing

mastectomy need immediate reconstruction.

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 Tissue Expanders With Permanent Implants
• One method of reconstruction is the tissue expander
with permanent implant.

• After the surgeon has completed the mastectomy, the

plastic surgeon creates a pocket inside the pectoralis
muscle and inserts a partially filled Silastic expander
and a drainage device.

• Then, over a period of weeks, the patient visit OPD for

injections of additional saline into the expander through
a port that is under the skin; this temporary expander
stretches the skin and muscle.
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Contd…

• When the implant is fully expanded (usually one

third larger than the other breast to create a natural
crease and droop to match the contralateral breast),
the patient has the temporary implant exchanged for
a permanent implant.

• This is usually performed as outpatient surgery.

• It may be done 4 to 6 months later to allow the

tissue to soften and become more pliable before the
permanent implant is inserted.

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 Tissue Transfer Procedures
• Another method of reconstruction is using the
patient’s own tissue and transferring it to the
mastectomy site.

• These flap surgeries can use the transverse rectus

abdominis myocutaneous flap (TRAM flap), gluteal
muscle, or latissimus dorsi muscle.

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Contd…..

• The plastic surgeon transfers the muscle flap with

attached circulatory structures, skin, and fatty tissue,
rotates it to the operative site, and molds it to create
a mound that simulates the breast.

• These procedures are far more extensive and involve

greater operative time (about 8 to 10 hours total
time for the mastectomy and reconstruction) and
duration of general anesthesia than does the tissue
expander procedure.

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 Nipple–Areola Reconstruction
• After the breast mound has been created and the site has
healed, some women choose to have a nipple–areola
reconstruction.

• A nipple is created using a skin graft from the inner thigh

or labia because this skin has darker pigmentation than
the skin on the reconstructed breast.

• After the nipple graft has healed, the areolar complex is

usually completed with micropigmentation (tattooing).

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THANK YOU

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