BREAST

Mary Strong, FNP-BC

Hinds Community College
Associate Degree Nursing
▪ Malignant: In regard to a tumor, characterized by
uncontrolled growth; cancerous, invasive, or
metastatic
▪ Benign: Not malignant. A benign tumor is one that
does not invade surrounding tissue or spread to
other parts of the body; it is not a cancer.
▪ Breast cancer: A neoplastic disease in which
normal body cells are transformed into malignant
ones
▪ Major health problem in the United States
▪ A woman’s risk (over a lifetime) of developing breast cancer is about
12% or one out of every 8 women
▪ Risk of developing breast cancer increases with age
▪ About 2 of 5 invasive breast cancers are found in women 55 years or
older
▪ About 5-10% of breast cases are thought to be hereditary
▪ Incidence rates vary substantially by race and ethnicity
▪ Higher death rates in African Americans
▪ Attributed to later stage at diagnosis
▪ Driven in large part by differences in socioeconomic status
▪ Unregulated cell growth results in the formation of a tumor
▪ All cancer is the result of changes in DNA or chromosome structure
that cause the mutation of specific genes
▪ Most genetic mutations that cause cancer occur by chance and are
not necessarily due to inherited mutations
▪ Cancer development is thought to be clonal (think clone) in nature,
which means that each cell is derived from another cell. If one cell
develops a mutation, any daughter cell derived from that cell will
have that same mutation, and this process continues until a malignant
tumor forms
▪ Types of Breast Cancer
▪ Ductal Carcinoma in Situ (DCIS)
▪ Invasive Breast Cancer

▪ Ductal Carcinoma in Situ (DCIS)

▪ Characterized by the proliferation of malignant cells inside the milk ducts without
invasion into the surrounding tissue
▪ Does not metastasize and death from DCIS generally does not occur unless it develops
into invasive breast cancer
▪ May develop into invasive breast cancer if left untreated
▪ 14% to 53% of untreated DCIS progresses to invasive breast cancer over a period of
10 years or more
▪ Frequently manifested on a mammogram with the appearance of calcifications and it is
considered stage 0
▪ Ductal carcinoma in situ (DCIS) – pathologist assesses
▪ Size
▪ Type – how abnormal do the cells look compared to normal tissue
▪ Grade – how fast are the cells growing
▪ Margins
▪ Grade I (low-grade)
▪ Grade II (moderate-grade)
▪ Grade III (high-grade DCIS) cells tend to grow more quickly and look
much different from normal breast cells
▪ Accurate grading of DCIS is critical
▪ Breast conservation (treatment of a breast cancer without the loss of
the breast) can be curative for well defined subsets of women with
DCIS
▪ Infiltrating Ductal Carcinoma
▪ Most common histologic type of breast cancer
▪ Accounts for 80% of all cases
▪ Tumors arise from the duct system and invade the surrounding tissues
▪ Often form a solid irregular mass in the breast
▪ Spreads rapidly to axillary and other lymph nodes, even while small
▪ Infiltrating Lobular Carcinoma
▪ Accounts for 10-15% of breast cancers
▪ Tumors arise from the lobular epithelium and typically occur as an are of ill-defined
thickening of the breast
▪ Often multicentric and can be bilateral
▪ By the time it is discovered the prognosis is usually poor
▪ Other Invasive Breast Cancers
▪ Medullary Carcinoma
▪ Mucinous Carcinoma
▪ Tubular Ductal Carcinoma
▪ Micropapillary Invasive Ductal Carcinoma
▪ Paget Disease
▪ Inflammatory Carcinoma
▪ No single, specific cause
▪ A combination of genetic, hormonal and possibly
environmental factor
▪ More than 80% of cases sporadic
▪ There is NO evidence that silicone breast implants, the use
of antiperspirants, underwire bras, or abortion (induced or
spontaneous) increases the risk of the disease
▪ Some evidence that long-term smoking, starting before first
pregnancy and night shift work may increase the risk of
breast cancer
▪ BRCA 1 and BRCA 2
▪ Tumor suppressor genes
▪ Normally function to identify damaged DNA and thereby restrain abnormal cell
growth
▪ Account for majority of inherited cases of breast cancer
▪ Mutations in these genes on chromosome 17 are responsible
▪ In women have been associated with an overall risk of breast cancer up to 65%
▪ Women who are BRCA positive are counseled to start screening, typically using
mammography once a year and then MRI 6 months after the yearly mammogram
by 25 years of age, or 5 to 10 years earlier than their youngest affected family
member
▪ Males who carry BRCA 2 mutation may have a lifetime risk of 6% to 7% of
developing breast cancer
▪ Female gender

▪ Increasing age

▪ Family history of breast cancer

▪ Genetic mutation

▪ Hormonal factors
▪ Early menarche
▪ Late menopause
▪ Nulliparity
▪ Late age at first full-term pregnancy
▪ Hormone therapy

▪ Exposure to ionizing radiation during adolescence and early adulthood

▪ History of benign proliferative breast disease

▪ Obesity

▪ Alcohol intake (2 to 5 drinks daily of beer, wine, or liquor increases the risk about one and a half
times
▪Breastfeeding for at least a year
▪Regular or moderate physical activity
▪Maintaining a healthy body weight
▪Some research suggests that the use of
extra virgin olive oil regularly may be
protective against breast cancer
▪ Mammography
▪ Can be used for screening or for diagnostic purposes
▪ A screening tool used to identify and characterize a breast mass and to detect an early malignancy. It
remains the gold standard screening method for women at average risk for breast cancer.
▪ A screening mammogram can detect lesions as small as 0.5 cm [the average size of a
tumor detected by a woman practicing occasional breast self examination (BSE) is
approximately 2.5 cm]
▪ PREPARING FOR A SCREENING MAMMOGRAM
▪ Schedule the procedure just after menses, when breasts are less tender.
▪ Do not use deodorant or powder on the day of the procedure, because they can appear
on the x-ray film as calcium spots.
▪ Acetaminophen (Tylenol) or acetylsalicylic acid (aspirin) can relieve any discomfort after
the procedure.
▪ Remove all jewelry from around your neck, because the metal can cause distortions on
the film image.
▪ Select a facility that is accredited by the American College of Radiology to ensure
appropriate credentialed staff.
▪ Breast Cancer Prevention Strategies in the Patient who is at High Risk
▪ Consultation with a breast specialist is of paramount importance prior to embarking on
any of the prevention strategies
▪ Long-Term Surveillance
▪ Focuses on early detection
▪ American Cancer Society (ACS) recommends additional screening using MRI along with a yearly
mammogram
▪ Clinical breast examination (CBE) may be performed twice a year, starting as early as 25 years old
▪ Screening tests, including ultrasonography may be helpful
▪ Chemoprevention
▪ Main modality that aims to prevent the disease
▪ Tamoxifen and raloxifene (Evista)- effective chemopreventive agents for women who are high risk
▪ Anastrozole (Arimidex) and exemestane (Aromasin) also used for chemoprevention
▪ Breast Cancer Prevention Strategies in the Patient who is at High Risk
▪ Prophylactic mastectomy (does not confer 100% protection against
the development of breast cancer)
▪ Another primary prevention modality that can reduce the risk of breast cancer by 90%
▪ Sometimes referred to as a “risk-reducing” mastectomy
▪ Consists of a total mastectomy and is usually accompanied by immediate breast
reconstruction
▪ Only done after extensive counseling related to its risks and benefits
▪ Physical and psychological- anxiety, depression, altered body image
▪ Consults- genetic counselor, plastic surgeon, medical oncologist, and psychiatrist
▪ Possible candidates
▪ Women with strong family history of breast cancer
▪ Diagnosis of lobular carcinoma in situ (LCIS) or atypical hyperplasia
▪ A mutation in a BRCA gene
▪ Previous cancer in one breast
▪ Can occur anywhere in the breast, but usually found in the upper outer quadrant
▪ Nontender lesions
▪ Fixed rather than mobile lesions
▪ Lesions are hard with irregular borders
▪ Often have no signs or symptoms
▪ Mammographic abnormality
▪ Advanced signs may include
▪ Skin dimpling
▪ Nipple retraction
▪ Skin ulceration

Complaints of diffuse breast pain and tenderness with menstruation are usually
associated with benign breast disease
▪ Various types of biopsies
▪ Tumor staging and analysis of additional prognostic factors are used
to determine the prognosis and optimal treatment regimen
▪ Staging
▪ Involves classifying the cancer by the extent of the disease in the body
▪ Based on whether the cancer is invasive or noninvasive, the size of the tumor, how many
lymph nodes are involved, and if it has spread to other parts of the body
▪ One of the most important factors in determining prognosis and treatment options
▪ Most common system used to describe the stages of breast cancer the American Joint
Committee of Cancer (AJCC) TNM (tumor, nodes, metastasis) system
▪ Other factors considered in staging include hormone receptors and genetic mutations
▪ CXR, CT scan, MRI scan, positron emission tomography (PET) scan, bone scans, and
blood work [CBC, CMP, and tumor markers (CEA, cancer antigen)]
Stage Characteristics

0 In situ (in place/on site), early type of

breast cancer
1 Localized tumor < (less than) 1 inch in
diameter

2 Tumor 1 – 2 inches in diameter; spread to

axillary lymph nodes

3 Tumor 3 inches or larger; spread to other

lymph nodes and tissues

4 Cancer has metastasized to other organs

▪ Two of the most important factors are tumor size and whether the
tumor has spread to the axillary lymph nodes
▪ The smaller the tumor appears, the better the prognosis
▪ Depends on the extent of spread of the breast cancer
▪ The 5-year survival rate is approximately 88% for a stage 1 breast
cancer and 15% for a stage IV breast cancer
▪ Most common route of regional spread is to the axillary lymph nodes
▪ Other sites of lymphatic spread include the internal mammary and
supraclavicular nodes
▪ Distant metastasis can affect any organ, but the most common sites
are the bone, lungs, liver, pleura, adrenals, skin and brain
▪ Approximately 25% of invasive breast cancers, which
typically involve the more aggressive tumors, have
amplification or over expression of the HER2/neu (also
known as ERBB2) oncogene

▪ HER2/neu: A protein involved in normal cell growth.

HER2/neu may be made in larger than normal amounts
by some types of cancer cells, including breast, ovarian,
bladder, pancreatic, and stomach cancers.
▪ Modified Radical Mastectomy
▪ performed to treat invasive breast cancer
▪ procedure involves removal of breast tissue, including the nipple–areola complex
▪ In addition, a portion of the axillary lymph nodes are also removed in axillary lymph node
dissection (ALND)
▪ If immediate breast reconstruction is desired, the patient is referred to a plastic surgeon prior
to the mastectomy to explore all available options
▪ The pectoralis major and pectoralis minor muscles are left intact, unlike in radical mastectomy,
in which the muscles are removed
▪ Total Mastectomy
▪ Involves removal of the breast and nipple–areola complex but does not include ALND
▪ May be performed in patients with noninvasive breast cancer (e.g., DCIS), which does not tend to spread to
the lymph nodes
▪ May be performed prophylactically in patients who are at high risk for breast cancer (e.g., LCIS, BRCA
mutation)
▪ May be performed in conjunction with sentinel lymph node biopsy (SLNB) for patients with invasive breast
cancer
▪ Breast Conservation Treatment
▪ The goal of breast conservation treatment (i.e., lumpectomy, wide
excision, partial or segmental mastectomy, quadrantectomy) is to
excise the tumor in the breast completely and obtain clear margins
while achieving an acceptable cosmetic result
▪ If the procedure is being performed to treat a noninvasive breast
cancer, lymph node removal is not necessary
▪ For an invasive breast cancer, lymph node removal (SLNB or ALND)
is indicated
▪ The lymph nodes are removed through a separate semicircular
incision in the axilla.
▪ (Table 58-5 compares SLNB and ALND)
▪ Sentinel Lymph Node Biopsy
▪ Less invasive alternative to Axillary Lymph Node Dissection (ALND) and is considered a
standard of care for the treatment of early-stage breast cancer
▪ Studies suggest that SLNB is highly accurate and is associated with a local recurrence rate
similar to that of ALND
▪ The sentinel lymph node, which is the first node (or nodes) in the lymphatic basin that
receives drainage from the primary tumor in the breast, is identified by injecting a
radioisotope and/or blue dye into the breast; the radioisotope or dye then travels via the
lymphatic pathways to the node
▪ In SLNB, the surgeon uses a handheld probe to locate the sentinel lymph node, excises it,
and sends it for pathologic analysis, which is often performed immediately during the
surgery using frozen-section analysis
▪ If the sentinel lymph node is positive, the surgeon can proceed with an immediate ALND,
thus sparing the patient a return trip to the operating room and additional anesthesia (The
patient could also return for additional surgery at a later time)
▪ If the sentinel lymph node is negative, a standard ALND is not needed, thus sparing the
patient the possible complications of the procedure
▪ After the procedure is complete, all specimens are sent to pathology for more thorough
analysis
▪ RELIEVING PAIN AND DISCOMFORT
▪ MANAGING POSTOPERATIVE SENSATIONS
▪ PROMOTING POSITIVE BODY IMAGE
▪ PROMOTING POSITIVE ADJUSTMENT AND COPING
▪ IMPROVING SEXUAL FUNCTION
▪ MONITORING AND MANAGING POTENTIAL COMPLICATI
ONS
▪ PROMOTING HOME, COMMUNITY-
BASED, AND TRANSITIONAL CARE
▪ The patient must be informed that although frozen-section analysis is highly
accurate, false-negative results can occur.
▪ A negative sentinel lymph node on frozen-section analysis may show metastatic
disease on subsequent analysis, indicating that ALND is still necessary.
▪ The patient should also be reassured that the radioisotope and blue dye are
generally safe.
▪ The nurse informs patients that they may notice a blue-green discoloration in the
urine or stool for the first 24 hours as the blue dye is excreted.
▪ The incidence of lymphedema, decreased arm mobility, and seroma formation
(collection of serous fluid) in the axilla is generally low, but the patient should be
prepared for these possibilities.
▪ Women who have SLNB alone have neuropathic sensations similar to those who
undergo ALND, although the prevalence and severity of these sensations and the
resulting distress are lower with SLNB
▪ Axillary Lymph Node Dissection
▪ Surgery to remove lymph nodes from the armpit (underarm or axilla)
▪ ALND is associated with potential morbidity, including lymphedema, cellulitis,
decreased arm mobility, and sensory changes
▪ Most patients are discharged 1 or 2 days after ALND or mastectomy (possibly later
if they have had immediate reconstruction) with surgical drains in place
▪ Initially, the drainage fluid appears bloody, but it gradually changes to a
serosanguineous and then a serous fluid over the next several days.
▪ The patient is given instructions about drainage management at home (see Chart
58-6). If the patient lives alone and drainage management is difficult, a referral for
a home care nurse should be made. The drains are usually removed when the
output is less than 30 mL in a 24-hour period (approximately 7 to 10 days)
▪ The home care nurse also reviews pain management and incision care
▪ Hand and Arm Care After Axillary Lymph Node Dissection
▪ The nurse instructs the patient to:
• 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 insect bites
• Wear gloves for gardening
• Use cooking mitt for removing objects from oven
• Avoid cutting cuticles; push them back during manicures
• Use electric razor for shaving armpit
• Avoid lifting objects heavier 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
▪ Lymphedema is a complication characterized by a chronic swelling
of an extremity due to interrupted lymphatic circulation.
▪ It often affects both the breast and ipsilateral limb.
▪ It is associated with a painful swelling of the arm as well as weakness,
shoulder pain, and tingling sensations in the arm and shoulder.
▪ Transient edema in the postoperative period occurs until collateral
circulation has completely taken over this function, which generally
occurs within a month.
▪ Performing prescribed exercises, elevating the arm above the heart
several times a day, and gentle muscle pumping (making a fist and
releasing) can help reduce the transient edema
▪ Once lymphedema develops, it tends to be chronic, so preventive
strategies are vital
▪ After ALND, the patient is taught hand and arm care to prevent injury or
trauma to the affected extremity, thus decreasing the likelihood for
development of lymphedema. The patient is instructed to follow these
guidelines for the rest of her life
▪ Also instructed to contact her primary provider immediately if she suspects
that she has lymphedema, because early intervention provides the best
chance for control
▪ Treatment may consist of a course of antibiotic agents if an infection is
present
▪ A referral to a rehabilitation specialist (e.g., occupational or physical
therapist) may be necessary for a compression sleeve or glove, exercises,
manual lymph drainage, and a discussion of ways to modify daily activities
to avoid worsening lymphedema.
▪ Radiation therapy—external beam, brachytherapy
▪ Chemotherapy
▪ Hormonal therapy
▪ Estrogen and progesterone receptor assay
▪ Selective estrogen receptor modulators (SERMs)—
tamoxifen
▪ Aromatase inhibitors—anastrozole, letrozole, exemestane

▪ Targeted therapy
▪ Radiation therapy is used to decrease the chance of a local
recurrence in the breast by eradicating residual
microscopic cancer cells
▪ Breast conservation treatment followed by radiation
therapy for stages I and II breast cancer results in a survival
rate equal to that of a modified radical mastectomy
▪ If radiation therapy, which is part of breast conservation
treatment, is contraindicated, a mastectomy would then be
indicated
▪ In general, radiation therapy is well tolerated
▪ Acute side effects consist of mild to moderate erythema, breast edema, and
fatigue. Occasionally, skin breakdown may occur in the inframammary fold
or near the axilla toward the end of treatment
▪ Fatigue can be depressing, as can the frequent trips to the radiation
oncology unit for treatment
▪ The patient needs to be reassured that the fatigue is normal and not a sign
of recurrence
▪ Side effects usually resolve within a few weeks to a few months after
treatment is completed
▪ Rare long-term effects of radiation therapy include pneumonitis, rib
fracture, heart disease, breast fibrosis or necrosis
▪ Chemotherapy regimens for breast cancer combine
several agents (polychemotherapy), generally
given over a period of 3 to 6 months.
▪ Decisions regarding the optimal regimen are based
on a variety of factors, including tumor
characteristics (i.e., tumor size, lymph node status,
hormone receptor status, HER-2/neu status) and the
patient’s age, physical status, and existing comorbid
conditions.
▪ Common physical side effects of chemotherapy for breast cancer
may include nausea, vomiting, bone marrow suppression, taste
changes, alopecia (hair loss), mucositis, neuropathy, skin changes,
and fatigue.
▪ Most serious side effect is bone marrow suppression
(myelosuppression).
▪ This causes an increased risk of infection, bleeding, and a reduced red
and white blood cell count. Counts that are too low would stop or delay
the use of chemotherapy.
▪ A weight gain of more than 10 pounds occurs in about half of all
patients; the cause is unknown.
▪ Women who are premenopausal may also experience temporary
or permanent amenorrhea.
 ▪ Mucositis is the painful inflammation
and ulceration of the mucous
membranes lining the digestive tract,
usually as an adverse effect of
chemotherapy and radiotherapy
treatment for cancer.

Mucositis is painful inflammation or ulceration of the mucous membranes anywhere along the gastrointestinal tract.
Stomatitis (oral mucositis) refers to inflammation and ulceration that occur in the mouth.
▪ The use of adjuvant hormonal therapy, with or without the addition of
chemotherapy, is considered in women who have hormone receptor–
positive tumors.
▪ Its use can be determined by the results of an estrogen and
progesterone receptor assay (a test to determine whether the breast
tumor is nourished by hormones)
▪ Hormonal therapy involves the use of synthetic hormones or other
medications that compete with estrogen by binding to the receptor
sites (SERMs)
▪ Hormonal therapy also involves the use of aromatase inhibitors,
which block estrogen production and the effects of estrogen on the
growth of breast cancer cells
▪ See TABLE 58-7 for Adverse Reactions Associated With Adjuvant
Hormonal Therapy Used to Treat Breast Cancer
Therapeutic Agent
Selective Estrogen Receptor Modulator
tamoxifen (Soltamox)
Aromatase Inhibitors
anastrozole (Arimidex)
letrozole (Femara)
exemestane (Aromasin)
Adverse Reactions/Side Effects
Hot flashes, vaginal
dryness/discharge/bleeding, irregular
menses, nausea, mood disturbances,
rashes; increased risk for endometrial
cancer; increased risk for thromboembolic
events (deep vein thrombosis, pulmonary
embolism, superficial phlebitis)
Musculoskeletal symptoms (arthritis,
arthralgia, myalgia), increased risk of
osteoporosis/fractures, nausea/vomiting,
hot flashes, fatigue, mood disturbances,
rashes