Breast cancer
• Breast cancer is a disease in which abnormal breast cells grow out of
control and form tumours. If left unchecked, the tumours can spread
throughout the body and become fatal.
• Breast cancer cells begin inside the milk ducts and/or the milk-
producing lobules of the breast. The earliest form (in situ) is not life-
threatening and can be detected in early stages. Cancer cells can
spread into nearby breast tissue (invasion). This creates tumours that
cause lumps or thickening.
• Invasive cancers can spread to nearby lymph nodes or other organs
(metastasize). Metastasis can be life-threatening and fatal.
• In 2022, there were 2.3 million women diagnosed with breast cancer and
670 000 deaths globally. Breast cancer occurs in every country of the world
in women at any age after puberty but with increasing rates in later life.
Global estimates reveal striking inequities in the breast cancer burden
according to human development. For instance, in countries with a very
high Human Development Index (HDI), 1 in 12 women will be diagnosed
with breast cancer in their lifetime and 1 in 71 women die of it.
• In contrast, in countries with a low HDI; while only 1 in 27 women is
diagnosed with breast cancer in their lifetime, 1 in 48 women will die from
it.
• Breast cancer types
• Healthcare providers determine cancer types and subtypes so they can
tailor treatment to be as effective as possible with the fewest possible side
effects. Common types of breast cancer include:
• Invasive (infiltrating) ductal carcinoma (IDC): This cancer starts in your milk ducts
and spreads to nearby breast tissue. It’s the most common type of breast cancer in
the United States.
• Lobular breast cancer: This breast cancer starts in the milk-producing glands
(lobules) in your breast and often spreads to nearby breast tissue. It’s the second
most common breast cancer in the United States.
• Ductal carcinoma in situ (DCIS): Like IDC, this breast cancer starts in your
milk ducts. The difference is DCIS doesn’t spread beyond your milk ducts.
• Less common breast cancer types include:
• Triple-negative breast cancer (TNBC): This invasive cancer is aggressive
and spreads more quickly than other breast cancers.
• Inflammatory breast cancer (IBC): This rare, fast-growing cancer looks
like a rash on your breast. IBC is rare in the United States.
• Paget’s disease of the breast: This rare cancer affects the skin of your
nipple and may look like a rash. Less than 4% of all breast cancers are
Paget’s disease of the breast.
Causes/Risk factor
• Age: Being 55 or older.
• Sex: Women are much more likely to develop the condition than men.
• Family history: If your parents, siblings, children or other close
relatives have breast cancer, you’re at risk of developing the disease.
• Genetics: Up to 15% of people with breast cancer develop the disease
because they have inherited genetic mutations. The most common
genetic mutations involve the BRCA1 and BRCA2 genes.
• Smoking: Tobacco use has been linked to many different types of
cancer, including breast cancer.
• Drinking beverages containing alcohol: Research shows that drinking
beverages containing alcohol may increase breast cancer risk.
• Having obesity.
• Radiation exposure: If you’ve had prior radiation therapy — especially
to your head, neck or chest — you’re more likely to develop breast
cancer.
• Hormone replacement therapy: People who use
hormone replacement therapy (HRT) have a higher risk of being
diagnosed with the condition.
Clinical Features
• A change in the size, shape or contour of your breast.
• A mass or lump, which may feel as small as a pea.
• A lump or thickening in or near your breast or in your underarm that
persists through your menstrual cycle.
• A change in the look or feel of your skin on your breast or nipple. Your
skin may look dimpled, puckered, scaly or inflamed. It may look red,
purple or darker than other parts of your breast.
• A marble-like hardened area under your skin.
• A blood-stained or clear fluid discharge from your nipple.
Diagnostic Evaluation
• Mammography (most accurate method of detecting non-palpable lesions) shows
lesions and cancerous changes, such as microcalcification. Ultrasonography may
be used to distinguish cysts from solid masses.
• Biopsy or aspiration confirms diagnosis and determines the type of breast cancer.
• Estrogen or progesterone receptor assays, proliferation or S phase study (tumor
aggressive), and other test of tumor cells determine appropriate treatment and
prognosis.
• Blood testing detects metastasis; this includes liver function tests to detect liver
metastasis and calcium and alkaline phosphatase levels to detect bony metastasis.
• Chest x-rays, bone scans, or possible brain and chest CT scans detect metastasis.
Staging
• Stage 0: The disease is noninvasive, meaning it hasn’t spread from your breast
ducts to other parts of your breast.
• Stage I: There are cancerous cells in nearby breast tissue.
• Stage II: The cancerous cells have formed a tumor or tumors. The tumor is either
smaller than 2 centimeters across and has spread to underarm lymph nodes or
larger than 5 centimeters across but hasn’t spread to underarm lymph nodes.
Tumors at this stage can measure anywhere between 2 and 5 centimeters across,
and may or may not affect the nearby lymph nodes.
• Stage III: There’s breast cancer in nearby tissue and lymph nodes. Stage III is
usually referred to as locally advanced breast cancer.
• Stage IV: Cancer has spread from your breast to areas like your bones, liver, lungs
or brain.
Management
• Mastectomy.
• Lumpectomy.
• Breast reconstruction.
• Providers may combine surgery with one or more of the following treatments:
• Chemotherapy.
• Radiation therapy, including intraoperative radiation therapy (IORT).
• Immunotherapy.
• Hormone therapy, including selective estrogen receptor modulator (SERM)
therapy.
• Targeted therapy.
• Pharmacological Intervention
• Chemotherapy is the primary used as adjuvant treatment postoperatively ;
usually begins 4 weeks after surgery (very stressful for a patient who just
finished major surgery).
• Treatments are given every 3 to 4 weeks for 6 to 9 months. Because the drugs differ in
their mechanisms of action, various combinations are used to treat cancer.
• Principal breast cancer drugs include cyclosphosphamide, methotrexate, fluorouracil,
doxorubicin, and paclitaxel.
• Additional agents for advanced breast cancer include docetaxel, vinorelbine,
mitoxantrone, and fluorouracil.
• Herceptin is a monoclonal antibody directed against Her-2/neu oncogene; may be
effective for patients who express this gene
• Indications for chemotherapy include large tumors, positive lymph
nodes, premenopausal women, and poor prognostic factors.
• Chemotheraphy is also used as primary treatment in inflammatory
breast cancer and as palliative treatment in metastatic disease or
recurrence.
• Anti-estrogens, such as tamoxifen, are used as adjuvant systemic
therapy after surgery.
• Hormonal agents may be used in advanced disease to induce
remissions that last for months to several years.
Nursing management
• Assessment
• A firm lump or thickness in breast, usually painless; 50% are located in
the upper outer quadrant of the breast.
• Spontaneous nipple discharge; may be bloody, clear or serous.
• Asymmetry of the breast may be noted as the woman changes
positions; compare one breast with the other.
• Nipple retraction or scalliness, especially in Paget’s disease.
• Enlargement of auxiliary or supraclavicular lymph nodes may indicate
metastasis.
• Nursing Interventions
• Monitor for adverse effects of radiation therapy such as fatigue, sore throat,
dry cough, nausea, anorexia.
• Monitor for adverse effects of chemotherapy; bone marrow suppression,
nausea and vomiting, alopecia, weight gain or loss, fatigue, stomatitis,
anxiety, and depression.
• Realize that a diagnosis of breast cancer is a devastating emotional shock to
the woman. Provide psychological support to the patient throughout the
diagnostic and treatment process.
• Involve the patient in planning and treatment.
• Describe surgical procedures to alleviate fear.
• Prepare the patient for the effects of chemotherapy, and plan ahead for
alopecia, fatigue.
• Administer antiemetics prophylactically, as directed, for patients receiving
chemotherapy.
• Administer I.V. fluids and hyperalimentation as indicated.
• Help patient identify and use support persons or family or community.
• Suggest to the patient the psychological interventions may be necessary for
anxiety, depression, or sexual problems.
• Teach all women the recommended cancer-screening procedures.
• Documentation Guidelines
• Response to surgical interventions: Condition of dressing and wound,
stability of vital signs, recovery from anesthesia
• Presence of complications:Pain,edema,infection,seroma,limited ROM
• Knowledge of and intent to comply with adjuvant therapies
• Reaction to cancer and body changes
• Knowledge of and intent to comply with incision care, postoperative
exercises, arm precautions, follow-up care,and early detection methods
for recurrence
• Discharge and Home Healthcare Guidelines
• PATIENT TEACHING
• The patient can expect to return home with dressings and wound drains.
Instruct the patient to do the following:empty the drainage receptacle twice a
day,record the amount on a flow sheet,and take this information along when
keeping a doctor’s appointment; report symptoms of infection or excess
drainage on the dressing or the drainage device; sponge bathe until the
sutures and drains are removed; continue with daily lower arm ROM exercises
until the surgeon orders more strenuous exercises; avoid caffeinated foods
and drinks,nicotine,and secondary smoke for 3 weeks postoperatively. Review
pain medication instructions for frequency and precautions.
• Teach precautions to prevent lymphedema after node dissection (written
directions or pamphlet from American Cancer Society [ACS] is desirable
for lifetime referral):
• Request no blood pressure or blood samples from affected arm.
• Do not carry packages,handbags,or luggage with the affected arm; avoid
elastic cuffs.
• Protect the hand and arm from burns,sticks,and cuts by wearing gloves
to do gardening and housework,using a thimble to sew,applying
sunscreen and insect repellent when out-of-doors. Report
swelling,pain,or heat in the affected arm immediately. Put the arm above
the head and pump the fist frequently throughout the day.
• FOLLOW-UP
• Prepare the patient and family for a variety of encounters with healthcare
providers (radiologist, oncologist, phlebotomist). Try to provide a
continuity between the providers (yourself, clinical nurse specialist, or
nurse consultant system, if available) as a resource for the patient or
family to call with questions.
• Provide lists and information of local community resources and support
groups for emotional support:Reach to Recovery,Y-ME,Wellness
Center,Can Surmount,I Can Cope; a list of businesses that specialize in
breast prostheses; phone numbers for ACS and Cancer Information System
