Breast Cancer SURGICAL MANAGEMENT 1.

Radical mastectomy
2. Modified radical mastectomy3. Lumpectomy4. Quadrantectomy

67 Breast Cancer NURSING INTERVENTION : PRE-OP

1. Explain breast cancer and treatment options2. Reduce fear and anxiety and improve coping abilities3. Promote
decision making abilities4. Provide routine pre-op care:Consent, NPO, Meds, Teaching about breathing exercise

68 Breast Cancer NURSING INTERVENTION : Post-OP 1. Position patient:

SupineAffected extremity elevated to reduce edema

69 Breast Cancer NURSING INTERVENTION : Post-OP

2. Relieve pain and discomfortModerate elevation of extremityIM/IV injection of pain medsWarm shower on 2nd day
post-op

70 Breast Cancer NURSING INTERVENTION : Post-OP

3. Maintain skin integrityImmediate post-op: snug dressing with drainageMaintain patency of drain (JP)Monitor for
hematoma w/in 12H and apply bandage and ice, refer to surgeon

71 Breast Cancer NURSING INTERVENTION : Post-OP

3. Maintain skin integrityDrainage is removed when the discharge is less than 30 ml in 24 HLotions, Creams are applied
ONLY when the incision is healed in 4-6 weeks

72 Breast Cancer NURSING INTERVENTION : Post-OP Promote activity

Support operative site when movingHand, shoulder exercise done on 2nddayPost-op mastectomy exercise 20 mins
TIDNO BP or IV procedure on operative site

73 Breast Cancer NURSING INTERVENTION : Post-OP Promote activity

Heavy lifting is avoidedElevate the arm at the level of the heartOn a pillow for 45 minutes TID to relieve transient edema

74 Breast Cancer NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS

Lymphedema10-20% of patientsElevate arms, elbow above shoulder and hand above elbowHand exercise while
elevatedRefer to surgeon and physical therapist

75 Breast Cancer NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS

HematomaNotify the surgeonApply bandage wrap (Ace wrap) and ICE pack

76 Breast Cancer NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS

InfectionMonitor temperature, redness, swelling and foul-odorIV antibioticsNo procedure on affected extremity

77 Breast Cancer NURSING INTERVENTION : Post-OP TEACH FOLLOW-UP care

Regular check-upMonthly BSE on the other breastAnnual mammography

78 Discussion of Palliative Care Oncologic Emergencies Lung Cancer

Male & Female reproductive CancersBrain Tumors

79 Critical ThinkingScenario: A 49 y/o male has a 32 year history of cigarette smoking. He often eats out with
associates and typically eats red meat and potatoes. One of his associates is a 51 y/o female whose mother dies of
breast cancer. She is 40lbs over her ideal weight because she likes to snack during the day. She is also a heavy coffee
drinker because she is from Seattle.What risk factors does each of these clients have for development of cancer?Male:
smoker, diet, may have a high stress job.Female: obesity, caffeine intake, genetic history, age.

80 Case Study 1R.T. is a 64-year-old man who comes to his primary care provider’s (PCP’s) offi ce for a yearly
examination. He initially reports having no new health problems; however, on further questioning, he admits to having
developed some fatigue, abdominal bloating, and intermittent constipation. His nurse practitioner completes the
examination, which includes a normal rectal exam with a stool positive for guaiac. Diagnostic studies include a CBC
with differential, chem 14, and carcinoembryonic antigen (CEA). R.T. has not had a recent colonoscopy and is referred
to a gastroenterologist for this procedure.A 5-cm mass found in the sigmoid colon confirms a diagnosis of a polypof the
colon. A referralis made for surgery. The pathology report describes the tumor as stae 11, which meansthat the cancer
has extended into the mucous layer of the colon. A metastatic work-up is negative.Identify 6 risk factors for colon
cancer:Discuss the recommended screening procedures related to colon cancer.What warning sign did R.T.
have?What would early signs be for colorectal cancer?What would late signs be?

hysical Assessment/ Inspection

Retraction SignsSigns include skin dimpling, creasing, or changes in the contour of the breast or nippleSecondary to
fibrosis or scar tissue formation in the breastRetraction signs mayappear only withposition changes or withbreast
palpation.
4 Physical Assessment/ Inspection
Breast Cancer Mass (Malignant Tumor)Usually occurs as a single mass (lump) in one breastFirm, hard, embedded in
surrounding tissueReferral and biopsy indicated for definitive diagnosisUsually nontenderIrregular shape

5 Physical Assessment/ Inspection

Breast Cyst (Benign Mass)Occur as single or multiple lumps in one or both breastsUsually tender (omitting caffeine
reduces tenderness); tenderness increases during premenstrual periodRound shapeSoft or firm, mobileReferral and
biopsy indicatedfor definitive diagnosis,especially for first mass.

6 Physical Assessment/ Inspection

Fibroadenoma (Benign Breast Lump)Usually occurs as a single mass in women aged 15–35 yearsUsually
nontenderMay be round or lobularFirm, mobile, and not fixed to breast tissue or chest wallNo premenstrual
changesReferral and biopsy indicatedfor definitive diagnosis

7 Physical Assessment/ Inspection

Increased Venous ProminenceAssociated with breast cancer if unilateralUnilateral localized increase in venous pattern
associated with malignant tumorsNormal with breastenlargement associated withpregnancy and lactation ifbilateral
and bilateral symmetry

8 Physical Assessment/ Inspection

Peau d'Orange (Edema)Associated with breast cancerCaused by interference with lymphatic drainageBreast skin has
orange peel appearanceSkin pores enlargeMay be noted on the areolaSkin becomes thick, hard, immobileSkin
discoloration may occur

9 Physical Assessment/ Inspection

Nipple InversionConsidered normal if long-standingAssociated with fibrosis and malignancy if recent development

10 Physical Assessment/ Inspection

Acute Mastitis (Inflammation of the Breasts)Associated with lactation but may occur at any ageNipple cracks or
abrasions notedBreast skin reddened and warm to touchTendernessSystemic signs include fever and increased pulse

11 Physical Assessment/ Inspection

Paget Disease (Malignancy of Mammary Ducts)Early signs: erythema of nipple and areolaLate signs: thickening,
scaling, and erosion of the nipple and areola

12 Diagnostic Evaluation
Breast Self-Examination (BSE)Done on day 5-7 of menstrual cycle (some changes in breast occur due to hormones
around menstruation)Breast examination with the woman in a supine position. The entire surface of the breast is
palpated from the outer edge of the breast to the nipple. Alternative palpation patterns are circular or clockwise, wedge,
and vertical strip.

14 Breast-Self Examination

15 Diagnostic Evaluation Mammography

Detect nonpalpable lesions and assist in diagnosing palpable massesRecommended to be done every year beginning
at 40 years of age (women with family history, start at younger age)Mammography may detect a breast tumor before it
is clinically palpable (ie, smaller than 1 cm);

16 Diagnostic Evaluation
Magnetic Resonance ImagingProcedures for Tissue AnalysisPercutaneous BiopsyFine-Needle AspirationSurgical
BiopsyExcisional BiopsyIncisional Biopsy

17 Comparison of Various Breast Masses

18 Benign Neoplasms: Fibrocystic Breast Disease(FBD)

Also called chronic mastitis or lumpy breast syndrome, it is the most common breast lesion in females and usually
occurs between ages 35 and 50. Many cases will subside after menopause.

19 Benign Neoplasms: Fibrocystic Breast Disease(FBD)

Incidence of developing breast cancer is increased 3 to 4 times with FBD.PathologyCause is unknown; possible
hormonal imbalanceCondition occurs during reproductive years and disappears with menopauseA benign condition
affecting 25% of women over 30 years of age

20 Benign Neoplasms: Fibrocystic Breast Disease(FBD)

Signs and symptomsSubjective: breast tenderness and painObjective: small, round, smooth nodulesDiagnostic tests
and methodsMammography, thermomastography, xerographyTreatment: conservativeAspirationBiopsy examination
to rule out malignancy

21 Benign Neoplasms: Fibrocystic Breast Disease(FBD)

Nursing interventionExplain importance of monthly breast self-examinationEncourage patient to seek medical
evaluation if nodule forms, because cystic disease may interfere with early diagnosis of breast malignancy

22 Malignant Neoplasms: Breast Cancer

Second major cause of cancer death among women. Statistics indicate that 1 in 10 will develop cancer sometime
during her life.The key to cure is early detection by physical examination, mammography, and breast
self-examination.Image 1: Inflammatory Breast CAImage 2: Advanced Breast CA

23 Risk factors for Breast Cancer

Female genderIncreasing agePersonal history of breast cancerFamily history of breast cancerGenetic mutations
(BRCA-1 and BRCA-2 mutations are responsible for majority of inherited breast cancer cases)Late
menopauseNulliparity

24 Risk factors for breast Cancer

Hormonal factorsEarly menarcheFirst child after 30 years of ageHormone therapy (HT)Exposure to ionizing radiation
during adolescence and early adulthoodHistory of benign proliferative breast diseaseObesityHigh-fat diet
(controversial)Alcohol intake

25 Protective FactorsRegular exercise (after age of 35, strenuous excursive ˅ chance for BC by
14%.BreastfeedingHaving completed a full-term pregnancy before 30 years of age

26 Types of Breast Cancer Ductal Carcinoma in Situ

Characterized by the proliferation of malignant cells inside the milk ducts without invasion into the surrounding tissue.It
is a noninvasive form of cancer (also called intraductal carcinoma).If not treated, ? become invasive cancer

27 Types of Breast Cancer Infiltrating Ductal Carcinoma

Is the most common histologic type of breast cancer.Accounts for 75% of all cases.The tumors arise from the duct
system and invade the surrounding tissues.They often form a solid irregular mass in the breast.

28 Other types of breast cancer

Infiltrating Lobular Carcinoma (5-10%)Medullary Carcinoma (5%)Mucinous Carcinoma (3%)Tubular Ductal Carcinoma
(2%)Inflammatory Carcinoma (2%)Paget Disease (1%)Infiltrating Lobular CarcinomaInfiltrating lobular carcinoma
accounts for 5% to 10% of breast cancers. The tumors arise from the lobular epithelium and typically occur as an area
of ill-defined thickening in the breast. They are often multicentric and can be bilateral.Medullary CarcinomaMedullary
carcinoma accounts for about 5% of breast cancers, and it tends to be diagnosed more often in women younger than 50
years. The tumors grow in a capsule inside a duct. They can become large and may be mistaken for a fibroadenoma.
The prognosis is often favorable.Mucinous CarcinomaMucinous carcinoma accounts for about 3% of breast cancers
and often presents in postmenopausal women 75 years and older. A mucin producer, the tumor is also slow-growing
and thus the prognosis is more favorable than in many other types.Tubular Ductal CarcinomaTubular ductal carcinoma
accounts for about 2% of breast cancers. Because axillary metastases are uncommon with this histology, prognosis is
usually excellent.Inflammatory CarcinomaInflammatory carcinoma is a rare (1% to 2%) and aggressive type of breast
cancer that has unique symptoms. The cancer is characterized by diffuse edema and brawny erythema of the skin,
often referred to as peau d'orange (resembling an orange peel). This is due to malignant cells blocking the lymph
channels in the skin. An associated mass may or may not be present; if there is, it is often a large area of
indiscretethickening. Inflammatory carcinoma can be confused with an infection because of its presentation. The
disease can spread to other parts of the body rapidly. Chemotherapy often plays an initial role in controlling disease
progression, but radiation and surgery may also be useful.Paget DiseasePaget disease of the breast accounts for 1%
of diagnosed breast cancer cases. Symptoms typically include a scaly, erythematous, pruritic lesion of the nipple.
Paget disease often represents ductal carcinoma in situ of the nipple but may have an invasive component.
Mammography should be performed followed by a biopsy of the involved skin area.

29 Breast cancer Signs and symptoms Diagnostic tests and methods

Subjective: nontender noduleObjective:Enlarged axillary nodesNipple retraction or elevationSkin dimplingNipple
dischargeusually appeal in the upper outer quadrantDiagnostic tests and methodsMammography, breast biopsy
examination

30 Breast cancer Treatment

Lumpectomy: removal of the lump and partial breast tissue; indicated for early detectionMastectomySimple
mastectomy: removal of breastModified radical mastectomy: removal of breast, pectoralis minor muscle, and some of
an adjacent lymph nodesRadical mastectomy: removal of the breast, pectoral muscles, pectoral fascia, and axillary
lymph node disection
31 Breast cancer Treatment
Oophorectomy, adrenalectomy, hypophysectomy to remove source of estrogen and the hormones that stimulate the
breast tissueRadiation therapy to destroy malignant residual malegnant cellsChemotherapeutic agents to shrink, retard,
and destroy cancer growthCorticosteroids, antigens, and anti-estrogens to alter cancer that is dependent on hormonal
environment

32 Collaborative Problems/Potential Complications

Based on the assessment data, potential complications may include the following:LymphedemaHematoma/seroma
formationInfection

33 Breast Cancer/ Preop Nsg Dx

Deficient knowledge about the planned surgical treatmentsAnxiety related to the diagnosis of cancerFear related to
specific treatments and body image changesRisk for ineffective coping (individual or family) related to the diagnosis of
breast cancer and related treatment optionsDecisional conflict related to treatment options

34 Preoperative Nursing Interventions

Providing Education and Preparation About Surgical TreatmentsReducing Fear and Anxiety and Improving Coping
AbilityPromoting Decision-Making Ability

35 Breast Cancer/ Postop Nsg Dx

Pain and discomfort related to surgical procedureDisturbed sensory perception related to nerve irritation in affected arm,
breast, or chest wallDisturbed body image related to loss or alteration of breastRisk for impaired adjustment related to
the diagnosis of cancer and surgical treatmentSelf-care deficit related to partial immobility of arm

36 Breast Cancer/ Postop Nsg Dx

Risk for sexual dysfunction related to loss of body part, change in self-image, and fear of partner's responsesDeficient
knowledge: drain management after breast surgeryDeficient knowledge: arm exercises to regain mobility of affected
extremityDeficient knowledge: hand and arm care after an axillary lymph node dissection (ALND)

37 Postoperative Nursing Interventions

Relieving Pain and DiscomfortManaging Postoperative SensationsPromoting Positive Body ImagePromoting Positive
Adjustment and CopingMonitoring and Managing Potential Complications

38 LymphedemaOccurs in about 10% to 30% of patients who undergo ALND and in about 0% to 7% of patients who
have SLNBlymphatic channels become inadequate to ensure a return flow of lymph fluid to the general circulation.Risk
factors: age, obesity, extensive axillary disease, radiation treatment, and injury or infection to the extremity

39 Lymphedema Edema resolved after development of collateral circulation.

Postoperative transient edema develops 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. The patient needs
reassurance that this transient swelling is not lymphedema

40 Hand and Arm Care After Axillary Lymph Node Dissection

Avoid BP, injections, and blood draws in affected arm.Use sunscreen 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 greater than 2-4
kg.If a trauma or break in the skin occurs, wash the area with soap and water, and apply an antibacterial
ointment.Observe the area and extremity for 24 hours; if redness, swelling, or a fever occurs, call the surgeon or nurse.

41 Post-op arm exerciseWall handclimbingRope turning

42 Post-op arm exerciseRod or broomstick liftingPulley tugging

43 Breast cancer Nursing intervention

Provide atmosphere of acceptance, frequent patient contact, and encouragement in illness adjustmentEncourage
grooming activitiesArrange attractive environmentIf the patient is receiving radiation or chemotherapy, explain and
assist with potential site effects

44 Breast cancerIf the patient has undergone surgical intervention, follow post operative nursing actionsElevate
affected arm above level of right atrium to prevent edemaDrawing blood or administering parenteral fluids or taking
blood pressure on affected arm is contraindicatedMonitor dressing for hemorrhage, observed back for pooling of
bloodEmpty Hemovac and measure drainage every 8 hoursAssess circulatory status of affected limbMeasure upper
arm and forearm, twice daily, to monitor edemaEncourage exercises of the affected arm when approved by a physician;
avoid abduction
45 Breast cancer Patient teaching on discharge Exercise to tolerance
Sleep with arm elevatedElevated arm several times dailyAvoid injections, vaccinations, IV, and taking blood pressure,
in affected arm

46 Malignant Neoplasms: Breast Cancer

Five year survival rate is 97% for localized cancer, 76% for cancer that has spread regionally, and 21% for cancers
having distant metastases.Metastatic breast cancer to the back

47 Male Breast CancerAccounts for less than 1% of all cases of breast cancerAverage age at diagnosis is 67
yearsRisk factors:A history of mumps orchitis,Radiation exposure,Decreased testosterone levelsLiver disease
(compromises estrogen metabolism).

ctivity and Rehabilitation

Patients are encouraged to resume normal mobility and function as soon as it is

suitable after surgery.

Most patients with breast-conserving surgery (BCS) and simple mastectomies will be
able to resume usual daily activities immediately after surgery, with special precautions
for those with breast reconstruction surgery, where management will differ according
to their surgeries.

Arm Exercise Programme

Our Arm Exercise Programme conducted by our Occupational Therapists or

Physiotherapists on the day after surgery aims to prevent shoulder and arm stiffness.
This will enable you to use the arm as you had before surgery in activities at home,
work and in recreation.

The exercises also promote circulation of the lymphatic system, thus preventing
swelling of the affected arm. Over-strenuous activities are to be avoided in the first few
weeks after discharge.

These exercises are to be done once daily, and each set of exercises is to be repeated 5
times. Instructions from the Occupational Therapist or Breast Care Nurse on the
limitations will be advised as needed.
 Arm and Hand Care

Following axillary surgery, lymphoedema and increased risk of infection of the arm
may occur as lymph nodes also contain cells which fight infection.

Therefore, extra care to protect the hand and arm on the operated side from injury is
recommended.

Patients will be referred to a physiotherapist or occupational therapist

specially-trained in treating lymphoedema. They will recommend programmes which
include skin care, exercise, manual lymphatic drainage (a special massage technique),
and compression garments to help reduce the swelling.

Arm care measures include:

 Skin care is important to prevent injury and infection. Use moisturisers to

prevent the skin from drying and chapping, protective clothing against skin injury and
insect bites, and gloves against cuts while working.
 Exercise care when carrying out home activities such as sewing, cooking, and
personal care activities including nail care and shaving, and exercise sunburn
prevention.
 Avoid blood-taking and injections on the affected side.
 Avoid activities that cause pooling of blood in the affected arm. These include
the application of heat to the affected arm and prolonged exposure of the arm to hot
temperatures like hot water when bathing or washing dishes or in hot tubs, spas or
saunas.
 Avoid tight-fitting jewellery, watches and clothing, as well as the measuring of
blood pressure on the affected arm as they may obstruct the flow of lymph. It is
recommended that you reduce the load of your bag and carry it on the unaffected
shoulder.
 Care of cuts and burns is important to prevent infections. These need to be
washed thoroughly with soap and water. Apply antibacterial cream on them and cover
with a clean dressing (to be changed once or twice a day). Inspection of the skin for
signs of increased warmth, redness and sudden increase in swelling, pain and fever is
important. If the wound does not improve within 3 days, it is important to see a
doctor or consult the BCN for treatment.
 Exercise and activities to maximise lymph flow is also as important. Exercise,
even after surgery and radiation, until the return of normal shoulder and arm
movements.

Slowly build up the duration and intensity of exercise or strenuous activity and
monitor the arm and hand during and after activity for signs of lymphoedema.

Maintenance of an optimal weight through exercise and change in dietary habits as

necessary is important. Arm exercise and the use of compression bandage or garments
for the arm for long flights or where there are increased periods of inactivity is also
recommended.

Self-arm massage may be recommended to encourage lymph drainage and minimise

risk of arm lymphoedema. The following is a simple technique. The massage should be
light and gentle without causing redness during and after the massage.
 Physical Appearance

With a mastectomy, physical appear-ance can be maintained by wearing a prosthesis

(called a breast form), or by undergoing breast reconstruction.

There are women who choose not to have breast reconstruction after mastectomy.
Some make this decision because they want to avoid extra surgery. For others, it is
because they are comfortable with their appearance and body image.

Breast forms or prostheses are used to maintain appearance and a sense of balance, as
well as to relieve the strain on posture that may occur after a mastectomy. They are
available in a variety of sizes, shapes and colours. Some are designed to fit into a special
bra. Others can be attached securely to your chest using a special adhesive.

 Our BCN will give you an appointment for prosthesis-fitting about 6 weeks
after the surgery. In the meantime, you may use soft padding underneath your bra
while your wound heals.
 When choosing a breast form, it is important that it has the same size and
weight as your other breast. This will help maintain your posture and prevent back
strain.