Breast Cancer

Diana Pasqua,BSN,RN,OCN

There are many types of breast

cancer
DCIS
Invasive Ductal Carcinoma
Invasive Lobular Carcinoma
Types
of breast
cancers
Inflammatory
Breast
cancer

This is the most common breast cancer.

It starts in the cells lining a duct, and then

the abnormal cells break through the wall

of the duct and grow into (invade) the
Invasive
(or breast.
infiltrating)
ductal
tissue of the
From there,
the cancer
carcinoma
(IDC)to nearby lymph nodes or
cells can spread
other parts of the body.

Invasive (infiltrating) lobular

carcinoma (ILC)
Less common
This cancer starts in the cells lining the milk

glands (the lobules).

The cells grow through the wall of the
lobules and then can spread to nearby
lymph nodes or other parts of the body.

Inflammatory breast cancer

This is a rare type of invasive breast cancer.

(IBC)

Often, there is no single lump or tumor.

IBC makes the skin of the breast look red and feel
warm. It also may make the skin look thick and
pitted, something like an orange peel. The breast
may get bigger, hard, tender, or itchy.
In its early stages, inflammatory breast cancer is
often mistaken for infection. Because there is no
defined lump, it may not show up on a
mammogram, but other tests may be helpful.
It has a higher chance of spreading and a worse
outlook than other types of breast cancer.

Breast Cancer Statistics

It is the most common malignancy in women
The second leading cause of cancer death after

lung cancer
The lifetime risk of a woman developing
invasive breast cancer is 1 in 8
The American Cancer Society's estimates for
breast cancer in the United States are for 2013:
About 232,340 new cases of invasive breast

cancer will be diagnosed in women.

About 64,640 new cases of carcinoma in situ (CIS)
will be diagnosed (CIS is non-invasive and is the
earliest form of breast cancer).
American Cancer Society

Breast Cancer Risk Factors

Being a female
Increasing age
Genetic risk factors
Benign breast conditions,

especially hyperplasia with atypia

Number of menstrual periods (early
menarche or late menopause)

Risk Factors continued

Not having children or having them

later in life
radiation
Recent use of birth control pills
Using hormone therapy after
menopause
Alcohol use
Being overweight or obese

Prevention/Detection
Mammography:
Women should receive annual mammography starting

at age 40
Clinical Breast Exam:
A health care provider should perform clinical

examination every 1-3 years in women aged 20-39

Annually in women aged 40 and older
Breast Self Exam:
At age 20, women should begin monthly self

examination 7-10 days after menses, as taught by a

Healthcare professional

Diagnosis
Clinical Breast Exam
Diagnostic Mammograms are used to
diagnose breast disease in women who have
breast symptoms (like a lump or nipple
discharge) or an abnormal result on a
screening mammogram.
o includes more images of the area of concern.
o In some cases, special images known as
cone or spot views with magnification are
used to make a small area of abnormal
breast tissue easier to evaluate.
American Cancer Society

Diagnostic Tests
MRI :can be used along with mammograms for
screening women who have a high risk of developing
breast cancer, or it can be used to better examine
suspicious areas found by a mammogram.
o also sometimes used for women who have been
diagnosed with breast cancer to better determine the
actual size of the cancer and to look for any other
cancers in the breast

Ultrasound: is used to target a specific area of

concern found on the mammogram.
helps distinguish between cysts (fluid-filled sacs) and
solid masses and sometimes can help tell the
difference between benign and cancerous tumors.

Biopsy
Any distinct mass should be considered for a

biopsy, even if the mammograms are

negative
Standard methods

o Fine needle aspiration:

o fine, thin needle attached to a syringe used to collect
tissue from a lump

o Core needle biopsy:

o similar to FNA but allows for a larger needle to obtain a
larger tissue sample

o Excisional biopsy: The tumor or mass is

removed surgically. The tumor or mass is cut into thin
sections and studied to see if cancer cells are present

Workup and Staging of Breast

Cancer
Pathologic evaluation should include:
standard tumor, node, metastasis staging (TNM)
staging according to the latest American Joint
Committee on Cancer (AJCC)
estrogen receptor
progesterone receptor
Her 2 measurements
Tumor grade
Margin status

TNM Classification
T = Tumor

local involvement, invasion

N = Nodes
Lymph node involvement
M = Metastasis
Distant locations
T followed by a number from 0 to 4 describes the tumor's size

and spread to the skin or to the chest wall under the breast.
Higher T numbers mean a larger tumor and/or wider spread to
tissues near the breast.
The letter N followed by a number from 0 to 3 indicates
whether the cancer has spread to lymph nodes near the breast
and, if so, how many lymph nodes are affected.
The letter M followed by a 0 or 1 indicates whether the
cancer has spread to distant organs -- for example, the lungs or
bones.
American Cancer Society

Staging of Breast Cancer

Stage is expressed in Roman numerals

from stage I (the least advanced stage) to

stage IV (the most advanced stage).
Non-invasive cancer is listed as stage 0.

Determines treatment
Offers prognostic information
Evaluates the treatments

Genetic Testing: What is

BRCA1 and BRCA2

BRCA1andBRCA2are humangenesthat

producetumor suppressorproteins.
These proteins help repair damagedDNAand,
therefore, play a role in ensuring the stability of
thecells genetic material.
When either of these genes is mutated, or
altered, such that its protein product is not made
or does not function correctly, DNA damage may
not be repaired properly.
As a result, cells are more likely to develop
additional genetic alterations that can lead to
cancer.

Genetic testing continued

Breast cancer:
About 12 percent of women in the general population

will develop breast cancer sometime during their lives .

A womanslifetime riskof developing breast and/or

ovarian cancer is greatly increased if she inherits a

harmful mutation inBRCA1orBRCA2.
According to the most recent estimates, 55 to 65

percent of women who inherit a

harmfulBRCA1mutation and around
45 percent of women who inherit a
harmfulBRCA2mutation will develop breast cancer by
age 70 years

Genetic Testing continued

Ovarian cancer:
About 1.4 percent of women in the general

population will develop ovarian cancer

sometime during their lives.
According to the most recent estimates, 39

percent of women who inherit a

harmfulBRCA1mutation and 11 to 17
percent of women who inherit a
harmfulBRCA2mutation will develop
ovarian cancer by age 70 years.

Who should consider genetic testing

forBRCA1andBRCA2mutations?
These tools assess family history factors that are

associated with an increased likelihood of having a

harmful mutation inBRCA1orBRCA2, including:
Breast cancer diagnosed before age 50 years
Cancer in both breasts
Both breast and ovarian cancers
Multiple breast cancers
Two or more primary types ofBRCA1-orBRCA2related cancers in a single family member
Cases ofmale breast cancer
Ashkenazi Jewishethnicity
www.cancer.gov

Treatment
Breast Cancer is treated with a

multidisciplinary approach
involving surgical oncology,
radiation oncology, and medical
oncology, which has been
associated with a reduction in
breast cancer mortality

Treatment methods
Surgery
Radiation
Chemotherapy
Hormone Therapy
Biological Therapy

Surgery
It is the most common treatment for breast

cancer
There are several types of surgery:
Breast Conserving Surgery
Lumpectomy
Partial Mastectomy
These surgeries are usually followed by radiation
to kill any cancer cells that may remain in the
breast area
Removal of the whole breast
Total mastectomy
Modified Radical Mastectomy

Side effects of surgery

Pain
Risk of Infection
Bleeding
Nerves may be injured causing numbness

and tingling
Lymphedema

Sentinel Node Biopsy

Removal and examination of the sentinel

node

the first lymph node to which the cancer has

spread

Sentinel lymph node involves removing an

average of 2-3 lymph nodes

Axillary Lymph node dissection involves

removing most of the lymph nodes from

the underarm closest to the breast tumor
( about 10-30 nodes)

Sentinel Node Biopsy

The argument in support of sentinel node biopsy

compared to axillary node dissection is that if no

cancer has spread to the sentinel lymph nodes,
removal of the remaining lymph nodes is not
warranted.
Removing the remaining lymph nodes would only

increase postsurgical complications without providing further

benefits.

Accuracy of sentinel node biopsy are comparable or

better to those of axillary lymph node dissection

Not all women are candidates for a sentinel node

biopsy

Reduced Risk of
Lymphedema

Women who have had a sentinel node

biopsy are at less risk of lymphedema

(about 10-12%)
whereas the traditional procedure of axillary

lymph node dissection is about 10-20% that

will develop lymphedema

Radiation
Radiation is the use of high energy rays to

kill cancer cells

Most women receive adjuvant radiation

therapy after breast sparing surgery

The purpose of RT is to destroy any cancer

cells that may remain in the area

Chemotherapy
Is a systemic therapy, as anticancer drugs

are distributed throughout the body or

bloodstream
Anticancer drugs destroy cancer cells by
stopping them from growing or multiplying
Chemotherapy for breast cancer patients is
usually a combination of drugs

Cancer Treatment Goals

Adjuvant Therapy

Neoadjuvant Therapy

Surgery is primary

Chemotherapy/bioth

treatment.
Chemotherapy/bioth
erapy is given after
surgery as an
adjunct (adjuvant).

erapy is given prior

to surgery to shrink
tumor bulk and load.
Can limit the surgical
procedure that
follows therapy

Goals of Chemotherapy
Cure
Keep the cancer from spreading
Slow the cancers growth
Relieve symptoms caused by cancer

Administration of
Chemotherapy

Most drugs are administered intravenously

Multi-drug chemotherapy is common
Many patients will choose to have a long-

term venous access device placed.

Subcutaneous Implanted ports are used
frequently
The factors they consider before deciding :
o The frequency and duration of therapy
o The frequency of blood draws
o The nature of therapy ( vesicants )
o The need for supportive therapies

NCCN Preferred Regimens for

Invasive Breast Cancer
Dose-dense AC followed by Paclitaxel
Doxorubicin 60mg/m2 IV day 1
Cyclophosphamide 600mg/m2 IV day 1
Cycled every 14 days for 4 cycles
Paclitaxel 175mg/m2 by 3hour infusion day 1
Cycled every 14 days for 4 cycles
Dose-dense AC followed by weekly Paclitaxel chemotherapy
Doxorubicin 60mg/m2 IV day 1
Cyclophosphamide 600mg/m2 IV day 1
Cycled every 14 days for 4 cycles followed by
Weekly Paclitaxel 80mg/m2 by 1hour infusion weekly for 12 weeks

TC chemotherapy
Taxotere 75mg/m2 IV day 1
Cyclophosphamide 600mg/m2 IV day 1
Cycled every 21 days for 4 cycles

ALL REGIMENS ARE WITH FILGRASTIM(NEULASTA)

SUPPORT
NCCN Guidelines Version 3.2013

Side effects of Chemotherapy

Chemotherapy drugs are made to kill fast

growing cells, but because these drugs

travel throughout the entire body they can
affect normal healthy cells
Damage to healthy cells is what causes

side effects

Most common side effects in Breast

Cancer Patients
Fatigue and Lethargy
Alopecia
Nausea and Vomiting
Induction of Menopause
Myelosuppression
Oral Mucositis
Weight Gain

Myelosuppression
Suppression of bone marrow activity
Can result in decrease in any combination

of WBC, RBC and /or platelets

It is the most common dose limiting
toxicity
(dose limiting toxicity means that the
chemotherapy may have to be dose
delayed or doses reduced if the blood
counts have not recovered)
Potentially Lethal:
Infection

is the most common cause of death in

patients with cancer
( ONS )

Oncology Nursing Society (ONS)

Alopecia
Alopecia is one of the most visible signs

that a person has cancer

Hair loss can occur on all parts of the body,
not just the head
It begins about 2 weeks after start of
therapy
Regrowth usually begins in 3-5 weeks after
end of therapy
May take 3-5 months for regrowth

Fatigue
Persistent, subjective sense of tiredness,

related to cancer or cancer treatment that

interferes with usual functioning.
It is the most common and most distressing

symptom associated with cancer and

cancer therapy. ( ONS )

Oncology Nursing Society

Oral Mucositis
Inflammation of the mucosa, including the

oral cavity
Painful sores
Increases risk for infection

Induction of Menopause
Menstrual periods may become irregular or

stop completely during chemotherapy

A womans age and the drugs and dosages
will determine whether she experiences
menopause

o The closer a woman is to age 40 or greater the

more likely she will have permanent cessation
of menses after chemotherapy ( ONS )
o Women under age 35 can tolerate higher doses
of chemo without becoming infertile ( ONS )

Oncology Nursing Society (ONS)

Weight Gain
Weight gain is often reported by women

treated with tamoxifen or chemotherapy

The average weight gain is about 7 pounds,
although greater gains are not unusual
(ACS)
Good nutrition is important

American Cancer Society

Biological Therapy
The use of agents derived

from biological sources or

agents that affect biological
responses

Cytokines
Hematopoietic Growth Factors
Action: Stimulate the differentiation, proliferation,

maturation, and functioning of hematopoietic

cells.
Side effects: bone pain, injection site pain, N/V,
other
Examples:
G-CSF filgastrim

(Neupogen) is dosed daily and should not be

given within 24 hours pre or post chemotherapy
pegfilgastrim ( Neulasta) is dosed as a single 6 mg dose
given once per chemotherapy cycle 24 hours after
chmeotherapy is complete

Monoclonal Antibodies
Trastuzamab (Herceptin)
Humanized monoclonal antibody that binds to

the extracellular domain of the human

epidermal growth factor receptor 2 protein
(HER2).
HER2 protein overexpression is seen in 2530% primary breast cancers.
Administration:
Loading

dose of 4mg/kg administered as a 90 minute infusion

and then a weekly maintenance dose of 2mg/kg
Titrate slowly to reduce the risk infusion-related hypersensitivity
Cardiotoxic: Left ventricular function should be evaluated prior
to treatment

Side effects of Herceptin

Rarely, may cause hypersensitivity/allergic

reactions, so emergency equipment should

be available during infusions
May result in left ventricular dysfunction

and congestive heart failure

Nursing Implications
Monitor for signs and symptoms of an

allergic reactions
Assess baseline cardiac function
Obtain medical history and identify patients

at risk who have CHF, Hypertension and

find out what chemotherapy they may have
received

Anti-Estrogen Hormonal
therapy

Anti-Estrogen Hormone therapy is only

effective in women who have breast cancer

tumors that are dependent on estrogen for
cell growth ,also known as hormone
positive breast cancer
ER+/PR + status
Every breast cancer should be tested for

these receptors

Anti-estrogen drugs
Tamoxifen-blocks estrogen receptors on

breast cancer cells, preventing estrogen

from binding to them , the cancer cells then
die
Taking Tamoxifen for 5years after surgery for

breast cancer reduces the chances for

recurrence and prolongs survival
The results from the ATLAS trial has shown
additional benefits for taking Tamoxifen for
10 years

Side effects of Tamoxifen

Risk of blood clots
Stroke
Cataracts
Endometrial and Uterine Cancers
Bone loss in premenopausal women
Mood swings, depression and loss of libido

Aromatase Inhibitors
Three drugs that stop estrogen

production in post-menopausal women

and have been approved to treat both
early and advanced cancer are:
Letrozole(Femara)
Anastrozole(Arimidex)
Exemestane(Aromasin)
They work by blocking an enzyme (aromatase) in

fat tissue that is responsible for making small

amounts of estrogen in post menopausal women

Side effects of Aromatase

Inhibitors
Risk of Heart attack
Bone Loss
Joint Pain
Mood Swings and Depression

Recommended Medical Care after

the treatment for Breast Cancer
All breast cancer survivors need to

continue to see their health care providers

regularly
Need to have regular physical exams,
mammograms, pelvic exams, and bone
health assessments
For men, follow up primarily includes
regular physical exams, with additional
tests as needed

References
Mahon, S.M. (Ed.). (2011). Site-specific cancer series: Breast
cancer (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.
National Comprehensive Cancer Network. (2011a). NCCN Clinical
Practice Guidelines in Oncology: Breast cancer screening and
diagnosis [v.1.2011]. Retrieved from
http://www.nccn.org/professionals/physician_gls/pdf/
breast-screening.pdf
National Comprehensive Cancer Network. (2011b). NCCN
Guidelines for Patients: Breast cancer [v.2.2011]. Retrieved
from http://www.nccn.org/
patients/patient_guidelines/breast/index.html
National Cancer Institute (2014)
http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA
Payne, J.K. (2014) State of the Science: Stress, inflammation and
Cancer. Oncology Nursing Forum, 41, 533-540