Breast Cancer

Breast cancer is second only to lung cancer as a cause of cancer deaths in American women One out of every seven women will be diagnosed with breast cancer in 2007 Fortunately, radical mastectomy (surgical removal) is rarely needed today with better treatment options 2

What exactly is Breast Cancer?

What is Cancer?
Cancer involves the abnormal multiplication and spread of cells in the body. It is usually caused by mutations in somatic cell genes that regulate cell growth. Almost every tissue in the body can produce cancer; some even generate many different types of cancer. However, cancer mostly occurs in cells that divide and reproduce more than other cells.

Breast Cancer
Breast Cancer occurs when a mutation takes place in the cells that line the lobules that manufacture milk or more commonly in the ducts that carry it to the nipple. The area around the center of the breast is where most cancers occur. It is fairly rare for cancers to form in the fat or nonglandular tissues of the breast.

How does someone get Breast Cancer?

The causes of breast cancer are not completely understood and are not set in stone. But certain women are more susceptible of developing one form of cancer.
http://www.cancerbacup.org.uk/info/brest/brest-5.htm

This is a picture of breast cancer cells.

http://www.photostogo.com/store/search.asp?SearchStr=cancer

Risk Factors that cause Breast Cancer

Factors that Cannot be Prevented
Gender Aging Genetic Risk Factors (inherited) Family History Personal History Race Menstrual Cycle Estrogen

Lifestyle Risks
Oral Contraceptive Use Not Having Children Hormone Replacement Therapy Not Breast Feeding Alcohol Use Obesity High Fat Diets Physical Inactivity Smoking

Environmental Factors
Exposure to Estrogen Radiation Electromagnetic Fields Xenoestrogens Exposure to Chemicals

This is a Breast Cancer Cell

http://www.cellsalive.com/stock4.htm

Exogenous Estrogen
Hormonal replacement therapy(HRT) 30% increased risk with long term use Oral Contraceptives(OC) risk slight risk returns to normal once the use of OCs has been discontinued

Risk Factors for Breast Cancer

Radiation exposure Breast disease Atpyical Hyperplasia Intraductal carcinoma in situ Intralobular carcinoma in situ Obesity Diet Fat Alcohol

Genetics
BRCA-1 BRCA-2 P53, Rb-1 Her-2/neu, c-erB2, c-myc

BRCA 1 and BRCA 2

Both of these genes code for DNA repair. If a woman has a mutation on either one of these genes, the risk of her getting breast cancer increases from 10% to 80% in her lifetime. Mutations in BRCA1 or BRCA2 account for 4050% of all cases of inherited breast cancer. These genes are also associated with ovarian cancer in women and prostate cancer in men. These genes can be inherited either from the mother or the father.

Signs and Symptoms

Most common: lump or thickening in breast. Often painless

Discharge or bleeding Change in size or contours of breast

Redness or pitting of skin over the breast, like the skin of an orange Change in color or appearance of areola

14

Types of Breast Cancer

Ductal Carcinoma in situ (DCIS)

Ductal cancer cells

16
Illustration Mary K. Bryson

Norma l ductal cell

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 organs

17
Illustration Mary K. Bryson

Invasive Lobular Carcinoma (ILC)

18
Illustration Mary K. Bryson

Lobular cancer cells breaking through the wall

Cancer Can also Invade Lymph or Blood Vessels

Cancer cells invade lymph duct Cancer cells invade blood vessel
19
Illustration Mary K. Bryson

Staging of Breast Cancer

The American Joint Committee on Cancer (AJCC) has designated staging by TNM T= tumor size N = lymph node involvement M = metastasis

Stage 1
Tumor < 2.0 cm in greatest dimension No nodal involvement (N0) No metastases (M0)

Stage II
Tumor > 2.0 < 5 cm or Ipsilateral axillary lymph node (N1) No Metastasis (M0)

Stage III
Tumor > 5 cm (T3) or ipsilateral axillary lymph nodes fixed to each other or other structures (N2) involvement of ipsilateral internal mammary nodes (N3) Inflammatory carcinoma (T4d)

Stage IV (Metastatic breast cancer)

Any T Any N Metastasis (M1)

How do you detect Breast Cancer?

Breast Self Examination

Opportunity for woman to become familiar with her breasts Monthly exam of the breasts and underarm area May discover any changes early Begin at age 20, continue monthly

When to do BSE
Menstruating women- 5 to 7 days after the beginning of their period Menopausal women same date each month Pregnant women same date each month Takes about 20 minutes Perform BSE at least once a month Examine all breast tissue

Breast Exam
Breast exam. The doctor will check both of your breasts, feeling for any lumps or other abnormalities. Your doctor will likely check your breasts in varying positions, such as with your arms above your head and at your side.

Mammogram
A Mammogram is a X-ray of the breast that takes pictures of the fat, fibrous tissues, ducts, lobes, and blood vessels. When should a mammogram be performed?
If a lump has been found during self-examination or by a physician Younger women who have a strong history of breast cancer in their family All women over forty Women who have had previous diagnosis of breast cancer.

http://www.photostogo.com/store/search.asp?Se archStr=cancer

Breast Ultrasoud
Breast ultrasound. Ultrasound uses sound waves to produce images of structures deep within the body. Your doctor may recommend an ultrasound to help determine whether a breast abnormality is likely to be a fluidfilled cyst or a solid mass, which may be either benign or cancerous. Breast ultrasound is helpful to guide radiologic biopsy to get a sample of breast tissue if a solid mass is found.

Breast Biopsy
Breast biopsy is necessary to confirm or rule out cancer. Needle biopsy or fine-needle biopsy can provide a core of tissue or a fluid aspirate, but needle biopsy should be restricted to fluid-filled cysts and advanced malignant lesions.
Open biopsy provides a complete tissue specimen, which can be sectioned to allow more accurate evaluation.

Nursing Interventions:
If the patient has received a general or local anesthetic, monitor the patients vital signs regularly. If she has received a general anesthetic, check her vital signs every 15 minutes for 1 hour, every 30 minutes for 2 hours, every hour for the next 4 hours, and then every 4 hours. Administer analgesics for pain, as ordered, and provide ice bags for comfort. Instruct the patient to wear a support bra at all times until healing is complete. Observe for and report bleeding, tenderness, and redness at the biopsy site. Provide emotional support to the patient awaiting diagnosis. Abnormal Results: Benign tumors may suggest fibrocystic disease, adenofibroma, intraductal papilloma, mammary fat necrosis, or plasma cell mastitis. Malignant tumors may suggest adenocarcinoma, cystosarcoma, intraductal and infiltrating carcinoma, inflammatory carcinoma, medullary or circumscribed carcinoma, colloid carcinoma, lobular carcinoma, sarcoma, or Pagets disease.

Breast magnetic resonance imaging (MRI).

Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio waves to create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye. This test may be ordered after a breast biopsy confirms cancer, but before surgery to give your doctor an idea of the extent of the cancer and to see if there's any evidence of cancer in the other breast.

Different Views
Side-to-Side MRI - Cancer can have a unique appearance many small irregular white areas that turned out to be Top-to-Bottom cancer (used for diagnosis)

34

Treatments of Breast Cancer

There is no cure for breast cancer.

Treatment of Breast Cancer

Chemotherapy Radiation Therapy Drugs Surgery

Chemotherapy
Chemotherapy works by destroying cells that are dividing and multiplying all the time. Chemotherapy is used for treatment of breast cancer because there is a possibility of the cancer to spread to other parts of the body. Chemotherapy works better for premenopausal women. Systemic chemotherapy can prevent the spread of cancer. Chemotherapy drugs are administered intravenously.

Radiation
Radiation, at high energy levels, has the ability to destroy what is in its path, including normal and abnormal cells
Fortunately new technologies have found a way to battle cancer with radiation.

Radiation usually destroys rapidly dividing cancerous cells.

Normal cells have the ability to repair themselves.

Drugs
Usually drugs used to battle cancer are taken while receiving some other type of treatment. Most of the time as well, three or four drugs are used at the same time, so there is an overlapping effectiveness. There are four drugs that are commonly used to battle breast cancer.

Types of Drugs used to Treat Breast Cancer

Alkylating Agents
Cytoxan These types of drugs usually damage the programs that control the growth in tumor cells.

Natural Products
Vincristine (Oncovin and vinblastine (Velban) come from the periwinkle plant. These drugs interfere with cell structure as well as cell division.

Antimetabolites
Methotrexate & 5fluorouracil This type of drug interferes with the making of nucleotides, which are the substances that make up DNA.

Hormones
Prednisone Hormones affect the growth of hormones and usually enhances the effects of other cytotoxic drugs.

Surgical Management:
Lumpectomy: Surgery to remove a tumor (lump) and a small amount of normal tissue around it. Partial mastectomy: Surgery to remove the part of the breast that has cancer and some normal tissue around it. This procedure is also called a segmental mastectomy.

Surgical Management:

Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or after. This is done through a separate incision.

Surgical Management:
Modified radical mastectomy: Surgery to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles. Radical mastectomy: Surgery to remove the breast that has cancer, chest wall muscles under the breast, and all of the lymph nodes under the arm. This procedure is sometimes called a Halsted radical mastectomy.

Psychological Impacts of Breast Cancer

What do Patients Go Through After Diagnosis?

Depression Anxiety Hostility Fear Changes in life patterns due to discomfort and pain Marital/sexual disruptions

Reduction of activities Panic Guilt Difficulty adapting to illness Overwhelmed Disappointment

Preoperative Nursing Diagnoses:

Knowledge deficit about breast cancer and treatment option. Anxiety related to breast cancer diagnosis. Fear related to specific treatments, body image changes or possible death. Risk for ineffective coping (individual or family coping)related to the diagnosis of breast cancer and related treatment options. Decisional conflict related to treatment options.

Nursing interventions:
1. Explain breast cancer and treatment options
 The patient confronting the diagnosis of breast cancer reacts with feelings of fear, dread, and anxiety. The patient must be given time to absorb significance of diagnosis and in any formation that will help her to evaluate available treatment options. The nurse caring for the patient with breast cancer should be knowledgeable enough to inform her patient about the things she should learn . Methods to compensate for physical changes related to mastectomy are also discussed.  

2.

Reducing fear and anxiety and improving coping ability

   Fears and concerns are common and are discussed with the patient The nurse provides anticipatory teaching and counseling at each stage of the process and identifies sensations that can be expected during additional diagnostic procedures. The nurse also discusses the implications of treatment course and lifestyle.

3. Promoting decision making ability

  Careful guidance and supportive counseling are the interventions the nurse can use to help such patients. Encouraging one step of the treatment process at a time can be helpful.

Postoperative Nursing Diagnoses

Pain related to surgical procedure Impaired skin integrity related to surgical incision Risk for infection related to surgical incision and presence of surgical drain. Body image disturbance related to loss or alteration of the breast related to the surgical procedure Self-care deficit related to partial immobility of upper extremity on operative side. Risk for sexual dysfunction related to loss of body part, change in self-image , and fear of partners responses.

Nursing Interventions
1. Relieving pain and discomfort
  Assess pain and discomfort Moderately elevate the involved extremity to relieve pain because it decreases tension on the surgical incision, promotes circulation, and prevents venous congestion on the affected extremity. Give intravenous or intramuscular opioid analgesics to manage pain. by the following day after surgery after the patient takes in food and fluid and anesthesia has cleared sufficiently oral analgesics can be effective in relieving pain. patient teaching before discharge is important in managing discomfort after surgery. Patients should be encourage to take analgesic like Acethaminophen before exercise or at bedtime. Take warm shower twice daily (2nd postoperative day) to alleviate discomfort that comes from referred muscle pain.

 

  

2. Maintaining skin integrity and preventing infection

   Maintain the patency of the surgical drain. The dressing and drain should be inspected for bleeding and the extent of drainage monitored regularly. initially, the fluid in the surgical drain appears bloody , but it gradually change into serosanguinos and then serous fluid during the next several days. the 2nd day the patient may shower and wash the incision and drain site with soap and water to prevent infection. Dry dressing should be applied to the incision each day for 7 days. After incision is completely healed (usually 4-6 weeks) , lotions or creams may be applied to the area to increase skin elasticity.

  

3. Reducing stress and improving coping skills

   Privacy is a consideration when assisting the woman to view her incision for the first time. Allowing her to express what she perceives, acknowledging her feelings and allowing her to express her emotions. Patients support system is important and the patients spouse or partner may need guidance, support and education as

well.  Answering questions and addressing the patients concerns about treatment options that may follow surgery.

4. Promoting participation in care.

  ambulation is encourage when client is free of post anesthesia nausea and can tolerate fluid. Exercise are initiated on the 2nd day to increase circulation and muscle strength, prevent joint stiffness, contractures, and restore full range of motion. exercise is performed 3 times daily for 20 mins. Showering before exercising loosens stiff muscle encourage self care activities such as brushing, combing etc. Heavy lifting is avoided Driving may begin after the drain is removed and patient has full ROM women are encourage to elevate the arm above the level of the heart on a pillow for 45 minutes at a time.( 3 times daily)

    

5. Managing postoperative sensation



Common sensations are tightness, pulling, burning, and tingling along the chest wall in the axilla and along the inside aspect of the upper arm are normal part of the healing process.  Performing the exercises may decrease the sensations.  Acetaminophen assist in managing this discomfort.

Prevention

Fat
Research shows that dietary fat should be 20% or less in order to gain meaningful protection against cancer. Fat cells make estrogen, which promotes breast cancer. Diets high in fat are associated with the increasing breast density in mammograms, which makes interpretation more difficult.

Fiber
Fiber provides protection against breast cancer because it has a mechanism that decreases the amount of estrogen in the body. The amount of fiber in the diet affects the activities of intestinal bacteria, which affects the amount of reabsorbed estrogens.

Antioxidant Nutrients
Antioxidants are important in fighting breast cancer because they can disarm cancer-causing substances called free radicals. Vitamin C Vitamin E Beta-carotene Vitamin A Selenium

Other Preventative Measures

Early Detection!!!! Exercise No Smoking!! Good Diet

10 Super Foods to Fight Breast Cancer

1. Crunchy Vegetables Broccoli may not win cool points with kids, but we love the supreme cancer-fighting power it wields. Grouped with cauliflower, brussel sprouts and mustard greens, all contain antioxidants and help to covert unhealthy estrogens into healthy ones. 2. Cherries Pretty and perfect for popping into your mouth as a treat, cherries contain an alcohol that fights many kinds of cancer, including breast cancer. They also have a natural anti-inflammatory agent and antioxidants. 3. Tomatoes Whether diced, sliced, pureed, pasted or sundried, tomatoes are well-known for containing lycopene, a powerful, cancer-fighting antioxidant and anti-inflammatory. It's no wonder this garden vegetable is the most popular in the United States. Choose your variety (cherry, grape, heirlooms) and enjoy! 4. Garlic Strong in smell but wonderful as a seasoning for soups and sauces, garlic contains a group of compounds that work to kill bacteria and fungus, and stimulate the immune system. Research shows that breast cancer cells die when exposed to garlic in test tubes. 5. Salmon Studies show eating some fish twice a week is good for your health, especially if salmon is on the menu. Rich with fish oil, this super food contains essential omega-3 fatty acids, which research shows lowers the risk of breast cancer, reduces inflammation, improves blood flow characteristics, and may improve response to chemotherapy.

6. Turmeric Very popular in East Indian dishes, this ginger-based herb, often ground into a yelloworange powder, is mainly used for adding flavor and color to foods. Think curry-based dishes. As a health benefit, turmeric contains aromatic oils that demonstrate antiinflammatory and anti-cancer activity. It also protects against free radicals. 7. Soy Vegetarians dig soy for its versatility and its usefulness as a protein source in place of red meat. But theres more to soy than meets the eye. Soy also contains phytochemicals that are known to greatly reduce your risk of developing breast cancer. 8. Green Tea Theres no doubt youve heard about the many health benefits of green tea for weight loss, age-fighting and skin protection, for example. Its potent antioxidants also discourage cancer cells from growing. Studies show that people who regularly drink green tea reduce their risk of many cancers, including breast cancer. 9. Flaxseed This tiny wonder food contains cancer-fighting compounds that protect because of their ability to reduce the chances of cancer cells spreading. Flaxseeds are packed with fiber and omega-3 fatty acids that fight inflammation in the body. 10. Berries Theyre yummy to eat, yes, but strawberries, blackberries and raspberries contain a common and powerful cancer fighter called ellagic acid. Blueberries, raspberries and blackberries especially contain an abundance of antioxidants that can help reduce the risk of a number of cancers.

Prevention Table
Recommendations for Women of Different Ages.

This table shows the recommendations and benefits of these recommendations by age to prevent breast cancer from occurring. http://rex.nci.nih.gov/MAMMOG_WEB/PUBS_POSTERS/FACTS_BC.html

Prognosis
Breast cancer is the second most lethal cancer in women. (Lung cancer is the leading cancer killer in women.) The good news is that early detection and new treatments have improved survival rates. The 5-year survival rate for women diagnosed with cancer is 80%. About 88% of women diagnosed with breast cancer will survive at least 10 years. Unfortunately, women in lower social and economic groups still have significantly lower survival rates than women in higher groups. Several factors are used to determine the risk for recurrence and the likelihood of successful treatment. They include: Location of the tumor and how far it has spread Whether the tumor is hormone receptor-positive or -negative Tumor markers Gene expression Tumor size and shape Rate of cell division The good news is that women are living longer with breast cancer. Due to better treatment options, breast cancer mortality rates declined by about 25% since 1990. However, survivors must live with the uncertainties of possible recurrent cancer and some risk for complications from the treatment itself. Recurrences of cancer usually develop within 5 years of treatment. About 25% of recurrences and half of new cancers in the opposite breast occur after 5 years.