Alcantara, John Renefrank B. Alejandro, Wyeth Paul R.

THE BREAST CANCER Oncology Nursing

June 13, 2013 Ms. Beverly S. Angot

BREAST CANCER
Breast cancer is a malignant tumor that starts in the cells of the breast. A malignant tumor is a group of cancer cells that can grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body. The disease occurs almost entirely in women, but men can get it, too. One of every 13 Filipino women is expected to develop breast cancer in her lifetime. (Philippine Star, 2013) Breast cancer is the most common cancer in the Philippines, taking at least 16 percent of the 50,000 cases diagnosed. (Department of Health and Philippine Cancer Society, 2010) In men, less than 1% of all breast cancers. (Dr. Aldine Basa, 2010) The Normal Breast The female breast is made up mainly of lobules (milk-producing glands), ducts (tiny tubes that carry the milk from the lobules to the nipple), and stroma (fatty tissue and connective tissue surrounding the ducts and lobules, blood vessels, and lymphatic vessels). Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in the cells that line the lobules (lobular cancers), while a small number start in other tissues.

The lymph (lymphatic) system of the breast The lymph system is important to understand because it is one way breast cancers can spread. This system has several parts. Lymph nodes are small, bean-shaped collections of immune system cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the breast. Lymph contains tissue fluid and waste products, as well as immune system cells. Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes.
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Alcantara, John Renefrank B. Alejandro, Wyeth Paul R.

THE BREAST CANCER Oncology Nursing

June 13, 2013 Ms. Beverly S. Angot

Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes). Some lymphatic vessels connect to lymph nodes inside the chest (internal mammary nodes) and those either above or below the collarbone (supraclavicular or infraclavicular nodes). If the cancer cells have spread to lymph nodes, there is a higher chance that the cells could have also gotten into the bloodstream and spread (metastasized) to other sites in the body. The more lymph nodes that have breast cancer, the more likely it is that the cancer may be found in other organs as well. Because of this, finding cancer in one or more lymph nodes often affects the treatment plan. Still, not all women with cancer cells in their lymph nodes develop metastases, and some women can have no cancer cells in their lymph nodes and later develop metastases. Pathogenesis of Breast Cancer Normal cells in the body communicate with each other and regulate each other's proliferation (division).Cells proliferate to replace worn-out cells. When cancer occurs, cells escape the normal controls on their growth and proliferation. How do cells escape their normal growth and proliferation? By acquiring damage (mutations) to genes that normally regulate cell proliferation. What are the genes that are being damaged? Tumor Suppressor Genes They control the processes of cell growth and cell death (called apoptosis). Proto-oncogenes Responsible for promoting cell growth. What happens to the genes when mutated? Tumor Suppressor Genes (acquired/inherited) This can lead to tumor formation or growth. Proto-oncogenes (acquired) They become oncogenes and then can promote tumor formation or growth. Two Categories of Breast Cancer Noninvasive Breast Cancer Ductal Carcinoma in Situ located within the duct and have not invaded the surrounding fatty breast tissue. Lobular Carcinoma in Situ abnormal cells grow inside the lobules of the breast, but have not spread to the nearby tissue or beyond.

Alcantara, John Renefrank B. Alejandro, Wyeth Paul R.

THE BREAST CANCER Oncology Nursing

June 13, 2013 Ms. Beverly S. Angot

Invasive Breast Cancer Infiltrating Ductal Carcinoma originates in the mammary glands and grows in the epithelial cells lining these ducts. Possible Outcomes of Metastasis of Breast Cancer 70% of breast cancer patients suffer from bone metastases. 10% suffer from brain metastases. 20% suffer from lung and liver metastases. Manifestation of Metastases Metastatic breast cancer to the lung or pleura causes chronic cough, dyspnea abnormal chest X-ray chest pain Metastatic disease to the bone causes severe, progressive pain less commonly pathological fracture erythema over the affected bone swelling Metastatic breast cancer to the brain causes the following symptoms: persistent, progressively worsening headache, visual changes, seizures, nausea or vomiting, vertigo, behavioral and personality changes, Increased intracranial pressure. Metastatic disease to the liver causes Jaundice elevated liver enzymes abdominal pain loss of appetite nausea vomiting

Alcantara, John Renefrank B. Alejandro, Wyeth Paul R.

THE BREAST CANCER Oncology Nursing

June 13, 2013 Ms. Beverly S. Angot

Causes of Gene Mutation: Resulting to Cancer Gender Simply being a woman is the main risk factor for developing breast cancer. Men can develop breast cancer, but this disease is about 100 times more common among women than men. This is likely because men have less of the female hormones estrogen and progesterone, which can promote breast cancer cell growth Aging Your risk of developing breast cancer increases as you get older. About 1 out of 8 invasive breast cancers are found in women younger than 45 , while about 2 of 3 invasive breast cancers are found in women age 55 or older. Genetics Inherited DNA changes can increase the risk for developing cancer and are responsible for the cancers. The BRCA1 and BRCA2 are Tumor Suppressor Genes that are inherited. Personal history of Breast Cancer A woman with cancer in one breast has a 3- to 4-fold increased risk of developing a new cancer in the other breast or in another part of the same breast. Race and Ethnicity Overall, White women are slightly more likely to develop breast cancer than are African-American women, but African-American women are more likely to die of this cancer. However, in women under 45 years of age, breast cancer is more common in African-American women. Asian, Hispanic, and Native-American women have a lower risk of developing and dying from breast cancer. Dense Breast Tissue Women with dense breasts are four to five times more likely to get breast cancer than women with less dense breasts. Certain benign breast conditions Non-proliferative lesions: These conditions are not associated with overgrowth of breast tissue. Proliferative lesions without atypia: These conditions show excessive growth of cells in the ducts or lobules of the breast tissue. They seem to raise a woman's risk of breast cancer slightly (1 to 2 times normal).

Alcantara, John Renefrank B. Alejandro, Wyeth Paul R.

THE BREAST CANCER Oncology Nursing

June 13, 2013 Ms. Beverly S. Angot

Proliferative lesions with atypia: In these conditions, there is an overgrowth of cells in the ducts or lobules of the breast tissue, with some of the cells no longer appearing normal. They have a stronger effect on breast cancer risk, raising it 3 1/2 to 5 times higher than normal. Menstrual periods Women who have had more menstrual cycles because they started menstruating early (before age 12) and/or went through menopause later (after age 55) have a slightly higher risk of breast cancer. The increase in risk may be due to a longer lifetime exposure to the hormones estrogen and progesterone. Having children Women who have had no children or who had their first child after age 30 have a slightly higher breast cancer risk. Hormone Therapy and Birth Control Pills Women using these therapeutic regimens can increase the risk of developing breast cancer due to the prolonged exposure of estrogen and progesterone. Alcohol Alcohol causes cancer cells' blood vessels to grow which in turn fuels the growth of the tumor, a process known as angiogenesis. Overweight and Obese Most of a woman's estrogen comes from fat tissue. Having more fat tissue especially after menopause can increase your chance of getting breast cancer by raising the estrogen levels. Tobacco Smoking For a long time, studies found no link between cigarette smoking and breast cancer. In 2009, the International Agency for Research on Cancer concluded that there is limited evidence that tobacco smoking causes breast cancer. It is Suggestive but not Sufficient evidence of a link at this point. (The 2006 US Surgeon General's report, The Health Consequences of Involuntary Exposure to Tobacco Smoke) Signs and Symptoms The most common symptom of breast cancer is a new lump or mass. A painless, hard mass that has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or rounded. They can even be painful. Other possible signs and symptoms: Swelling of all or part of a breast (even if no distinct lump is felt) Skin irritation or dimpling Breast or nipple pain Nipple retraction (turning inward) Redness, scaliness, or thickening of the nipple or breast skin Nipple discharge (other than breast milk) Lymph nodes under the arm
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Alcantara, John Renefrank B. Alejandro, Wyeth Paul R. Early Cancer Detection

THE BREAST CANCER Oncology Nursing

June 13, 2013 Ms. Beverly S. Angot

Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health. Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional preferably every 3 years. Starting at age 40, women should have a CBE by a health professional every year. Breast self-examination (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away. Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Screening Procedures for Early Detection
Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Observe for: Breasts that are their usual size, shape, and color. Breasts that are evenly shaped without visible distortion or swelling If you see any of the following changes, bring them to your doctor's attention: Dimpling, puckering, or bulging of the skin A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out) Redness, soreness, rash, or swelling Step 2: Now, raise your arms and look for the same changes. Step 3: While you're at the mirror, look for any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood). Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a

Alcantara, John Renefrank B. Alejandro, Wyeth Paul R.

quarter.

THE BREAST CANCER Oncology Nursing

June 13, 2013 Ms. Beverly S. Angot

Cover the entire breast from top to bottom, side to side from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. This up-and-down approach seems to work best for most women. Be sure to feel all the tissue from the front to the back of your breasts: for the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use firm pressure for the deep tissue in the back. When you've reached the deep tissue, you should be able to feel down to your ribcage. Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

Mammogram a mammogram is an X-ray of the breast. It is the best screening tool used today to find breast cancer early. A mammogram can find cancer at an early stage when it is small and easier to treat. Mammogram images can be stored on film (standard) or on a computer (digital). Clinical Breast Exam a breast exam by a health care provider should be part of your regular medical checkup. If it is not, ask for it. A clinical breast exam includes a visual examination and carefully feeling the entire breast from the collarbone to the bra line, and from the armpit to the breastbone. If you are 40 or older, schedule your mammogram close to the time of your clinical breast exam. Nursing Diagnosis Deficient knowledge about the planned surgical treatments. Anxiety related to the diagnosis of cancer Fear related to specific treatments and body image changes Risk for ineffective coping related to the diagnosis of breast cancer Decisional conflict related to treatment options. Disturbed body image related to loss or alteration of the breast Screening Procedures Self-Breast Examination Clinical Breast Examination Mammogram Diagnostic exams in Breast CA Biopsy It is the examination of affected tissue in detecting presence of cancer cells.
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Alcantara, John Renefrank B. Alejandro, Wyeth Paul R.

THE BREAST CANCER Oncology Nursing

June 13, 2013 Ms. Beverly S. Angot

Nuclear Magnetic Resonance Imaging This is viewing the structure of the breast using a high tech radiation imaging in detecting presence of mass or tumors. Ductogram A type of X-ray that helps determines the cause of nipple discharge. A ductogram can show if there is a mass inside the duct at the nipple Treatment Lumpectomy Partial or segmental mastectomy Simple mastectomy Modified radical mastectomy Axillary lymph node dissection Chemotherapy Radiation Therapy Surgical Nursing Intervention Pre-operative Obtain informed consent Provide good care for a breast care Be sure to know what kind of surgery to be performed in order to prepare the patient If mastectomy is scheduled: Prevent pulmonary complications and thromboembolism Place patient on the affected side Post-operative Inspect dressing anteriorly and posteriorly Check circulatory status Encourage coughing exercises and turning schedule every two hours Provide psychological and emotional support Explain to the patient that she may experience phantom breast syndrome Nursing Intervention 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.
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Alcantara, John Renefrank B. Alejandro, Wyeth Paul R.

THE BREAST CANCER Oncology Nursing

June 13, 2013 Ms. Beverly S. Angot

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. Medications Trastuzumab (Herceptin) Pertuzumab (Perjeta) Ado-trastuzumab emtansine (KadcylaLapatinib (Tykerb) Bevacizumab (Avastin)