St. Paul Hospital Cavite, Inc.

Burol II, City of Dasmarinas, Cavite

POST-GRADUATE CLINICAL NURSE TRAINING PROGRAM

CASE STUDY:

BREAST CANCER STAGE IV

By: Abatay, Joeven M. Calagui, Allan R. Inot, Jury Ann Elizabeth P. Malapo, Lara Danica P.

OVERVIEW OF THE DISEASE

Breast cancer is an uncontrolled growth of breast cells. Cancer occurs as a result of mutations, or abnormal changes, in the genes responsible for regulating the growth of cells and keeping them healthy. The genes are in each cells nucleus, which acts as the control room of each cell. Normally, the cells in our bodies replace themselves through an orderly process of cell growth: healthy new cells take over as old ones die out. But over time, mutations can turn on certain genes and turn off others in a cell. That changed cell gains the ability to keep dividing without control or order, producing more cells just like it and forming a tumor. A tumor can be benign (not dangerous to health) or malignant (has the potential to be dangerous). Benign tumors are not considered cancerous: their cells are close to normal in appearance, they grow slowly, and they do not invade nearby tissues or spread to other parts of the body. Malignant tumors are cancerous. Left unchecked, malignant cells eventually can spread beyond the original tumor to other parts of the body. The term breast cancer refers to a malignant tumor that has developed from cells in the breast. Usually breast cancer either begins in the cells of the lobules, which are the milkproducing glands, or the ducts, the passages that drain milk from the lobules to the nipple. Less commonly, breast cancer can begin in the stromal tissues, which include the fatty and fibrous connective tissues of the breast. Over time, cancer cells can invade nearby healthy breast tissue and make their way into the underarm lymph nodes, small organs that filter out foreign substances in the body. If cancer cells get into the lymph nodes, they then have a pathway into other parts of the body. The breast cancers stage refers to how far the cancer cells have spread beyond the original tumor. Breast cancer is always caused by a genetic abnormality (a mistake in the genetic material). However, only 5-10% of cancers are due to an abnormality inherited from your mother or father. Instead, 85-90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process and the wear and tear of life in general. Developing breast cancer is not your or anyone's fault. Feeling guilty, or telling yourself that breast cancer happened because of something you or anyone else did, is not productive.

There are three ways that cancer spreads in the body. Cancer can spread through tissue, the lymph system, and the blood:

Tissue. The cancer spreads from where it began by growing into nearby areas. Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.

Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

RISK FACTORS MODIFIABLE Weight. Being overweight is associated with increased risk of breast cancer, especially for women after menopause. Fat tissue is the bodys main source of estrogen after menopause, when the ovaries stop producing the hormone. Having more fat tissue means having higher estrogen levels, which can increase breast cancer risk. Diet. Diet is a suspected risk factor for many types of cancer, including breast cancer, but studies have yet to show for sure which types of foods increase risk. Its a good idea to restrict sources of red meat and other animal fats (including dairy fat in cheese, milk, and ice cream), because they may contain hormones, other growth factors, antibiotics, and pesticides. Some researchers believe that eating too much cholesterol and other fats are risk factors for cancer, and studies show that eating a lot of red and/or processed meats is associated with a higher risk of breast cancer. A low-fat diet rich in fruits and vegetables is generally recommended. Exercise. Evidence is growing that exercise can reduce breast cancer risk. The American Cancer Society recommends engaging in 45-60 minutes of physical exercise 5 or more days a week.

Alcohol consumption. Studies have shown that breast cancer risk increases with the amount of alcohol a woman drinks. Alcohol can limit your livers ability to control blood levels of the hormone estrogen, which in turn can increase risk. Smoking. Smoking is associated with a small increase in breast cancer risk. Exposure to estrogen. Because the female hormone estrogen stimulates breast cell growth, exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Some of these risk factors are under your control, such as:

taking combined hormone replacement therapy (estrogen and progesterone; HRT) for several years or more, or taking estrogen alone for more than 10 years

being overweight regularly drinking alcohol

Recent oral contraceptive use. Using oral contraceptives (birth control pills) appears to slightly increase a womans risk for breast cancer, but only for a limited period of ti me. Women who stopped using oral contraceptives more than 10 years ago do not appear to have any increased breast cancer risk. Stress and anxiety. There is no clear proof that stress and anxiety can increase breast cancer risk. However, anything you can do to reduce your stress and to enhance your comfort, joy, and satisfaction can have a major effect on your quality of life. So-called mindful measures (such as meditation, yoga, visualization exercises, and prayer) may be valuable additions to your daily or weekly routine. Some research suggests that these practices can strengthen the immune system. NON- MODIFIABLE Gender. Being a woman is the most significant risk factor for developing breast cancer. Although men can get breast cancer, too, womens breast cells are constantly changing and growing, mainly due to the activity of the female hormones estrogen and progesterone. This activity puts them at much greater risk for breast cancer.

Age. Simply growing older is the second biggest risk factor for breast cancer. From age 30 to 39, the risk is 1 in 227, or .44%. That jumps to 1 in 28, or just under 4%, by the time you are in your 60s. Family history of breast cancer. If you have a first-degree relative (mother, daughter, sister) who has had breast cancer, or you have multiple relatives affected by breast or ovarian cancer (especially before they turned age 50), you could be at higher risk of getting breast cancer. Personal history of breast cancer. If you have already been diagnosed with breast cancer, your risk of developing it again, either in the same breast or the other breast, is higher than if you never had the disease. Race. White women are slightly more likely to develop breast cancer than are African American women. Asian, Hispanic, and Native American women have a lower risk of developing and dying from breast cancer. Radiation therapy to the chest. Having radiation therapy to the chest area as a child or young adult as treatment for another cancer significantly increases breast cancer risk. The increase in risk seems to be highest if the radiation was given while the breasts were still developing (during the teen years). Breast cellular changes. Unusual changes in breast cells found during a breast biopsy (removal of suspicious tissue for examination under a microscope) can be a risk factor for developing breast cancer. These changes include overgrowth of cells (called hyperplasia) or abnormal (atypical) appearance. Exposure to estrogen. Because the female hormone estrogen stimulates breast cell growth, exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Some of these risk factors are not under your control, such as:

starting menstruation (monthly periods) at a young age (before age 12) going through menopause (end of monthly cycles) at a late age (after 55) exposure to estrogens in the environment (such as hormones in meat or pesticides such as DDT, which produce estrogen-like substances when broken down by the body)

Pregnancy and breastfeeding. Pregnancy and breastfeeding reduce the overall number of menstrual cycles in a womans lifetime, and this appears to reduce future breast cancer risk. Women who have never had a full-term pregnancy, or had their first full-term pregnancy after age 30, have an increased risk of breast cancer. For women who do have children, breastfeeding may slightly lower their breast cancer risk, especially if they continue breastfeeding for 1 1/2 to 2 years. For many women, however, breastfeeding for this long is neither possible nor practical. DES exposure. Women who took a medication called diethylstilbestrol (DES), used to prevent miscarriage from the 1940s through the 1960s, have a slightly increased risk of breast cancer. Women whose mothers took DES during pregnancy may have a higher risk of breast cancer as well. SYMPTOMS Early breast cancer usually does not cause symptoms. This is why regular breast exams are important. As the cancer grows, symptoms may include: Breast lump or lump in the armpit that is hard, has uneven edges, and usually does not hurt Change in the size, shape, or feel of the breast or nipple -- for example, you may have redness, dimpling, or puckering that looks like the skin of an orange Fluid coming from the nipple -- may be bloody, clear to yellow, green, and look like pus Men can get breast cancer, too. Symptoms include breast lump and breast pain and tenderness. Symptoms of advanced breast cancer may include: Bone pain Breast pain or discomfort Skin ulcers Swelling of in the armpit (next to the breast with cancer) Weight loss

Stage IV Breast Cancer Stage IV breast cancer. The cancer has spread to other parts of the body, most the bones, lungs, liver, or brain.often In stage IV, cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain. Stage IV and metastatic breast cancer Treatment of stage IV or metastatic breast cancer may include the following:

Hormone therapy and/or chemotherapy with or without trastuzumab. Monoclonal antibody therapy with trastuzumab and pertuzumab combined with chemotherapy.

Antibody-drug conjugate therapy with ado-trastuzumab emtansine. Tyrosine kinase inhibitor therapy with lapatinib combined with capecitabine. Radiation therapy and/or surgery for relief of pain and other symptoms. Bisphosphonate drugs to reduce bone disease and pain when cancer has spread to the bone.

Clinical trials testing new chemotherapy and/or hormone therapy. Clinical trials of new combinations of treatments, including targeted therapy, hormone therapy, and chemotherapy.

Clinical

trials

testing

other

treatments,

including high-dose

chemotherapy with stem cell transplant. TREATMENTS Surgery Most patients with breast cancer have surgery to remove the cancer from the breast. Some of the lymph nodes under the arm are usually taken out and looked at under a microscope to see if they contain cancer cells.

Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:

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. The lining over the chest muscles below the cancer may also be removed. This procedure is also called a segmental mastectomy.

Breast-conserving surgery. Dotted lines show the area containing the tumor that is removed and some of the lymph nodes that may be removed. Patients who are treated with breast-conserving surgery may also have some of the lymph nodes under the arm removed for biopsy. This procedure is called lymph node dissection. It may be done at the same time as the breast-conserving surgery or after. Lymph node dissection is done through a separate incision. Other types of surgery include the following:

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. Total (simple) mastectomy. The dotted line shows where the

entire breast is removed. Some lymph nodes under the arm may also be removed.

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.

Modified radical mastectomy. The dotted line shows where the entire breast and some lymph nodes are removed. Part of the chest wall muscle may also be removed.

Chemotherapy may be given before surgery to remove the tumor. When given before surgery, chemotherapy will shrink the tumor and reduce the amount of tissue that needs to be removed during surgery. Treatment given before surgery is called neoadjuvant therapy. Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given radiation therapy, chemotherapy, or hormone therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy. If a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a breasts shape after a mastectomy) may be considered. Breast reconstruction may be done at the time of the mastectomy or at a future time. The reconstructed breast may be made with the patients own (nonbreast) tissue or by using implants filled with saline or silicone gel. Sentinel lymph node biopsy followed by surgery Sentinel lymph node biopsy is the removal of the sentinel lymph node during surgery. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph node the cancer is likely to spread to from the tumor. A radioactive substance and/or blue dye is injectednear the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under amicroscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. After the sentinel lymph node biopsy, the surgeon removes the tumor (breastconserving surgery or mastectomy). Sentinel lymph node biopsy of the breast. A radioactive substance and/or blue dye is injected near the tumor (first panel). The injected material is detected visually and/or with a probe that detects radioactivity (middle panel). The sentinel nodes (the first lymph nodes to take up the material) are removed and checked for cancer cells (last panel). Radiation therapy Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiationtherapy uses a machine outside the body to send radiation toward

the cancer. Internal radiationtherapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stageof the cancer being treated. Chemotherapy Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into avein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Hormone therapy Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances made by glands in the body and circulated in the bloodstream. Some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy is used to reduce the production of hormones or block them from working. The hormone estrogen, which makes some breast cancers grow, is made mainly by the ovaries. Treatment to stop the ovaries from making estrogen is called ovarian ablation. Hormone therapy with tamoxifen is often given to patients with early stages of breast cancer and those with metastatic breast cancer (cancer that has spread to other parts of the body). Hormone therapy with tamoxifen or estrogens can act on cells all over the body and may increase the chance of developing endometrial cancer. Women taking tamoxifen should have a pelvic exam every year to look for any signs of cancer. Any vaginal bleeding, other than menstrual bleeding, should be reported to a doctor as soon as possible. Hormone therapy with an aromatase inhibitor is given to

some postmenopausal women who have hormone-dependent breast cancer. Hormonedependent breast cancer needs the hormone estrogento grow. Aromatase inhibitors decrease

the body's estrogen by blocking an enzyme called aromatase from turning androgen into estrogen. For the treatment of early stage breast cancer, certain aromatase inhibitors may be used as adjuvant therapy instead of tamoxifen or after 2 or more years of tamoxifen. For the treatment of metastaticbreast cancer, aromatase inhibitors are being tested in clinical trials to compare them to hormone therapy with tamoxifen. Targeted therapy Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Monoclonal

antibodies and tyrosine kinase inhibitorsare two types of targeted therapies used in the treatment of breast cancer. PARP inhibitors are a type of targeted therapy being studied for the treatment of triple-negative breast cancer. Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory, from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given byinfusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Monoclonal antibodies may be used in combination with chemotherapy as adjuvant therapy. Trastuzumab is a monoclonal antibody that blocks the effects of the growth factor protein HER2, which sends growth signals to breast cancer cells. About one-fourth of patients with breast cancer have tumors that may be treated with trastuzumab combined with chemotherapy. Pertuzumab is a monoclonal antibody that may be combined with trastuzumab and chemotherapy to treat breast cancer. It may be used to treat certain patients with HER2positive breast cancer that hasmetastasized (spread to other parts of the body). Ado-trastuzumab emtansine is a monoclonal antibody linked to an anticancer drug. This is called an antibody-drug conjugate. It is used to treat HER2-positive breast cancer that has spread to other parts of the body or recurred (come back).

Tyrosine kinase inhibitors are targeted therapy drugs that block signals needed for tumors to grow. Tyrosine kinase inhibitors may be used with other anticancer drugs as adjuvant therapy. Lapatinib is a tyrosine kinase inhibitor that blocks the effects of the HER2 protein and other proteinsinside tumor cells. It may be used with other drugs to treat patients with HER2positive breast cancer that has progressed after treatment with trastuzumab. PARP inhibitors are a type of targeted therapy that block DNA repair and may cause cancer cells to die. PARP inhibitor therapy is being studied for the treatment of triplenegative breast cancer. High-dose chemotherapy with stem cell transplant High-dose chemotherapy with stem cell transplant is a way of giving high doses of chemotherapy and replacing blood -forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the bodys blood cells. Studies have shown that high-dose chemotherapy followed by stem cell transplant does not work better than standard chemotherapy in the treatment of breast cancer. Doctors have decided that, for now, high-dose chemotherapy should be tested only in clinical trials. Before taking part in such a trial, women should talk with their doctors about the serious side effects, including death, that may be caused by high-dose chemotherapy. Stage IV and metastatic breast cancer Treatment of stage IV or metastatic breast cancer may include the following:

Hormone therapy and/or chemotherapy with or without trastuzumab. Monoclonal antibody therapy with trastuzumab and pertuzumab combined with chemotherapy.

Antibody-drug conjugate therapy with ado-trastuzumab emtansine.

Tyrosine kinase inhibitor therapy with lapatinib combined with capecitabine. Radiation therapy and/or surgery for relief of pain and other symptoms. Bisphosphonate drugs to reduce bone disease and pain when cancer has spread to the bone.

Clinical trials testing new chemotherapy and/or hormone therapy. Clinical trials of new combinations of treatments, including targeted therapy, hormone therapy, and chemotherapy.

Clinical

trials

testing

other

treatments,

including high-dose

chemotherapy with stem cell transplant.

INCIDENCE IN THE PHILIPPINES October is Breast Cancer Awareness Month, and many countries in the world, including the Philippines, are planning a set of activities in line with this event. Everyone is encouraged to participate by helping to raise funds for research and indigent patients, volunteering to help those battling the disease in any way you can or simply educating yourself on breast cancer prevention and treatment.

The Philippines is at the center of the fight against breast cancer in Asia. The country has the highest incidence of breast cancer in the continent and an estimated 3 out of 100 Filipino women will contract the disease before age 75; 1 out of 100 will die before age 75, according to the Philippine Society of Medical Oncology in 2012. This complements the Department of Health and Philippine Cancer Society, Inc. report, which states that breast cancer is the most common cancer in the country, comprising 16 percent of the 80,000 new cancer cases in 2010.

PATIENTS PROFILE

Name: Address: Birthdate: Age: Religion: Nationality: Occupation: Date of admission: Time of admission: Chief Complaint: Attending Physician: Admitting Diagnosis: Final Diagnosis:

Mrs. L.B. Burol I, Dasmarinas, Cavite November 12, 1962 51 Iglesia ni Cristo Filipino Housewife December 01, 2013 7:20 pm Loss of appetite Dr. Manansala Breast Cancer Breast Cancer Stage 4

PAST HEALTH HISTORY Patient Mrs.L.B cannot remember if she received complete immunizations for the different childhood illnesses. When asked about the childhood illnesses she had experienced, patient Mrs.L.B said that she had chicken pox and mumps during her elementary years. She has no known allergies to food and drugs and has no history of asthma, accidents or falls. FAMILIAL HISTORY: There is no history of cancer on her family.

HISTORY OF PRESENT ILLLNESS (CANCER) According to Mrs.L.B, she first felt a lump in her left breast (upper quadrant) sometime on June 2012 while she was taking a bath. She first ignored this since she thought it was nothing to be worried about because it was not painful after all. Hindi ko na pinansin kasi akala ko wala lang yun and that it will go away by itself, she verbalized. It was in May 2013 when she noticed that the lump was getting bigger and she noticed redness and dimpling in the area where the lump was felt. Parang pumaloob yung skin ko dito (pointing to her breast), parang dimples, na wala naman noong una kong napansin last

year, she verbalized. She mentioned this to her daughter, then later she was advised to consult and went to a Private Hospital and diagnosed of a Breast Cancer Stage 4. Her latest confinement on December 1, 2013 was due to the body weakness she was experiencing for almost 3 days already prior to admission accompanied by loss of appetite, cough and loss of appetite. Mabilis akong manghina at I have difficulty of breathing at wala pa akong ganang kumain.as she verbalized.

GORDONS FUNCTIONAL ASSESSMENT

A. Health Perception/ Health Management Pattern The patient describes health as being free of any common illness such as cough, colds and fever. They do self-medication treatments during the event of common sickness and only visit the doctor if the illness will not be managed by these medications from drug stores.

B. Nutritional/ Metabolic Pattern Last August of this year that a loss of appetite was noted and that precipitated the 1st hospitalization of the patient to another hospital for the management of weakness and loss of appetite. There were no mentioned set of meals offered on the previous hospitalization. During her hospitalization in our institution loss of appetite is also a problem and patient refused to insert an NGT for her nutrition. But according to the patient and her eldest daughter before the illness occurred, the patient and her family usually eats 3 to 4 times a day and would usually have pizza, pasta and breads for all of their meals. The patient usually drinks 5-6 glasses of water per day.

C. Elimination Before hospitalization, the patient urinates 4-5 times a day, reddish in color with moderate amount and with difficulty in urinating, she complains of pain during urination. She defecates 2 times a day and described the stool as light brown, semi-formed and moderate in amount. During the hospitalization, the patient urinates 3-4 times a day, yellowish in color and small in amount. Sometimes she defecates usually in the morning but there is an instance that she cannot defecate the whole day.

D. Activity-Exercise Pattern Before hospitalization, the patient do house hold chores like washing the dishes, cleaning the house, washing the clothes as her only form of exercise. During hospitalization, the patient is lying in her bed because of her difficulty of breathing, body weakness, enlargement of the abdomen and edematous lower extremities and so she has to be assisted with her activities of daily living.

E. Sleep-Rest Pattern Before hospitalization, the patient sleeps 6-7 hours every night. She usually sleeps at 11 oclock in the evening and wakes up at 7 oclock in the morning. According to her, she takes a rest whenever she feels tired from any activity that she conducts within the day. During hospitalization, the patient is on bed all the time due to body weakness. Then wakes up when she feels something painful or any discomforts.

F. Cognitive-Perceptual Pattern The patient is conscious and coherent and oriented time, where she is and the persons around her. The memory is still intact. She is a college graduate.

G. Self-Perception/ Self Concept She considers herself a responsible person though a simple one. She is loving and understanding to family and friends.

H. Role-Relationship Pattern Prior hospitalization, the patient has a strong bond with her family. She is loved by her family. Her husband is a Seaman and sees to it that whenever her husband comes back to the Philippines they will have a vacation time for the whole family. During Hospitalization: Family bonding is still intact. But the role of being a mother to her children is not that good due to her present condition.

I. Sexual Reproductive

At the age of 11 she had her menarche and she is married to her husband for 20 years and has 3 children. J. Coping Stress Tolerance When there was stressful event in her life, her children is always there for her. They talk it among themselves and find ways to alleviate stress such as going out and cooking their favorite meals. K. Value Belief Before hospitalization, the patient is an Iglesia ni Cristo. She attends their samba regularly. During hospitalization, the patient still prays to God that whatever happens to her, God will still be with her.

ANATOMY AND PHYSIOLOGY OF THE BREAST

Women and men both have breasts, but women have more breast tissue than men. Each breast lies over a muscle of the chest called the pectoral muscle. The female breast covers a fairly large area. It extends from just below the collarbone (clavicle), to the armpit (axilla) and across to the breastbone (sternum).

Structure The breast is a mass of glandular, fatty and connective tissue. The breast is made up of:

lobules glands that produce milk ducts tubes that carry milk from the lobules to the nipple fatty and connective tissue surrounds and protects the ducts and lobules and gives shape to the breast areola the pink or brown, circular area around the nipple that contains small sweat glands, which release (secrete) moisture as a lubricant during breast-feeding nipple the area at the centre of the areola where the milk comes out

Ligaments support the breast. They run from the skin through the breast and attach to muscles on the chest.

There are several major nerves in the breast area, including nerves in the chest and arm. There are also sensory nerves in the skin of the chest and axilla.

The lymphatic system of the breast The breast has many blood vessels and lymph vessels. Lymph vessels are thin tubes similar to blood vessels. They collect and move lymph fluid away from the breast into small beanshaped masses of lymphatic tissue, called lymph nodes, in the area around the breast. The lymph vessels and lymph nodes are part of the lymphatic system, which helps fight infections.

The breast lymph nodes include:

supraclavicular nodes above the collarbone infraclavicular (or subclavicular) nodes below the collarbone axillary nodes in the armpit (axilla) internal mammary nodes inside the chest around the breastbone (sternum)

Axillary lymph nodes There are about 3050 lymph nodes in the axilla. The number varies from woman to woman. The axillary lymph nodes are divided into 3 levels according to how close they are to the pectoral muscle on the chest:

level I (low axilla) located in the lower or bottom part of the armpit, along the outside border of the pectoral muscle level II (mid axilla) located in the middle part of the armpit, beneath the pectoral muscle level III (high axilla) located below and near the centre of the collarbone, above the breast area and along the inside border of the pectoral muscle

When breast cancer spreads, it usually goes to level I lymph nodes first, to level II next and then to level III.

Breast development Breast tissue changes at different times during a womans life. It changes during puberty, during the menstrual cycle, during pregnancy and after menopause. Female breasts do not begin growing until puberty (around 1012 years of age). At this time, the breasts respond to hormonal changes (mostly increased estrogen and progesterone) in the body and begin to develop. During puberty, the breast ducts and milk glands grow. The breast skin stretches as the breasts grow, creating a rounded appearance. Young women tend to have denser breasts (more glandular tissue) than older women.

In older women, much of the glandular and ductal tissue is replaced with fatty tissue and breasts become less dense. Ligaments also lose their elasticity when women age, causing the breasts to sag. The size and shape of womens breasts vary considerably. Some women have a large amount of breast tissue and have larger breasts. Others have a smaller amount of tissue with little breast fat. A womans breasts are rarely the same size. Often one breast is slightly larger or smaller, higher or lower or shaped differently than the other. Hormones and the breast Estrogen is the main female hormone. It influences female sexual characteristics, such as breast development, and it is necessary for reproduction. Most of the estrogen in a womans body is made by the ovaries, though a small amount is made by the adrenal glands.

Progesterone is the other female sex hormone made in the ovaries. Its role is to prepare the uterus (womb) for pregnancy and the breasts for producing milk for breast-feeding (lactation).

The breast tissues are exposed to monthly cycles of estrogen and progesterone throughout a womans childbearing years.

In the first part of the menstrual cycle, estrogen stimulates the growth of the milk ducts. Progesterone takes over in the second part of a womans menstrual cycle, stimulating the lobules.

After menopause, the monthly cycle of estrogen and progesterone end. However, the adrenal glands continue to produce estrogen so that a woman keeps her sexual characteristics. Function The breasts main function is to produce, store and release milk to feed a baby. Milk is produced in lobules throughout the breast when they are stimulated by hormones in a womans body after giving birth. The ducts carry the milk to the nipple. Milk passes from the nipple to the baby during breast-feeding.

PATHOPHYSIOLOGY OF BREAST CANCER 1.Predisposing Factors > Age (greatest at the age of 50 and beyond) > Sex 98-99% of cases occur in women > Menstrual Cycle (early menarche and late menopause) > Genetics

3.Etiology -Idiopathic-

2.Precipitating Factors > Exposure to exogenous estrogen (Oral Contraceptives) >Lifestyle (She is active and does household chores)

Inheritance of mutated BrCa1/BrCa2 genes DNA, RNA and cellular aberrations Mutation Normal tumor suppressor gene inactivated Protooncogene activated

Stimulates development of breast ducts; stimulates the replication of damaged DNA cells

Unregulated epithelial cell division along ducts / lobes

A

Communicates with breast stromal cells Stimulation of Vascular endothelial growth factor (VEGF) pathways

Proliferation of tumor cells near primary tumor Venous obstruction Venous engorgement

Invasion and adhesion of tumor cells in pectoral (deep fascia) muscles

Angiogenesis

Breast Dimpling / Retraction

Entry to cancer cells in blood circulation

Nourishment to primary and adjacent tumors

Lymphatic involvement

Further Growth of Primary Tumor

Metastasis

Bones

Disruption in hematopoiesis

Erythropoiesis disruption Decreased RBC Production

Disruption in Leukocyte formation Suppression of leukocyte production Decreased WBC production

Anemia Paleness

Low HCT Low HgB

Leukopenia / Neutropenia

Kidney

Liver

Portal hypertension

Splanchnic vasodilation

Decreased effective circulatory volume

Activation of renin-angiotensinaldosterone system Renal sodium avidity and hepatorenal syndrome

Ascites

Edema of both lower extremities

LABORATORY/DIAGNOSTICS EXAMINATIONS

Date: December 1, 2013 Procedure Hemoglobin Normal Value 12-15 gm/L Result 9.9 Interpretation Decreased due to due to disruption in erythropoiesis secondary to bone metastasis and chemotherapy Decreased due to due to disruption in erythropoiesis secondary to bone metastasis Severe infection A decrease implies anemia and fluid overload Sign of infection Normal Immunedeficiency Implies anemia Defective tubular reabsorption, malnutrition and nephrosis Due to ascites, renal insufficiency Normal Normal

Hematocrit HEMATOLOGY

37-47%

31.5

WBC RBC

5-10 4.2-5.4

25.4 3.8

Segmenters Monocytes Lymphocytes Platelet BUN

50-70 2.5-8 20-40 150,000500,000 2.147.14

90 2 6 760 10.3

Clinical Chemistry

Serum Sodium

135-148

126

Serum Potassium Creatinine

3.5-5.3 45-84

4.8 71

Chest Xray-PA Findings: Hazy densities are seen in the in the Right Lower Lobe Heart Shadow is Borderline in size The Right Hemidiaphragm is Slightly Elevated The Left Hemidiaphragm is Slightly Intact The Rest of the visualized Thoracic Structures are Unremarkable

Impression: Pneumonia Slightly Elevated Right Hemidiaphragm Subpulmonic Effusion is Is not Ruled Out. Aright Lateral Decubitus View or Chest Ultrasound Correlation is Recommended for further evaluation.

NURSING CARE PLAN

DATE/ TIME December 2, 2012 6AM FOCUS F> Difficulty of Breathing DATA/ ACTION/ RESPONSE D> RR: 30s,gasping, nasal flaring, and used of accessory muscles, irritable O2 Sat 93%,

A>Assessed for signs and symptoms of respiratory distress. AP and ROD informed. Placed on moderate high back rest. Changed oxygen via nasal cannula to face mask as ordered. Encouraged to do deep breathing exercise. Advised patient to rest.

6:15AM

R> RR= 23, O2 Sat 98%, no nasal flaring, gasping and used of accessory muscles noted. Endorsed.

DATE/ TIME December 2, 2013 6AM

FOCUS F> Increased in blood pressure

DATA/ ACTION/ RESPONSE D> Blood pressure of 160/ 100, restless, irritability noted.

A> Assessed patient condition. Promoted calm, comfortable and safety environment. Kept well rested. Maintained activity restrictions and assessed patient with self- care activities. Monitored for signs and symptoms of severely elevated blood pressure such as headache feeling of vomiting and nausea. Monitored patient frequently. Catapress 150mcg/tab sublingual given as ordered. 7AM R> Reassessed patient, blood pressure of 140/ 90. Patient was able to have rest, not irritable. Endorsed

DATE/ TIME December 03, 2013 6AM F> Anxiety

FOCUS

DATA/ ACTION/ RESPONSE D> Natatakot ako sa maaring mangyare o sa sakit ko. With a scale of moderate anxiety. Irritability, restless, cold clammy skin, pale in appearance noted.

A> Assessed patient general health status. Assessed level of anxiety. Encouraged verbalization of feelings. Provided accurate information about the situation. Encouraged therapeutic relationship and be available to client for listening and talking. Monitored patient frequently. 7AM R> Patient still in a moderate anxiety due to her condition. Endorsed.

REFERENCES

Books Balita, C.E. (2008). Ultimate Learning Guide to Nursing Review. Philippines. TriMega Printing.

Burstein, H.J., Harris, J.R., & Morrow, M. Cancer of the Breast: Section 2: Malignant Tumors of the Breast. Devita, V. T., Jr., Lawrence, T. S., & Rosenberg, S. A. (2008). Cancer: Principles & Practice of Oncology. (8th Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 43(2) pp. 1606-1654. Martini, F. H., Timmons, M. J., & Tallitsch, R. B. (2009). Human Anatomy. (6th Edition). San Francisco: Pearson Benjamin Cummings. Wilson, B.A., Shannon, M.T., & Shields, K. (2011). Nurses Drug Guide 2011. Upper Saddle River, NJ: Pearson/Prentice Hall.

Online Resources American Cancer Society. Cancer Facts and Figures 2013. Atlanta, Ga: American Cancer Society; 2013. Breastcancer.org 7 East Lancaster Avenue. 3rd Floor Ardmore. PA 19003 2013 Breastcancer.org- All rights reserved. Last modified on May 5, 2013 at 4:54 pm http://www.breastcancer.org/symptoms/understand_bc. GMA Network News Story retrieved from http://www.gmanetwork.com/news/story/329126/cbb/phl-has-highest-breast-cancerrate-in-asia.