1 I.

INTRODUCTION

Breast cancer is a malignant tumor that starts from breast tissue, most commonly from the inner lining of milk ducts (Sariego J., 2010). A malignant tumor is a group of cancer cells that may grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body (cancer.org, 2011). The primary route of metastasis is the lymphatic system which, ironically enough, is also the body's primary system for producing and transporting white blood cells and other cancer-fighting immune system cells throughout the body, forming new tumors and perpetuating the disease process (Evert J. and McDonald B., 2010). The size, stage, rate of growth, and other characteristics of the tumor determine the kinds of treatment. Treatment may include surgery, drugs (hormonal therapy and chemotherapy), radiation and/or immunotherapy (Florescu A., Amir E., Bouganim N., and Clemons M., 2011). Surgical removal of the tumor provides the single largest benefit, with surgery alone being capable of producing a cure in many cases. To somewhat increase the likelihood of long-term disease-free survival, several chemotherapy regimens are commonly given in addition to surgery. Most forms of chemotherapy kill cells that are dividing rapidly anywhere in the body, and as a result cause temporary hair loss and digestive disturbances. Radiation may be added to kill any cancer cells in the breast that were missed by the surgery, which usually extends survival somewhat, although radiation exposure to the heart may cause heart failure in the future (Buchholz T., 2009). Some breast cancers are sensitive to hormones especially on women, such as estrogen and/or progesterone, which make it possible to treat them by blocking the effects of these hormones. Breast cancer is not just a woman's disease. It is quite possible for men to get breast cancer, although it occurs less frequently in men than in women (Evert J. and McDonald B., 2010).

2 Prognosis and survival rate varies greatly depending on cancer type and staging. With best treatment and dependent on staging, 5-year relative survival varies from 98% to 23, with an overall survival rate of 85% (International Agency for Research on Cancer, 2008). Reason for choosing the case Primarily, the reason for choosing this case is to conduct an in-depth study to a case that is mostly encountered to the researcher. And since there are significant numbers of cancer cases in the country, making it ranks third in leading causes of morbidity and mortality in the Philippines, thorough study of the case is needed. This case study has enabled the nurse to be more familiarized with the different aspects of such condition. The case was appreciated by the student nurses since they were able to see an actual breast cancer patient, making them have an application of the topic theyve been discussing in NCM 106 about oncology nursing. The group showed interest with the condition and keen to know the disease. Furthermore, awareness towards the risk factors of the disease can help in the prevention of its occurrence. This case may serve as a foundation for the student nurses in their future patients, as to providing health teachings and nursing interventions can be based from this study. The group chose the case for the reason they wanted to show the readers the process on how breast cancer occurs, for them to fully understand and be reminded on the complications. The group was captivated to know how it occurs and challenged to be familiar with the condition fully. Statistics The Department of Health (DOH) said that after heart related disease, breast cancer is the second most leading cause of death in Central Luzon every year. DOH Regional Director Rio Magpantay said that with a population of 9,770,100 in the region, the department has traced 4,141 cancer-all forms, breast cancer being the first on the list (Mapiles J., 2010).

3 Breast cancer is now the leading cancer site overtaking lung cancer for both sexes in the Philippines. It is also the number one cause of cancer morbidity and mortality among Filipino women accounting for almost 30 percent of all female malignancies adding it is estimated that there were a total of 12,262 new breast cancer cases in 2010 with 4,371 deaths (Tong X., 2011). Latest data revealed that three out of every 100 Filipinas are likely to develop breast cancer in their lifetime and that one out of every 100 are likely to die from the disease before the age of 75 (Ona E., 2011). In Asia, the Philippines is among the countries with the highest age standardized incidence rate for breast cancer. Survival rate for breast cancer in the Philippines is below 40 percent compared to the high survival rates of 80 to 98 percent already achieved in developed countries (Tong X., 2011). Worldwide, breast cancer comprises 10.4% of all cancer incidence among women, making it the second most common type of non-skin cancer (after lung cancer) and the fifth most common cause of cancer death. In 2004, breast cancer caused 519,000 deaths worldwide (7% of cancer deaths; almost 1% of all deaths). Breast cancer is about 100 times more common in women than in men, although males tend to have poorer outcomes due to delays in diagnosis. (Black J., 2008) Objectives (Nurse-centered) After accomplishing this case study, the student nurses shall have: Cognitive Domain:
Presented patients history and health assessment. Learned the disease process, on how it occurs and its possible manifestations. Acquainted with the predisposing and precipitating factors that lead to the

occurrences of the disease, thus letting them be much aware of its causative factor.

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Familiarized themselves with the possible complications of the disease condition. Obtained and provided possible prevention in the occurrence of the disease. Formulated and learned different management of the disease thus learning the

curative aspect of the condition.

Acquired information regarding the disease and able to use them for future

studies. Psychomotor Domain:

Used the skills in physical assessment. Identified health problems and needs of the client that will be the basis of further

assessment and evaluation in the understanding of the disease process.

Provided quality nursing care by setting specific goals and appropriate nursing

intervention which are essential to the clients condition.

Given health teachings to the client especially factors that will contribute to the

continuity of care. Affective:

Developed therapeutic relationship between the patient and health care provider

as well as with the significant others. II. NURSING HISTORY

1. Personal History a. Demographic Data Mrs. Vicky (not her real name) is a 45-year old housewife who resides somewhere in San Nicholas, Bamban Tarlac. She was born in Tayug, Pangasinan on June 16, 1966.

5 Mrs. Vicky was admitted in a tertiary hospital in Angeles City on on June 21 at 5:15 pm with the chief complaint of rapid shallow breathing, body weakness and pallor, diagnosed with cancer of the left breast. She was confined for nine days and was discharged on June 30 of 2011. b. Socio-Economic and Cultural Factors Pertaining to economic indices, Mrs. Vicky doesnt have a job at present. She previously worked as a caregiver in Taiwan for 3 years, but due to stressful job day and night with low salary she decided to go back in the Philippines with her family. Few months later she found out that she have a cancer. Mr. Joey on the other hand, is a construction worker before he was laid off last month. At that time, he was earning 404 php per day, six days a week. Expenditures are being budget by Mrs. Vicky from the few savings they have when they are still working. It is estimated that at least 215 php per day is consume to meet their needs. Most of the time Mrs. Vicky prefers to eat preserved foods for their meals such us tocino, longganisa, hotdog, ham, buro and BBQ. Mrs. Vicky is a college graduate, major in commerce. She is married to Mr. Joey and of Roman Catholic religious affiliation. Mrs. Vicky is the fourth child among six children that consists of four girls and two boys. She is a pure Filipino Citizen. The family believes in herbolaryo but medical experts are still priority when times of sickness. They used herbal plants in minor problem such as cough and colds. Mrs. Vicky is also using oral contraceptives as a method for family planning to prevent her from being pregnant, because they think that their children are enough and adding up more will make their lives more difficult.

6 Chemotherapy of Mrs. Vicky is being shouldered by the Philippine Charity Sweepstakes Office, six cycle to be exact, 22,000 php per cycle. Hospitalization and confinement were no longer free and so the family experience financial problem during this times and needed to borrow money from their relatives. c. Environmental Factors

Mrs. Vicky resides in a house inherited by his husband. The location has enough ventilation and no significant pollution. There are no nearby factories as well. Mrs. Vicky did not report problems regarding her environment that could aggravate her condition. 2. Family Health Illness History
FATHER Asthma Tuberculosis MOTHER

Sister 1

Sister 2

Brother 1

Mrs. Vicky Breast Cancer

Sister 3

Brother 2

7 Mrs. Vicky didnt remember how her grandparents pass away, while her father died in Asthma. Other than that they do not have any inherited disease. 3. History of Past Illness Included in the past illness of Mrs. Vicky are the usual childhood illness like mumps, chickenpox and common colds. Palpable mass on her left breast manifested which she ignored few months after giving birth to her youngest son. Mrs. Vicky doesnt breast fed her children since the start, instead she use milkformula bottle-feeding. She has been diagnosed with breast cancer at its second stage last February 2010 and was subjected to surgery the same month. She undergone radical mastectomy but since the tumor is cancerous, the malignant cells continue to proliferate. .Chemotherapy drugs were given in the month of June and October 2010 and followed by April and May this 2011, the fifth cycle is expected this July. 4. History of Present Illness a. Chief Complaint Mrs. Vicky was admitted with the chief complaint of rapid shallow breathing, pallor and body weakness wherein she cannot move her extremities. b. Sequence of the appearance of signs and symptoms Present complain started two days prior to admission when Mrs. Vicky has been doing preparing for dinner when she suddenly her breathing became rapid and shallow. She rested for a while and continued what she was doing. Unfortunately, she cannot even stand due to body weakness and pallor was evidence. She decided to call her husband and was rushed at the hospital.

III.PHYSICAL ASSESSMENT

A. General appearance Upon the initial interaction, the patient is on a sitting position, with no contraptions. She is wearing a cap, pink shirt and a black pajama. B. Vital signs

Temperature- 36.20C Pulse Rate- 88 beats/min Respiratory Rate- 23 breaths/min Blood Pressure- 90/60 mmHg

C. Assessment 1. Integumentary a. Skin b. Hair No hair present in the scalp Fine few hair in the eyebrow Light brown in color Lighter colored palms, soles, nails and lips Darker colored cheeks, forehead and nose Warm, dry Skin returns less than 2 seconds after pinching

9 c. Nails

Pink nail beds Round nails with 1600 angle Hard and immobile Smooth and firm

2. Head and Face a. Head b. Face 3. Eyes Lid margins are moist and pink Short, evenly spaced lashes Blinking symmetrical Bulbar conjunctiva is clear with tiny vessels visible Symmetric Round Temporal arteries are elastic and non tender Temporomandibular joints are non tender Symmetric Round Still and upright Hard Smooth No lesions

10 Palpebral conjunctiva is pink with no discharge Sclera is white Cornea is transparent, smooth and moist Iris and pupil are round, equal and uniform in color Both eyes move in a smooth coordinated manner in all directions Illuminated pupils constrict symmetrically No lesions and discharges Lacrimal apparatus free of swelling and tenderness

4. Ears

Equal in size and similar in appearance Alignment of pinna with the outer canthus of the eyes is within 100 angle of vertical position Smooth and without lesions Presence of moist, odorless, yellow earwax Canal walls are pink in color Auricles and tragus are non tender Mastoid process are non tender, warm and easily palpated

5. Mouth

Lips are brown to reddish-pink in color, symmetrical in position and free of lesions 12 pairs of teeth are shiny and yellowish in color, 8 teeth have tartar and dental caries Gums are light pink. Buccal mucosa is moist, intact, pink in color and free of lesions Tongue is pale pink and resists pressure exerted on the cheeks Uvula hangs freely on the midline Pharyngeal tonsils are free of lesions and swellings

11 6. Nose

Hard plate is pale pink Soft palate is pink

Color equal with the rest of the face Symmetric No change in nares with respiration Client is able to breathe on each nostril while the other one is occluded No masses and tenderness upon palpation Red glow is evident upon transillumination on frontal and maxillary sinuses, non tender upon palpation Clear secretion present

7. Thorax and Lungs a. Posterior Thorax

Scapulae are symmetric , non-protruding and at equal horizontal positions Breathes shallow and rapidly with the use of accessory muscles Sits relaxed Equal temperature bilaterally No tenderness upon palpation No lesions and masses Decreased breath sound Flat/ dull sound elicited upon percussion

b. Anterior Thorax Sternum is straight and located at the midline Respiration at irregular rhythm

12 8. Breasts Left breast

No tenderness upon palpation of lung area No crepitus and unusual bulges palpable Resonance elicited upon percussion Wheezes heard upon auscultation

Chest muscle (pectoralis major) intact No tenderness and masses upon palpation No lump No swelling

Right breast

No tenderness and masses upon palpation No lump No swelling No nipple discharge No nodularity

9. Lymph Nodes

With palpable left supraclavicular fossa lymph nodes, about 3-4 cm in size, rubbery fixed and non tender.

10. Heart and Neck Vessels Jugular vein not distended No swishing sounds upon auscultation Apical pulse not visible No abnormal pulsations and vibrations palpated Heart rate in irregular rhythm Murmurs heard upon auscultation

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11. Peripheral Vascular System a. Arms b. Legs Evenly distributed hair No edema Toes, feet and legs are warm bilaterally Dorsalis pedis and posterior tibial pulses have equal strength Scanty varicosities present Same color bilaterally No edema Warm to touch Capillary refill time of less than 2 seconds Radial and brachial pulses equal in strength bilaterally Ulnar pulse slightly detectable

12. Abdominal No scars present Umbilicus located at the midline Rounded abdomen No aortic pulsation at the epigastric region No visible peristaltic waves Tympany elicited on the stomach and intestines upon percussion Dullness elicited on liver and spleen upon percussion Soft and non-tender upon palpation

13. Musculoskeletal

14 a. Gait b. TMJ Protrudes and retracts easily Has full ROM against resistance No swelling Evenly distributed weight Able to stand on heels and toes Erect posture Coordinated and rhythmic movements

c. Cervical, Thoracic, Lumbar Spine Cervical spine curved anteriorly Thoracic spine curved posteriorly Lumbar spine curved more anteriorly Spinous processes are non tender, firm and smooth

d. Shoulders, Arms, Elbows Shoulders Symmetrically round

Elbows Symmetric and non-tender

Wrists No swelling Symmetric Non-tender

Hands and fingers

15 e. Hips

Symmetreic Non- tender

Buttocks equally sized Stable Non-tender ROM: flexes by 900

f. Knees Symmetric No deformities Non-tender No swelling

g. Ankles and Feet Smooth and rounded No corns, calluses and nodules

14. Neurologic a. Mental Status Consciousness Awake Alert Responds appropriately

Posture Relaxed Curved

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Grooming/hygiene Clean skin and nails Appropriate clothing No unpleasant odor present

Facial expressions Establishes eye contact Smiles upon welcoming the SN and frowns when pain becomes intolerable

Speech/ Mood Clear, moderate tone

Thought processes Follows directions accurately such as complying to the SNs health teachings on how to relieve pain

Cognitive abilities Aware of self and environment, able to distinguish hospital from home environment

b. Motor and Cerebellar Systems Fully developed muscles No tremors Steady gait Opposite arm swings Touches finger to nose with smooth and accurate movement Correctly identifies directions, movements and sensations

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c. Reflexes Abdominal reflex- abdominal muscles contract upon stroking

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39 III. ANATOMY AND PHYSIOLOGY The breasts are specialized organs, which are located on the anterior chest wall. The female breast is more developed than the male breast, as their primary function is to produce milk for nutrition of the infant and baby. There are lots of glands in our breasts, which grow and develop during puberty and maturation. Female hormones such as estrogen and progesterone are important in promoting growth and changes that occur in the breast, especially during pregnancy and the menstrual cycle. Lying in a superficial layer of our skin above our chest muscles, the mammary glands in our breast drain via many ducts to our nipples. There is a dark, circular layer around the nipple, called the areola. It is important for women to understand the normal anatomy and function of their breasts so that any abnormalities can be detected and treated. Breast components The breast consists of:

Milk glands (lobules) that produce and supply milk Special ducts that transfer milk from the lobules to the nipple Nipple Areola (pink/brown pigmented region surrounding the nipple) Fat Connective (fibrous) tissue Breast structure Female breasts are rarely symmetrical. In most cases, a breast is usually slightly

larger or smaller, higher or lower or of different shape to the other side. When fully

40 developed, the female adult breast is composed of 1520 lobes of branching glands. These lobes are separated by bands of connective tissue, which radiate out from the nipple like spokes from the middle of a bicycle wheel. There is lots of fat tissue within the breast. The amount of fat determines the size of the breast. The fatty tissue gives the breast its soft consistency. The special glands in the breast are called tuboalveolar glands, which are modified sweat glands. Each of these glands end in a lactiferous duct (24 mm in diameter) and opens up through a small hole onto the nipple. Deep to the areola, each duct has a dilated part called the lactiferous sinus, in which milk can accumulate and remain in the nursing mother. Cells which are important in contraction movements, called myoepithelial cells, are present in the gland and help in secreting fluids.

Nipple and areola structure and function The nipple and areola are the darker areas of the breast. The nipples contain no fat, hair or sweat glands. There are many smooth muscle fibers in tissues of the breast, which are specially arranged to help the nipple to become erect when stimulated. During

41 puberty, the pigment in the nipple and areola increases and the nipple becomes more prominent. Within the areola, there are sebaceous glands, sweat glands and modified mammary glands (glands of Montgomery). These glands produce small elevations on the areola surface. The sebaceous glands enlarge during pregnancy and secretes oily material, which acts as a lubricant for the areola and nipple. Vasculature of the breast Arteries carry oxygen-rich blood from the heart to the chest wall and the breasts, while veins take de-oxygenated blood back to the heart. The arterial supply of the breast is from:

Internal thoracic artery Lateral thoracic and thoracoacromial arteries Posterior intercostal arteries

Venous drainage of the breast is mainly through the axillary vein, and some drainage occurs through the internal thoracic veins. Drainage of lymph (a clear fluid that travels through the body's arteries, circulates through tissues to help clean them, and then drains away through the lymphatic system) through the breast is very important, especially in metastases involving breast cancer cells. Lymph runs from the nipple, areola and lobules into a special network, which then drains to the axillary lymph noses, parasternal and subclavicular nodes. The nerve supply of the breast is derived from the intercostal nerves. Nerves convey sensory fibres to the skin of the breast so there is sensation of the breast, and nerve fibres also run to the blood vessels and smooth muscles within the breast.

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Breast changes during pregnancy During pregnancy, many changes occur in the breast, to prepare for the baby and produce milk. Cells in the glands of breast tissue change shape and increase in size and number. The areola enlarges and becomes darker. Later in pregnancy, subsequent increases in breast size occur through cells which secrete milk products and these secretory products accumulating in the ducts. A special thick white/yellow fluid called colustrum is produced in the breast during the last few weeks of pregnancy and first few episodes of nursing. This is rich in protein and agents which protect the baby from harmful substances such as bacteria. Hormonal regulation effect on breasts During puberty, growth and development of the breast occurs due to estrogen and progesterone. After this development, changes in breast morphology occur during the ovarian cycle due to hormonal fluctuations. During pregnancy, estrogen and progesterone produced by the corpus luteum stimulate proliferation and development of the breast. Prolactin (produced by the adenohypophysis), somatomammotrophin from the placenta and adrenal corticoids also play a role during pregnancy. After delivery, levels of circulating hormones decrease with degeneration of the corpus luteum and the placenta. Milk secretion is stimulated by increased prolactin (as a neurohormonal response to suckling) and adrenal cortical steroids. Oxytocin is also produced, which stimulates contraction of myoepithelial cells in the mammary glands to eject milk.

43 With absence of ovarian hormones after menopause, breast glands atrophy and secretory cells of the alveoli degenerate. Connective tissue also shows degenerative changes with a decrease in stromal cells and collagen.

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2. Synthesis of the condition a. Definition of the disease Breast cancer is a condition in which malignant cells (cancer) develops in the breast tissue. Mammary gland (Breast) is made up of lobes and ducts. The most frequent type of breast cancer Ductal Carcinoma is, that develop from the ducts. Breast cancer that develops from the lobes or lobules is called lobular carcinoma is the most common type of breast cancer affecting both breasts. Inflammatory breast carcinoma is one of the rarest types of cancer, where breast shows signs of inflammation (redness, local heat and swelling). b. Predisposing/ precipitating factors Predisposing Factors Etiology of breast is still unknown, but there are predisposing and precipitating factors that are being linked to the increased risk of developing breast cancer. Breast cancer that is not attributable to DNA mutations that were inherited from a parent, such as the BRCA genes, are largely due to the effects of the natural, female hormone, estrogen. Females Females are highly at risk of developing breast cancer compared to males, though males also secrete estrogen at minimal amount. Females secrete high levels of estrogen. The age specific incidence curve, which is the incidence of breast cancer plotted against the age of women, shows breast-cancer rates start to rise about eight to ten years after the average age of the first menstrual cycle (menarche) when a woman is first exposed to increasing levels of estrogenic hormones. The incidence curve rises sharply until the approach of menopause when the incidence of breast cancer rises more slowly as her estrogen levels drop.

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Race According to the National Cancer Institute, white, non-Hispanic women have the highest overall incidence rate for breast cancer among U.S. racial/ethnic groups, while Korean American women have the lowest rate. Among women ages 40-50, African American women have a higher incidence of breast cancer than white women. African American women also have the highest death rate from breast cancer; Chinese American women have the lowest death rate. Several factors have been found to impact the breast cancer incidence and death rates among racial and ethnic groups. Differences in certain lifestyle behaviors such as diet, exercise, and acceptability of smoking and alcohol use can impact the risk of many diseases, including heart disease and breast cancer. The higher death rate from breast cancer among African American women has been linked to the stage, or extent, of the cancer at the time it's diagnosed. Studies show that African American women tend to seek treatment when their cancer is in a more advanced, less treatable stage. In addition, a higher percentage of African Americans and Hispanics lack a usual source of health care, such as a primary care provider. Having a primary care provider increases the chance that a person will receive appropriate preventive care -- including routine check-ups and screenings that can detect breast cancer at an early stage. Socioeconomic factors: These include income level, lack of transportation, and lack of access to health insurance or health care facilities, including screening programs. Language and communication barriers: These barriers can interfere with a person's ability to discuss health concerns and develop trust in a primary care physician. Education about or understanding of health care risks and symptoms: Women who are not aware of breast cancer risks and symptoms are more likely to wait to seek treatment until they are in pain or their symptoms interfere with daily tasks. Cultural practices and expectations: Women of some cultures may turn to traditional or "folk" remedies before seeking treatment from a doctor. Cultural and/or religious beliefs related to health and health care. Strong beliefs in healing and miracles, as well as distrust of the health care system may keep some people from participating in routine preventive care.

51 There continues to be an enormous need for more education and resources to reach women particularly minority women with the message of breast cancer screening and prevention. Prevention and early detection of breast cancer are important for all women. Nulliparity Nulliparity also predispose a female to breast cancer. A female who havent given birth is at risk due to accumulation and prolonged exposure to estrogen in which there is no way for the estrogen to be excreted out to the circulation. During pregnancy estrogen is synthesized and produces metabolites particularly estrione which is a metabolite of estradiol (potent type of estrogen) excreted and usually seen on pregnant women urine. History of benign breast disease Females who have history of benign breast diseases are at risk of developing malignant breast cancer. Benign tumors cells in the body may progress and develops into malignant type of cancer cell due to a lot of factors that stimulates the production of cancer cells. Upon this benign to malignant conversion, malignant cancer cells invades local areas and also into the different system. Family History of Breast cancer Mutations that are passed from parent to child are called hereditary mutations or germ line mutations (because they are present in the egg and sperm cells, which are also called germ cells). This type of mutation is present throughout a persons life in virtually every cell in the body. Females can inherit mutated BRCA genes from their parents who have history of breast cancer. Breast cancers can develop slowly for a long period of time (Lag time), and in due time onset of disease will occur.

52 Precipitating Factors Radiations Some atoms give off radiation, which is energy that travels through space. Prolonged or repeated exposure to certain types of radiation can cause cancer. Cancer caused by the sun's ultraviolet radiation is most common in people who spend long hours in strong sunlight. Ultraviolet radiation from sunlight is a low-strength type of radiation. Effective ways to protect against ultraviolet radiation and to prevent skin cancer are to avoid going into strong, direct sunlight and to wear protective clothing. Sunscreen lotions reduce the risk of some forms of skin cancers. Increased rates of cancer also have been detected in people exposed to highstrength forms of radiation such as X-rays or radiation emitted from unstable atoms called radioisotopes. Because these two types of radiation are stronger than ultraviolet radiation, they can penetrate through clothing and skin into the body. Therefore, highstrength radiation can cause cancers of internal body tissues. Examples include cancer caused by nuclear fallout from atomic explosions and cancers caused by excessive exposure to radioactive chemicals. Due to this radiation, normal cell are being damaged and causes gene mutation. This mutation causes a cell to behave abnormally. Mutated cells then begin to proliferates and they are poorly differentiated due to rapid division cause by the mutated genes. Oral Contraceptive (OCP) and Estrogen replacement therapy (ERT) The main content of OCPs and ERTs is estrogen primarily. One of the primary factors that causes cancer is estrogen, estrogen triggers proliferation of cells, by which cancers cells also proliferates and metastasize throughout the body. Therefore as long a there are estrogen cancer cells will continue to proliferate. The lack of estrogen in postmenopausal women is linked to several health problems. For example, estrogen has positive effects on blood vessels and on bones. After menopause, though, women are at increased risk for heart disease and for osteoporosis, a weakening of the bones that causes them to become more vulnerable to fractures.

53 To counteract these potential problems, many postmenopausal women take hormone pills containing estrogen to strengthen bones and help control other menopausal symptoms. But as a consequence, such women may also subject themselves to the harmful effects of estrogen, namely, an increased risk for invasive breast cancer and for uterine cancer. Diet Diet plays a role in the development of cancer. People who are funned of eating preserved foods such as meats, pickled food are at great risk of developing cancer due to a chemical Nitrosamine which is highly carcinogenic. This chemical promotes cancer development. Studies suggest that differences in diet may also play a role in determining cancer risk. Unlike clear-cut cancer risk factors such as tobacco, sunlight, and alcohol, dietary components that influence cancer risk have been difficult to determine. Limiting fat consumption and calorie intake appears to be one possible strategy to decrease risk for some cancers, because people who consume large amounts of meat, which is rich in fat, and large numbers of calories exhibit an increased cancer risk, especially for colon cancer. Obesity Leptin, an adipocyte-derived hormone, is best known for its efforts to send messages to the body that no more food is needed, a process that may go awry in many people with obesity. But it also is involved in many other processes, from reproduction and lactation to cell differentiation and proliferation. Leptin is activated by signals from the leptin receptor ObR, and it is this partnership that has previously been found to be involved in the development of breast cancer. It was recently reported, for example, that leptin was detected in 86.4 percent of primary breast tumors and that its expression was highly correlated with ObR. In previous studies, leptin was demonstrated to play a significant role in promoting breast cancer in obese women by increasing the amount of estrogen (estradiol) in breast tissue. In the current study, the researchers found that leptin also upregulated or

54 increases the production of E-cadherin, an intercellular adhesion molecule generally viewed as a tumor suppressor. Combined exposure to leptin and estradiol increased tumor size, sometimes doubling it, and these changes correlated with an increase in E-cadherin. It is reasonable to suggest that the tumor suppressor E-cadherin may serve as a tumor enhancer when exposed to leptin and estradiol, that its ability to help cells aggregate then enhances the transformation of normal cells to cancerous cones, stimulating the growth of tumor mass. When the researchers used an E-cadherin antibody or a calcium-chelating agent to block E-cadherin function in the present of estradiol, this enhanced cell growth stopped. Obese women may be more likely to develop breast cancer largely because their bodies produce more estrogen than thin women do. New research suggests that the increase in breast cancer risk faced by obese postmenopausal women may largely be due to higher levels of estrogens circulating in their bodies. High levels of estrogen are known to stimulate certain types of breast cancer tumors to grow and develop. The study, published in the Journal of the National Cancer Institute, shows that the average concentration of estrogens in obese women was between 50% and 219% higher than in thin women, and the risk of breast cancer increased by about 18% with each increase in body mass index (a measurement of weight and height used to indicate obesity). Stress Previous population studies have shown a relationship between the experiences of intense psychological stress, such as that associated with the loss of a spouse or loved one, and an elevation in breast cancer risk. The study, led by biochemist Christopher Mueller, found that the stress hormone hydrocortisone may repress the activity of a tumour-suppressing gene known as BRCA1 that is related to breast cancer. Hydrocortisone is also known to decrease immune system, making a person risk for diseases. Published recently in the journal Genes, Chromosomes and Cancer, Dr. Mueller sees strong potential to build upon these findings and identify opportunities for clinical interventions to reduce or manage stress-related breast cancer risk. However, more

55 research must be completed to confirm the effects of hydrocortisone on human breast tissue BRCA1 is a tumour-suppressing gene involved in a range of key cellular processes, including the repair of damaged DNA and the regulation of cell death. In researching the effects of various hormones on cultured mouse mammary cells, Mueller found that continuous exposure to hydrocortisone was associated with a decreased expression of BRCA1. Mueller theorizes that by disrupting BRCA1s normal activity, hydrocortisone may impede the ability of breast cells to maintain genomic stability and suppress transformation into a cancerous form. Changes in BRCA1 and its activity are known to contribute to some cases of breast cancer, the most common cancer among Canadian women. Mutations to the gene are implicated in a large proportion of familial breast cancers, while low levels of BRCA1 expression have been found in many sporadic cases of the disease. Tobacco smoking Cigarette smoke and nicotine act in a mutually antagonistic manner, with the smoke activating alveolar macrophages and therefore inducing local inflammatory response, while nicotine suppresses the antigen presentation function that is required for a specific immune response. Smokers have been found to have an increased rate of death from breast cancer in several epidemiologic studies, although they do not have an increased incidence of the disease. One potential explanation for this is that smoking, through its pulmonary or systemic effects, adversely affects the natural history of breast cancer. Since the lung is a common site of metastasis from breast cancer, and smoking is a cause of numerous changes in the lung that could affect the likelihood of metastatic spread to this organ, it is plausible that smoking might alter the course of breast cancer by increasing the frequency with which breast cancer metastasizes to the lung. Cigarette smoking and breast cancer are both sufficiently common that an effect of smoking on the natural history of breast cancer may have important implications for the health of women.

56 The susceptibility of an organ to invasion by malignant cells is a dynamic variable. Smoking causes a host of changes in the lung, including increased permeability and altered local immune function, and is associated with changes in the incidence and/or natural history of a broad variety of lung diseases. Smoking has systemic effects that could affect tumor defense mechanisms external to the lung. For example, the number of circulating natural killer cells is reversibly decreased in active smokers. Smoking also affects platelet function and coagulability, factors that are believed to play a role in the bodys defense against tumor cells lodged within capillary beds. In addition, oxidant constituents of cigarette smoke affect signal transduction mechanisms involved in the metastatic process. (Murin & Inciardi, 2001). c. Pathologic Sequence There is no known etiology of breast cancer, but there are a lot of factors that promotes cancer development. Mainly due to the natural, female hormone, estrogen. The breast and the uterus, which play central roles in sexual reproduction, are two of the main targets of estrogen. In addition, estrogen molecules act on the brain, bone, liver, and heart. Due to the increased availability of estrogen in the body, which is a mammary gland carcinogen (Yeager& Davidson 2006). Estrogen is being synthesized, distributed and metabolized in the body. Estrogen can goes into different pathways. Estrogens act on target tissues by binding to parts of cells that have estrogen receptors. The estrogen binds to its receptor, thereby causing the shape of the receptor to change. Then it undergoes signal transduction, wherein this estrogen-receptor complex binds to specific DNA sites, called estrogen response elements, which are located near genes that are controlled by estrogen. After it has become attached to estrogen response elements in DNA, this estrogen-receptor complex binds to coactivator proteins and more nearby genes become active. The active genes produce molecules of messenger RNA, which guide the synthesis of specific proteins. These proteins can then influence cell behavior in different ways, depending on the cell type involved. This synthesis of proteins causes cells to proliferate rapidly and differentiate poorly.

57 Metabolites of estrogen synthesis also causes imbalances such lipid peroxidation, oxidative imbalance, DNA adducts and redox imbalance. This metabolites, in normal way are being excreted out of the body specially during pregnancy and usually found in the urine of a pregnant mother particularly estrione which is secreted by the placenta during pregnancy which is a metabolite of estradiol.
d. Signs and Symptoms with Rationale

Carcinogenesis Stage 1: Initiation Carcinogen such as nitrosamines and radiation causes damages on the DNA. This causes changes on the structure and function of cells at molecular level. With this instance mutation occurs particularly mutation of the genes that controls cell growth, proliferation and differentiation ( BRCA1, BRCA2, P53). Activation of growth causing promotion of oncogenes, which then leads to formation of pre-cancerous cells. The programmed cell death or Apoptosis will then be activated to eliminate the pre cancerous cell before they become cancerous cells. With the alteration of the genes that controls apoptosis (P53 genes), apoptosis is halted and unregulated, precancerous cell escapes apoptosis. This causes abnormal growth of tissue. Immune system will be now stimulated, increasing the numbers of macrophages that will phagocytize the abnormal cells. T and B lymphocytes are also stimulated that will cause increased immune response. But due to the inactivation of the tumor suppressor genes BRCA1, BRCA 2 and P53, NK activity & T cell proliferation is decreased. Combined with the production of hydrocortisone by stress that causes decreased leukocyte antigen inhibition reactivity, and with suppression of antigen presentation required for specific immune response that causes decreased specific immunity caused by tobacco smoking, this causes depression of the development and expression of anti-tumor activity that will now lead to stage two of carcinogenesis: Promotion. Stage 2: Promotion In this stage further assaults and genetic damages occurs. There is progressive growth of neoplastic cells that are poorly differentiated serving no physiologic functions.

58 The progressive growth of neoplastic cell causes growth of epithelial cell on the mammary glands. Formation of adenocarcinomas (with estrogen receptor positive) occurs on the glandular epithelium of the milk ducts of the mammary glands. As cell grows, cell at the center that are surrounded by the tumor cell becomes hypoxic due to the compression cause by the tumor cell and because tumor cells are avascular, having no source of nutrients and oxygen. Tumor cells get its nutrients and oxygen from the normal cells. Tumor cells then now secrete angiogenic agents namely vascular endothelial growth factor (vEgF) and basic fibroblastic growth factor (bFgF). This protein stimulates angiogenesis. Endothelial cells are activated by VEGF or bFgF sets in motion a series of steps toward the creation of new blood vessels. First, the activated endothelial cells produce matrix metalloproteinases (MMPs), a special class of degradative enzymes. These enzymes are then released from the endothelial cells into the surrounding tissue. The MMPs break down the extracellular matrix which is a support material that fills the spaces between cells and is made of proteins and polysaccharides. Breakdown of this matrix causes degradation of the capillary basement membrane and vascular deformity that permits the migration of endothelial cells. As they migrate into the surrounding tissues, they proliferate; reorganization of endothelial cells making new capillaries. Anastomosis establishes new blood flow, supplying the tumor cells with nutrients allowing further growth and development resulting in increased tumor size. Tumor cells now then invade stroma using enzymes for mechanical expansion. Stage 3: Malignant Conversion In this stage benign tumors/ precancerous cell are converted into malignant/ cancerous cells. Appearance of cell are larger, heterogeneous in size, there is rapid growth and lack of lack of pattern of organization. Their growth pattern is through invasion of adjacent tissues, wherein cell proliferation exceeds cell death. Upon mitotic division, there is anaplasia wherein cells are differentiated poorly or undifferentiated. Causing alterations on their function and sometime serves no physiologic functions. These changes in cell characteristics particularly rapid cell proliferation and cell growth increases pressure on the surrounding tissues causing chest tightness, and then there is nociception. Due also to the changes in cell characteristics, it causes decrease and

59 nutrient supply to the cells, thereby causing hypoxia of the cells. This causes the cells to undergo anaerobic metabolism, causing lactic and pyruvic acid accumulation, causing pain. Stage 4: Progression Metastasis Detachment: Tumor cells decrease the expression of adhesion molecules on cell causing them to detach from tumor mass. Tumor cells lose cohesiveness, increases motility and detach from the primary tumor cells and create defects on the basement membranes. Migration: These results to stromal invasion and spreading into the circulation through direct extension into the lymphatic system that provides the most common pathway for the initial spread of the malignant cancer cells and also to the bloodstream. This causes migration of the cancer cells into the different parts of the body including, bones, lungs and brain. Dissemination: Due to the tobacco smoking, especially its content nicotine, expression of surface proteins related to antigen presentation by pulmonary macrophages and together with the tobacco smoke which also induces inflammatory response that cause increased capillary permeability then now results in decreased altered immune response. There is now susceptibility of malignant cells to invade the lungs. Lymphatic drainage in the pleural space of the lungs increases which results pleural effusion causing incomplete lung expansion. This will further cause poor oxygen supply causing cyanosis, atelectasis that causes absence of breath sounds and rapid shallow breathing with the use of accessory muscles. Breast cancer cells also migrates to the bones, Breast cancer cells establish tight interaction with the bone marrow microenvironment. There is increase breast cancer cells proclivity in the bones, cancer cells secretes osteolytic factor the causes dissolution of bones. This will cause bone demineralization and changes in bone surface, together with activation of tumors this will causes nerve compression and will causes intractable pain.

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65 2. Synthesis of the Disease (Client-Centered) a. Predisposing and Precipitating Females Females are highly at risk of developing breast cancer compared to males, though males also secrete estrogen at minimal amount, making Mrs. Vicky more prone to breast cancer. Lifestyle: Diet Most of the time Mrs. Vicky prefers to eat preserved foods for their meals such us tocino, longganisa, hotdog, ham and buro, BBQ. Precipitating Factors Radiations Mrs. Vicky spend long hours in strong sunlight thats why theres an increase radiation level. Ultraviolet radiation from sunlight is a low-strength type of radiation. But still, normal cell are being damaged and causes gene mutation. This mutation causes a cell to behave abnormally. Mutated cells then begin to proliferate and they are poorly differentiated due to rapid division cause by the mutated genes. Oral Contraceptive (OCP) and Estrogen replacement therapy (ERT) Mrs. Vicky is also using oral contraceptives as a method for family planning to prevent her from being pregnant, because they think that their children are enough and adding up more will make their lives more difficult. Stress She previously worked as a caregiver in Taiwan for 3 years, but due to stressful job day and night with low salary she decided to go back in the Philippines with her family. Few months later she found out that she have a cancer.

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b. Signs and Symptoms with Rationale Enlarge Lymph Node (Left Supraclavicular fossa) The cancer cells continuous to spread into the circulation through direct extension into the lymphatic system that provides the most common pathway for the initial spread of the malignant cancer cells and also to the bloodstream. This causes migration of the cancer cells into the different parts of the body including, bones, lungs and brain. Cyanosis and weakness, Rapid shallow breathing, Use of accessory Muscle The affectation of the lungs increases the lymphatic drainage in the pleural spaces, clearly evident in Mrs. Vickys condition since she developed Pleural Effusion. Her lung expansion is poor and oxygen is not enough, resulting into cyanosis and weakness. To compensate for the decrease oxygen, the lungs try to increase respiration rate needing to use accessory muscle.