Women's Chapter 6 - Disorders of the Breasts

fibrocystic breast changes

- also classified as non proliferative lesions - caused by an overgrowth of fibrous tissues in connective tissues supporting the breasts - frequently accompanied by presence of fluid filled cysts - cysts that develop move freely when palpated, and symptoms decline after menopause when levels of estrogen and progesterone drop - do not increase risk of breast cancer - breast exams and mammography become more difficult to interpret - most common b/w ages 30-50

fibroadenomas

- also classified as proliferative lesions w/o atypia (cell abnormalities) - common, slow growing, benign solid breast tumors - most common mass in women ages 15-30 years - considered hyper plastic lesions associated w/ aberration of normal development and involution - can be stimulated by external estrogen, progesterone, lactation, and pregnancy - composed of both fibrous and glandular tissue that feels round or oval, firm, rubbery, and smooth, and they are mobile and may be tender - usually unilateral - masses are frequently larger than 5 cm and occur most often in pregnant or lactating women - rarely associated w/ cancer

high dose brachytherapy

- alternative to traditional radiation - balloon catheter is used to insert radioactive seeds into breast after tumor has been removed surgically - procedure takes 4-5 days as opposed to 4-6 weeks that traditional radiation therapy takes - now used frequently after breast conserving surgery in selected women as alternative to whole breast irradiation - side effects - redness or discharge around catheters, fever, and infection

ACS mammogram recommendations for women w/ no symptoms or family hx

- annual mammograms and clinical breast exams for women starting at ages 40-54 and then biennially, starting at 55 - clinical breast exam about every 3 years for women in their 20s and 30s and every year for women older than 40 - BSE is an option for women starting in their 20s

other invasive carcinomas

- another invasive type of breast cancer is tubular carcinoma, which typically occurs in women aged 55 and older - colloid carcinoma occurs in women 60-70 years of age and is characterized by presence of large pools of mucus interspersed w/ small islands of tumor cells - medullary carcinoma accounts for 5-7% of malignant breast tumors; it occurs frequently in younger women (under 50) and grows into large tumor masses - inflammatory breast cancer often presents w/ skin edema, redness, and warmth, and is associated w/ poor prognosis - paget disease originates in nipple and typically occurs w/ invasive ductal carcinoma

nursing assessment of fibroadenomas

- ask woman about clinical manifestations - lumps are felt as firm, rubbery, round, well circumscribed, freely mobile nodules that might or might not be tender when palpated - usually detected incidentally during clinical or self exams and are usually in upper outer quadrant of breast - clinical breast exam by HCP is critical - diagnostic studies including imaging studies and some form of biopsy - if additional tissue needs to be evaluated, advanced breast biopsy instrument (ABBI) is used

immediate postop care

- assess respiratory status by auscultating lungs and observing breathing pattern - assess circulation; note vital signs, skin color, and skin temperature - observe neuro status by evaluating level of alertness and orientation - monitor wound for amount and color of drainage - monitor IV lines for patency, correct fluid, and rate - assess drainage tube for amount, color, and consistency of drain

therapeutic management of fibrocystic breast changes

- begins with self care - diet and lifestyle changes can help reduce comfort - other options include wearing a supportive bra, taking OTC pain relievers, and limiting salt consumption which can cause fluid retention - in severe cases, drugs including bromocriptine, tamoxifen, or danazol, can be used to reduce influence of estrogen on breast tissue undesirable sid effects, including masculinization, have been documented - aspiration or surgical removal of breast lumps will reduce pain and swelling by removing space occupying masses

physical exam for fibrocystic breast changes

- best to examine breast a week after menses, when swelling has subsided - breast exam is performed using triple touch method in which provider uses pads of middle three fingers and makes dime sized overlapping circles to feel breast tissue w/ three levels of pressure: light, medium, and firm - observe breasts for fibrosis, or thickening of normal breast tissues, which occurs in early stages - cysts form in the later stages and feel like multiple, smooth, well delineated tiny pebbles or bumpy oatmeal under skin - cancerous lesions are typically fixed and painless and may cause skin retraction - cysts tend to be mobile and tender and do not cause skin retraction in surrounding tissue

breast cancer metastasis

- breast cancer metastasizes widely and to almost all organs of the body, but primarily to bone, lungs, lymph nodes, liver, and brain - first sites of metastases are usually local or regional, involving chest wall or axillary supraclavicular lymph nodes or bone

breast augmentation

- breast size is enhanced - saline filled or silicone filled implants are used in cosmetic enhancement and reconstructive surgeries, but both have outer silicone shell - location is typically sub glandular (over pectoral muscle) or sub pectoral (under muscle) - potential complications - capsular contracture, rippling, implant rupture, asymmetry, breast pain, infection, or hematoma - breast examination in women w/ reconstructive surgery is done exactly the same way as natural breasts

nonlactational mastitis

- can be caused by duct ecstasia, which occurs when milk ducts become congested w/ secretions and debris, resulting in periductal inflammation - may be divided into central (periareolar) and peripheral breast lesions - periareolar infections consist of active inflammation around non dilated subareolar breast ducts - condition termed periductal mastitis - peripheral nonlactating breast abscesses and are often associated w/ underlying condition such as diabetes, RA, steroid txx, granulomatous, lobular mastitis, and trauma - women w/ these types of abscesses present w/ greenish nipple discharge, nipple retraction, and non cyclical pain

health hx for fibrocystic breast changes

- common clinical manifestations - lumpy, tender breasts and feeling of fullness, particularly during week of menses - changes in breast tissue produce pain by nerve irritation from edema in connective tissue and by fibrosis from nerve pinching - pain is cyclic and frequently dissipates after onset of menses - pain is described as dull, aching, feeling of fullness - masses or nodularity usually appear in both breasts and are often found in upper outer quadrants - some women also experience spontaneous clear to yellow nipple discharge when breast is squeezed or manipulated

nursing assessment for mastitis

- diagnosis is made clinically on basis of localized, unilateral area of erythema w/ associated fever - assess pt for clinical manifestations - flu like symptoms of malaise, nausea, headache, leukocytosis, fever, fatigue, and chills - physical exam of breasts reveals increased warmth, swollen area of one breast, redness, tenderness, and swelling - nipple usually cracked or abraded and breast distended w/ milk - in lactating women, severe engorgement can be differentiated from mastitis bc engorgement is bilateral w/ general involvement of whole breast - ultrasound scans can be undertaken to differentiate b/w types of mastitis or abscesses, but typically diagnosis made based on hx and exam

diagnosis of breast cancer

- diagnostic mammography or digital mammography - magnetic resonance mammography (MRM) - fine needle aspiration biopsy or core biopsy - stereotactic needle guided biopsy - sentinel lymph node biopsy - hormone receptor status - infrared thermal imaging - DNA ploidy status - cell proliferative indices - HER2/neu genetic marker

fine needle aspiration biopsy or core biopsy

- done to identify solid tumor, cyst, or malignancy - small needle connected to 10 mL or larger syringe is inserted into breast mass, and suction is applied to withdraw contents - core needle biopsy is similar except that larger needle is used to withdraw small cylinders or cores of tissue from abnormal area of breast

assessment for breast cancer

- early breast cancer has no symptoms - earliest sign is often abnormality seen on screening mammogram before woman or HCP feels it - take thorough hx of problem and explore woman's risk factors for breast cancer - assess woman for clinical manifestations of breast cancer - clinical breast exam - complete breast exam to validate clinical manifestations and findings of health history and risk factor assessment - recognize effects on emotional state, coping ability, and QOL

therapeutic management of mastitis

- effective milk removal, pain medication, and abx therapy have been mainstays of tx - management of both types of mastitis involves use of oral abx (usually penicillinase-resistant penicillin or cephalosporin), warm compress to inflamed area, continued breastfeeding, and acetaminophen for pain and fever

affected arm care

- elevate affected arm on pillow to promote lymph drainage - make sure no tx are performed on affected arm, including lab draws, IV lines, BP, and so on - place sign above bed to warn others not to touch affected arm

benign breast masses described as

- frequently painful - firm, rubbery mass - bilateral masses - induced nipple discharge - regular margins - no skin dimpling - no nipple retraction - mobile - no bloody d/c

patho of breast cancer

- group of diseases that result from unregulated cell growth - thought to be colonial in nature, which means that each cell is derived from another cell - breast cancer starts in epithelial cells that line mammary ducts w/n breast - growth rate depends on hormonal influences, mainly that of estrogen and progesterone

malignant breast masses described as

- hard on palpation - painless - irregularly shaped - immobile - skin dimpling - nipple retraction - unilateral mass - bloody, serosanguineous, or serous nipple d/c - spontaneous nipple d/c

invasive (infiltrating) breast cancers

- have extended into surrounding breast tissue w/ potential to metastasize

breast cancer incidence rates among ethnicities

- higher in non-hispanic white women compared w/ african american women for most age groups - african american women have higher incidence rate before 40 and more likely to die

reconstruction

- if woman decides to have it, it is ideally performed immediately after mastectomy - woman must also determine whether she wants surgeon to use saline implants or natural tissue from her abdomen (TRAM flap method) or back (LAT flap method) - whether to have reconstructive surgery in an individual and complex decision - each woman must be presented w/ all of the options and then allowed to decide

mastectomy

- in conjunction w/ mastectomy, lymph node surgery may need to be done to reduce risk of distant metastasis and improve woman's chance of long term survival - must decided whether to have further surgery to reconstruct the breast

noninvasive breast cancers

- in situ - those that have not extended beyond duct, lobule, or other point of origin into surrounding breast tissue

staging breast cancer

- incorporates grade, estrogen receptor status, progesterone receptor status, and HER2 (human epidermal growth factor receptor 2, a gene that can be a factor in developing breast cancer) status, along w/ tumor size, lymph node involvement, and evidence of metastasis - helps determine probability that tumor has metastasized to decide on appropriate course of therapy and assess pt's prognosis - overall 10 year survival rate for woman w/ stage I breast cancer is 80-90%, for stage II, it's about 50% - bone scan can be performed to assess the bones, and MRI can be used to detect metastases to liver, abdominal cavity, lungs, or brain

mastitis

- infection or inflammation of connective tissue in breast that occurs primarily in lactating or engorged women

breast conserving surgery

- least invasive procedure - wide local excision (or lumpectomy) or tumor along w/ 1 cm margin of normal tissue - often used for early stage localized tumors - goal is to remove suspicious mass along w/ tissue free of malignant cells to prevent recurrence - women may receive radiation after - in women who do not require adjuvant chemo, radiation begins typically 2-4 weeks after surgery to allow healing of incision site - sentinel lymph node biopsy may also be performed

lab and diagnostic tests for fibrocystic breast changes

- mammography can be helpful in distinguishing fibrocystic changes from breast cancer - ultrasound is useful adjunct for breast evaluation bc it helps differentiate cystic mass from solid one - fine needle aspiration biopsy can also be done to differentiate a solid tumor, cyst, or malignancy - in stereotactic needle biopsy, a computer maps exact location of mass using mammograms taken from two angles, and map is used to guide needle

therapeutic management of fibroadenomas

- may include period of "watchful waiting" bc many fibroadenomas stop growing or shrink on their own w/o any tx - other growths may need to be surgically removed if they do not regress or if they remain unchanged - cryoablation (cryotherapy), an alternative to surgery, can also be used to remove tumor - extremely cold gas is piped into tumor using ultrasound guidance and tumor freezes and dies - current trend is toward more conservative approach to tx after careful evaluation and continued monitoring

malignant breast disorder

- neoplasticism disease in which normal body cells are transformed into malignant ones - most common cancer in women and second leading cause of cancer deaths - cause of breast cancer is thought to be a complex interaction b/w environmental, genetic, and hormonal factors - progressive disease - most cancers grow from small size w/ low metastatic potential to larger size and greater metastatic potential

nursing management of fibroadenomas

- nurse should urge pt to return for reevaluation in 6 months, perform monthly BSEs, and return annually for clinical breast exam - recent studies suggest that women w/ high breast density and proliferative benign breast disease are at high risk for future breast cancer - women w/ low breast density are at low risk, regardless of their benign pathologic diagnosis

hormonal therapy

- objective of endocrine therapy is to block or counter the effect of estrogen - include selective estrogen receptor modulators (SERMs), estrogen receptor downregulators, aromatase inhibitors, luteinizing hormone release hormone, progestin, and biologic response modifiers - current recommendations for women w/ ER positive breast cancer are known to take hormone like medication known as SERM antiestrogenic agent - daily for up to 5 years after initial treatment - side effects - hot flashes, bone pain, bone thinning, insomnia, weight gain, depression, fatigue, mood swings, constipation, nausea, cough, dyspnea, and headache

invasive lobular carcinoma

- originate in terminal lobular units of breast ducts and account for 10% of all cases - peak incidence is women in early 60s - presents as area of ill defined thickening rather than palpable mass - tumor frequently located in upper outer quadrant of breast, and by time it's discovered, the prognosis is usually poor

chemotherapy

- particularly effective against malignant cells but affect all rapidly dividing cells, especially those of the skin, hair follicles, mouth, GI tract, and bone marrow - may be indicated for women w// tumors larger than 1 cm, positive lymph nodes, or cancer of an aggressive type - prescribed in cycles, w/ each period of tx followed by rest period - most active and commonly used chemo agents for breast cancer include alkylating agents, anthracyclines, antimetabolites, and vinca alkaloids - typical side effects - nausea and vomiting, diarrhea or constipation, hair loss, weight loss, stomatitis, fatigue, and immunosuppressive

factors that affect tx plan

- primary factors - whether cancer is invasive or noninvasive, tumor's size and grade, number of cancerous axillary lymph nodes, hormone receptor status, woman's overall health, ability to obtain clear surgical margins - BRCA1 and BRCA2 mutations

surgical options

- primary goal of breast cancer surgery is to successfully remove breast cancer - secondary and important goal is to reconstruct removed tissue so as to allow the woman to feel whole from a psychological perspective - women w/ tumors larger than 5 cm or inflammatory breast cancer may undergo non adjuvant chemo or radiotherapy to shrink tumor before surgical removal is attempted - surgical options depend on type and extent of cancer - choices are typically either breast conserving surgery (lumpectomy w/ radiation) or mastectomy w/ or w/o reconstruction

pain management

- provide analgesics as needed - teach woman how to communicate w/ her pain intensity on a scale of 0 to 10 - assess pain frequently and anticipate pain before assisting in ambulating

radiation therapy

- uses high energy rays to destroy cancer cells that might have been left behind in the breast, chest wall, or underarm area after tumor has been removed surgically - usually serial radiation doses are given 5 days a week to the tumor site for 6-8 weeks postop - side effects - inflammation, local edema, anorexia, swelling, and heaviness in breast; sunburn like skin changes in treated area; and fatigue

lactational mastitis

- usual causative organisms for lactational mastitis are staph aureus, hemophilus influenzas, and hemophilus and streptococcus species, source of which is baby's flora - lactating mastitis typically occurs in first 2-3 weeks of lactation, but can occur at any stage of lactation, but can occur at any stage - one or more ducts drain poorly or become blocked, resulting in milk stasis and bacterial growth in retained milk - only evidence predisposing factor that may lead to mastitis is development of milk stasis

two steps of BSE

- visual inspection - tactile palpation

nutritional recommendations to reduce breast cancer risk

Engaging in daily moderate exercise and weekly vigorous physical activity Consuming at least five servings of fruits and vegetables daily Not smoking or using any tobacco products Keeping a maximum BMI of 25 and limiting weight gain to no more than 11 lb since age 18 Consuming seven or more daily portions of complex carbohydrates, such as whole grains and cereals Limiting intake of processed foods and refined sugar Limiting consumption of energy-dense foods and sugary drinks Avoiding use of dietary supplements which are unlikely to improve prognosis Restricting red meat intake to approximately 3 oz daily Limiting intake of fatty foods, particularly those of animal origin Restricting intake of salted foods and use of salt in cooking

phytochemical rich foods

Green tea and herbal teas Garlic Whole grains and legumes Onions and leeks Soybeans and soy products Tomato products (cooked tomatoes) Fruits (citrus, apricots, pumpkin, berries) Green leafy vegetables (spinach, collards, romaine) Colorful vegetables (carrots, squash, tomatoes) Cruciferous vegetables (broccoli, cabbage, cauliflower) Flax seeds

caring for mastitis

Take medications as prescribed to reduce inflammation and infection. Continue breast-feeding as tolerated to keep the milk flowing. Begin feeding on most affected breast to allow it to be emptied first. Massage the breasts before and during breast-feeding to encourage milk extraction. Wear a supportive bra 24 hours a day to support the breasts for comfort. Increase fluid intake to stay hydrated. Gently massage toward nipple several times daily. Vary the infant's breast-feeding position: cradle, side-lying, football, and belly to belly. Make sure infant is positioned correctly on the nipple to prevent discomfort. Practice good hand hygiene techniques to reduce risk of bacterial transfer. Apply warm compresses to the affected breast or take a warm shower before breast-feeding. Frequently change positions while nursing to improve milk flow. Get adequate rest and nutrition to support or improve the immune system. Instruct the client to contact her health care provider if she experiences fever, chills, or worsening symptoms.

relieving symptoms of fibrocystic breast changes

Wear an extra supportive, well-made bra to prevent undue strain on the ligaments of the breasts to reduce discomfort. Take oral contraceptives as recommended by a health care practitioner to stabilize the monthly hormonal levels. Eat a low-fat diet rich in fruits, vegetables, and grains to maintain a healthy nutritional lifestyle and ideal weight. Apply heat or cool packs to the breasts to help reduce pain. Take diuretics as recommended by a health care practitioner to counteract fluid retention and swelling of the breasts. Reduce salt intake to reduce fluid retention and swelling in the breasts. Take over-the-counter medications, such as acetylsalicylic acid (Aspirin) or ibuprofen (Motrin, Advil, Nuprin), to reduce inflammation and discomfort. Use thiamine and vitamin E therapy. This has been found helpful for some women, but research has failed to demonstrate a direct benefit from either therapy. Take medications as prescribed (e.g., bromocriptine, tamoxifen, or danazol). Discuss the possibility of aspiration or surgical removal of breast lumps with a health care practitioner. Restrict use of alcohol. Avoid caffeinated drinks (coffee, tea, soda), which tend to trigger breast discomfort.

modified radial mastectomy

another surgical option conductive to breast reconstruction and resulting in greater mobility and less lymphedema involves removal of breast tissue, and few positive axillary lymph nodes breast conserving survives do not increase future risk of death from recurrent disease when compared to mastectomy

external beam radiation

- delivers carefully focused dose of radiation from a machine outside the body - tx position for external radiation has changed from supine to prone w/ arm on affected side raised above the head so that treated breast hangs dependently through opening of tx board

simple mastectomy

- removal of all breast tissue, nipple, and areola - axillary nodes and pectoral muscles are spared - procedure would be used for a large tumor or multiple tumors that have not metastasized to adjacent structures or the lymph system

stage 0 breast cancer

in situ, early type of breast cancer

internal radiation

- tiny pellets that contain radioactive material are placed into tumor

three components of early detection

BSE, CBE, and mammography

gold standard screening method for women at average risk for breast cancer

mammogram

mobility care

perform active ROM and arm exercises as ordered encourage self care activities for successful rehab perform dressing and drainage care; explain care during procedure

stage II breast cancer

tumor 1-2 inches in diameter, spread to axillary lymph nodes

lumpectomy is not an option for women who

who have two or more cancer sites that cannot be removed through one incision whose surgery will not result in a clean margin of tissue who have active connective tissue conditions (lupus or scleroderma) that make body tissues esp. sensitive to side effects of radiation who have had previous radiation to affected breast whose tumors are larger than 5 cm (2 in)

invasive ductal carcinoma

- carcinoma is malignant tumor that occurs in epithelial tissue; tends to infiltrate and give rise to metastases - incidence of this cancer peaks in sixth decade of life - spreads rapidly to axillary and other lymph nodes, even while small - infiltrating ductal carcinoma may take various histology classes forms - common type of breast cancer starts in ducts, breaks through duct wall, and invades fatty breast tissue

benign breast disorders

- fibrocystic breast changes - fibroadenomas - mastitis

nursing management of mastitis

- teach woman about etiology and encourage her to continue to breastfeed, emphasizing that it is safe to do so - stress to check for med safety before taking it - once safe to do so, nurse should encourage mother to take medication as prescribed until completed - continued emptying of breast or pumping improves outcome, decreases duration of symptoms, and decreases incidence of breast abscess - increased surveillance is necessary bc risk of cancer development - recommended follow up schedule is imaging (mammography or ultrasound) and clinical breast exam by surgeon at 6, 12, and 24 months after benign breast biopsy finding

immunotherapy

- used as an adjunct to surgery, represents an attempt to stimulate the body's natural defenses to recognize and attack cancer cells - trastuzumab emtansine, trastuzumab, and pertuzumab are immunotherapy options that target HER2 pathway - adverse effects of trastuzumab - cardiac toxicity, vascular thrombosis, hepatic failure, fever, chills, nausea, vomiting, and pain w/ first infusion

respiratory care

assist w/ turning, coughing, and deep breathing every 2 hours explain that this helps expand collapsed alveoli in lungs, promotes faster clearance of inhalation agents from body, and prevents postop pneumonia and atelectasis

lymphedema can be avoided by

avoiding using affected arm for drawing blood, inserting IV lines, or measuring BP (can cause trauma and possible infection) seeking medical care immediately if affected arm swells wearing gloves when engaging in activities such as gardening that might cause injury wearing well fitted compression sleeve to promote drainage return

stage IV breast cancer

cancer has metastasized to other body organs

changes in breast appearance

continued and persistent changes in breast lump or thickening in one breast persistent nipple irritation unusual breast swelling or asymmetry lump or swelling in axilla changes in skin color or texture nipple retraction, tenderness, or discharge

emotional care and referrals

encourage pt to participate in care assess coping strategies preoperatively explain possible body image concerns after discharge promote ACS websites, which provide latest cancer therapy news encourage pt to attend local support groups for survivors

nonmodifiable risk factors for breast cancer

gender (female) aging (older than 50) genetic mutations (BRCA1 and BRCA2 genes) personal hx of ovarian or colon cancer increased breast density increases risk three to fivefold family hx of breast cancer personal hx of breast cancer 9three to fourfold increase in risk for recurrence) race/ethnicity (higher in white women, though african american women are more likely to die) previous abnormal breast biopsy (atypical hyperplasia) exposure to chest radiation (radiation damages DNA) previous breast radiation (12 times normal risk) early menarche (younger than 12 years old) or late onset of menopause (older than 55), which represents increased estrogen exposure over lifetime

address woman's need for

info about diagnosis and tx physical care while undergoing tx contact w/ supportive people education about disease, options, and prevention measures discussion and support by a caring, competent nurse

stage I breast cancer

localized tumor < 1 inch in diameter

modifiable risk factors for breast cancer

not having children at all or having children after 30 post menopausal use of estrogens and progestins; women's health initiative study reported increased risks w/ long term (longer than 5 years) use of HRT failing to breast feed for up to a year after pregnancy; increases risk of breast cancer bc it does not reduce total number of lifetime menstrual cycles alcohol consumption; boosts level of estrogen in bloodstream smoking; exposure to carcinogenic agents found in cigarettes obesity and consumption of high fat diet; fat cells produce and store estrogen, so more fat cells create higher estrogen levels sedentary lifestyle and lack of physical exercise; increases body fat, which houses estrogen

wound care

observe wound often and empty drainage reservoirs as needed tell pt to report any evidence of infection early, such as fever, chills, or any area of redness or inflammation along incision line also tell pt to report any increase in drainage, foul odor, or separation at incision site

risk factors for mastitis

poor hand hygiene ductal abnormalities, nipple cracks and tissues, lowered maternal defenses d/t fatigue, tight clothing, poor support of pendulous breasts, failure to empty breast properly while breast feeding, or missing feedings

preparing for screening mammogram

schedule procedure just after menses when breasts are less tender do not use deodorant or powder on day of procedure, bc they can appear on x ray film as calcium spots acetaminophen or aspirin can relieve any discomfort after procedure remove all jewelry from around neck bc metal can cause distortions on film image select facility accredited by american college of radiology

nursing management of fibrocystic breast changes

teach about condition, provide tips for self care, suggest lifestyle changes, and demonstrate how to perform a monthly breast self examination after menses to monitor change

stage III breast cancer

tumor 2 inches or larger; spread to other lymph nodes and tissues