Chapter 6: Disorders of the Breasts

The side effects associated with these endocrine therapies include

hot flashes, bone pain, bone thinning, insomnia, weight gain, depression, fatigue, mood swings, constipation, nausea, cough, dyspnea, and headache

Breast cancer metastasizes widely and to almost all organs of the body, but primarily to the

bone, lungs, lymph nodes, liver, and brain. The first sites of metastases are usually local or regional, involving the chest wall or axillary supraclavicular lymph nodes or bone

The most common clinical manifestation of male breast cancer is a

painless, firm, subareolar breast mass. Any suspicious breast mass in a male should undergo diagnostic biopsy. If a malignancy is diagnosed, typical treatment is mastectomy with assessment of the axillary nodes.

Nurses can offer education about:

- Prevention - Early detection - Screening - Dispelling myths and fears - Self-examination techniques - Individual risk status and strategies for risk reduction

Mastitis

inflammation of the mammary gland

simple mastectomy

removal of an entire breast but with the underlying muscle and axillary lymph nodes left intact

Two major categories of breast cancer

The two major categories of breast cancer are noninvasive and invasive.

Adverse effects of trastuzumab include

cardiac toxicity, vascular thrombosis, hepatic failure, fever, chills, nausea, vomiting, and pain with the first infusion

Performed by a plastic surgeon, breast reconstruction can be done immediately after the mastectomy or at a later date. Breast reconstruction can be done with

breast implants (filled with saline or silicone); natural tissue flaps (using skin fat and muscle from the woman's own body); or a combination of both

Experience has shown that the lymph ducts of the breast typically drain to one lymph node first before draining through the rest of the lymph nodes under the arm. The first lymph node is called the

sentinel lymph node.

After the procedure is finished,

the biopsy area is cleaned and a sterile dressing is applied.

modified radical mastectomy

the surgical removal of the entire breast and all of the axillary lymph nodes under the adjacent arm

Breast-conserving surgery, the least invasive procedure, is the

wide local excision (or lumpectomy) of the tumor along with a 1-cm margin of normal tissue. A lumpectomy is often used for early-stage localized tumors.

Chemotherapy may be indicated for women with tumors larger than 1 cm, positive lymph nodes, or cancer of an aggressive type. Chemotherapy is prescribed in cycles,

with each period of treatment followed by a rest period. Treatment typically lasts 3 to 6 months, depending on the dose used and the woman's health status. Recent research indicates many women with early-stage breast cancer don't need adjuvant chemotherapy to prevent recurrence of cancer. Chemotherapy may be avoided in about 70% of women with HR-positive, HER2-negative, node-negative breast cancer

Adopt a holistic approach when addressing the nutritional needs of women with breast cancer. Incorporate nutritional assessment into the general overall assessment of all women. Culturally sensitive nutritional assessment tools need to be developed and used to enhance this process. Providing examples of appropriate foods associated with the

woman's current dietary habits, relating current health status to nutritional intake, and placing proposed modifications within a realistic personal framework may increase a woman's willingness to incorporate needed changes in her nutritional behavior. Be able to interpret research results and stay up to date on nutritional influences so that you can transmit this key information to the public.

Another consideration in making decisions about a treatment plan is genetic testing for BRCA1 and BRCA2 genetic mutations. This genetic testing became available in 1995 and can identify

women who have a significantly increased risk for breast, ovarian cancer, and contralateral breast cancer; individuals with BRCA1 and BRCA2 mutations have a 75% lifetime risk of breast cancer and a 30% lifetime risk of ovarian cancer.

It is best to examine a woman's breast a week after menses, when swelling has subsided. The breast exam is performed using the

"triple touch method" in which the health care provider uses the pads of the middle three fingers and makes dime-sized overlapping circles to feel the breast tissue with three levels of pressure: light, medium, and firm

Awareness is the first step toward a change in habits.

Raising the level of awareness about breast cancer is of paramount importance, and nurses can play an important role in health promotion, disease prevention, and education.

A screening mammogram typically consists of four views, two per breast. It can detect lesions as small as 0.5 cm; the average size of a tumor detected by a woman practicing occasional BSE is

approximately 2.5 cm

The basis of the high sensitivity of MRM is the

tumor angiogenesis (vessel growth) that accompanies a majority of breast cancers, even early ones. Currently, MRM is used as a complement to mammography and CBE because it is expensive, but recent research findings report that it is more accurate than mammography for size assessment of breast lesions

Testing positive for a BRCA1 or BRCA2 mutation can significantly alter health care decisions. In some cases,

before genetic testing was available, lumpectomy with radiation, or mastectomy was the treatment most often recommended.

In many women, lymphedema can be avoided by:

*Avoiding using the affected arm for drawing blood, inserting intravenous lines, or measuring blood pressure (can cause trauma and possible infection) *Seeking medical care immediately if the affected arm swells *Wearing gloves when engaging in activities such as gardening that might cause injury *Wearing a well-fitted compression sleeve to promote drainage return

Relieving Symptoms of Fibrocystic Breast Changes

*Wear extra-supportive bra to prevent undue strain on the ligaments of the breast 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 to the breasts to help reduce pain via vasodilation of vessels *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 OTC medications, such as 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

Many studies can be performed to make an accurate diagnosis of a malignant breast lump. Diagnostic tests include:

- Diagnostic mammography or digital mammography - Magnetic resonance mammography (MRM) - Fine-needle aspiration - Stereotactic needle-guided biopsy - Sentinel lymph node biopsy - Hormone receptor status - Infrared thermal imaging - DNA ploidy status - Cell proliferative indices - HER2/neu genetic marker

The American Institute for Cancer Research (2018) made the following recommendations to reduce a woman's risk for developing breast cancer:

- 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

Risk factors for breast cancer can be divided into those that cannot be changed (nonmodifiable risk factors) and those that can be changed (modifiable risk factors). Nonmodifiable risk factors include:

- Gender (female) - Aging (older than 50 years old) - Genetic mutations (BRCA1 and BRCA2 genes) - Personal history of ovarian or colon cancer - Increased breast density increases the risk three- to fivefold - Family history of breast cancer - Personal history of breast cancer (three- to fourfold increase in risk for recurrence) - Race/ethnicity (higher in white women, though African American women are more likely to die of breast cancer) - 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 years old), which represents increased estrogen exposure over the lifetime

This area of research provides hope for women seeking to prevent breast cancer as well as those recovering from it. Although the mechanism is not clear, certain foods demonstrate anticancer properties and boost the immune system. Phytochemical-rich foods include:

- 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

Instruct the woman to use three different degrees of pressure:

- Light (move the skin without moving the tissue underneath) - Medium (midway into the tissue) - Hard (down to the ribs)

Modifiable risk factors related to lifestyle choices include:

- Not having children at all or not having children until after age 30; this increases the risk of breast cancer by not reducing the number of menstrual cycles - Postmenopausal use of estrogens and progestins; the Women's Health Initiative study reported increased risks with long-term (longer than 5 years) use of HRT - Failing to breast-feed for up to a year after pregnancy; increases the risk of breast cancer because it does not reduce the total number of lifetime menstrual cycles - Alcohol consumption; boosts the level of estrogen in the 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

If appropriate, there are two steps in conducting a BSE: visual inspection and tactile palpation. The visual part should be done in three separate positions: with the arms up behind the head, with the arms down at the sides, and bending forward. Instruct the woman to look for:

- changes in shape, size, contour, or symmetry. - skin discoloration or dimpling, bumps/lumps. - sores or scaly skin. - discharge or puckering of the nipple.

However, lumpectomy may not be an option for some women, including those:

- 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 especially sensitive to the side effects of radiation. - who have had previous radiation to the affected breast. - whose tumors are larger than 5 cm (2 in) (National Comprehensive Cancer Network

Breast cancer can also affect men, but only

1% of all individuals diagnosed with breast cancer annually are men. About 2,550 men are diagnosed with breast cancer annually, with about a 1-in-4 mortality rate (ACS, 2020c). Because men are not routinely screened for breast cancer, the diagnosis is often delayed.

In conjunction with the mastectomy, lymph node surgery (removal of underarm nodes) may need to be done to reduce the risk of distant metastasis and improve a woman's chance of long-term survival. For women with a positive sentinel node biopsy,

10 to 20 underarm lymph nodes may need to be removed. Complications associated with axillary lymph node surgery include nerve damage during surgery, causing temporary numbness down the upper aspect of the arm; seroma formation (fluid buildup) followed by wound infection; restrictions in arm mobility (some women need physiotherapy); and lymphedema

breast implants

A procedure used to increase the size of the breasts using synthetic material such as silicone or saline implants

Breast cancer incidence rates are higher in non-Hispanic white women compared with African American women for most age groups. However,

African American women have a higher incidence rate before 40 years of age and are more likely to die from breast cancer at every age. Some of that gap is because of social factors such as poverty and restricted access to health care.

The three components of early detection are

BSE, CBE, and mammography. The ACS (2020e) has issued breast cancer screening guidelines that offer specific guidance for the women and greater clarification of the role of breast examinations

Depending on the type of benign breast disorder, treatment may or may not be necessary. Although these disorders are benign, the emotional trauma women experience can be severe.

Fear, anxiety, disbelief, helplessness, and depression are just a few of the feelings a woman may have when she discovers a lump in her breast. Many women believe that all lumps are cancerous, but in reality more than 80% of the lumps discovered are benign and need no treatment. Patience, support, and education are essential components of nursing care.

Current recommendations for most women with ER-positive breast cancer are to take a hormone-like medication—known as a

SERM antiestrogenic agent—daily for up to 5 years after initial treatment. Certain areas in the female body (breasts, uterus, ovaries, skin, vagina, and brain) contain specialized hormone receptors that allow estrogen to enter the cell and stimulate it to divide

Mastitis is divided into lactational or nonlactational types. The usual causative organisms for lactational mastitis are

Staphylococcus aureus, Hemophilus influenzae, and hemophilus and streptococcus species, the source of which is the baby's flora. Lactating mastitis typically occurs in the first 2 to 3 weeks of lactation, but can occur at any stage of lactation.

chemotherapy

The use of drugs to treat diseases such as cancer

duct ectasia

a benign condition of the subareolar ducts that can cause a nipple discharge

breast cancer

a carcinoma that develops from the cells of the breast and can spread to adjacent lymph nodes and other body sites

Carcinoma

a malignant tumor that occurs in epithelial tissue

mammography

a radiographic examination of the breasts to detect the presence of tumors or precancerous cells

Fibroadenoma

a round, firm, rubbery mass that arises from excess growth of glandular and connective tissue in the breast

To determine hormone receptor status,

a sample of breast cancer tissue obtained during a biopsy or a tumor removed surgically during a lumpectomy or mastectomy is examined by a cytologist.

breast self-examination

a self-care procedure for the early detection of breast cancer

In addition, diagnostic studies include imaging studies (mammography, ultrasound, or both) and some form of biopsy, most often a fine-needle aspiration, core needle biopsy, or stereotactic needle biopsy. The core needle biopsy removes

a small cylinder of tissue from the breast mass, more than the fine-needle aspiration biopsy. If additional tissue needs to be evaluated, the advanced breast biopsy instrument (ABBI) is used. This instrument removes a larger cylinder of tissue for examination by using a rotating circular knife. The ABBI procedure removes more tissue than any of the other methods except a surgical biopsy

Periareolar infections consist of

active inflammation around nondilated subareolar breast ducts—a condition termed periductal mastitis.

A diagnostic mammogram is performed when a woman has suspicious clinical findings on a breast examination or an abnormality has been found on a screening mammogram. A diagnostic mammogram uses

additional views of the affected breast as well as magnification views. Diagnostic mammography provides the radiologist with additional detail to render a more specific diagnosis. Currently, digital mammography is being used to diagnose breast lesions.

Cancer is considered to be a chronic disease that may be influenced at many stages by nutrition. These factors may

affect prevention, progression, and treatment of the disease. Research suggests that approximately one third of breast cancer diagnoses could be prevented by reducing alcohol intake, increasing the fruit and vegetable intake in the diet, and increasing levels of physical activity

Breast cancer is thought to develop in response to a number of related factors:

aging; gender (99% of cases occur in women); delayed childbearing or nulliparity; genetic influences; BRCA1 and BRCA2 genetic mutations; history of receiving ionizing radiation; high breast density on a mammogram; postmenopausal obesity; family history of cancer; hormonal factors such as early menarche younger than 12 years, late menopause older than 50 years, first term pregnancy older than 30 to 35 years of age; HRT with estrogen plus progestin; obesity; lifelong physical inactivity; white race; and ingestion of two drinks or more alcohol each day

Different classes of drugs affect different aspects of cell division and are used in combinations or "cocktails." The most active and commonly used chemotherapeutic agents for breast cancer include

alkylating agents, anthracyclines, antimetabolites, and vinca alkaloids. There are more than 50 chemotherapeutic agents that can be used to treat breast cancer; however, a combination drug approach appears to be more effective than a single-drug treatment

Being overweight or obese is a risk factor for breast cancer in postmenopausal women. Excess body weight has been linked to

an increased risk of postmenopausal breast cancer, and growing evidence also suggests that obesity is associated with poorer prognoses in women diagnosed with early-stage breast cancer.

Fibrocystic breast changes, also classified as a nonproliferative lesions, represent a variety of changes in the glandular and structural tissues of the breast. Because this condition affects 50% of all women at some point, it is more accurately defined as a "change" rather than a "disease." Fibrocystic changes are caused by

an overgrowth of fibrous tissues in the connective tissues supporting the breasts. This is frequently accompanied by the presence of fluid-filled cysts, which contribute to the lumpy feeling women notice.

The American College of Obstetricians and Gynecologists (ACOG) recommends that mammography screening be offered

annually or biennially to women beginning at ages 40 to 75. ACOG continues to recommend annual CBEs for women ages 40 and older and every 1 to 3 years for women ages 20 to 39. Additionally, it encourages breast self-awareness for women ages 20 and older

Cancer development is thought to be clonal in nature, which means that each cell is derived from another cell. If one cell develops a mutation,

any daughter cell derived from that cell will have that same mutation, and this process continues until a malignant tumor forms.

Benign breast disorders are a common complaint among women from puberty to menopause. A benign breast disorder is

any noncancerous breast abnormality. Though not life-threatening, benign disorders can cause pain and discomfort, and they account for a large number of visits to primary care providers.

Invasive or infiltrating lobular carcinomas originate in the terminal lobular units of breast ducts and account for 10% of all cases of breast cancer. The peak incidence is in women in their early 60s. It presents as an

area of ill-defined thickening rather than a palpable mass. The tumor is frequently located in the upper outer quadrant of the breast, and by the time it is discovered, the prognosis is usually poor

There is no completely accurate way to know whether the cancer has micrometastasized to distant organs, but certain tests can help determine if the cancer has spread. A bone scan can be performed to

assess the bones, and magnetic resonance imaging (MRI) can be used to detect metastases to the liver, abdominal cavity, lungs, or brain.

Due to the limited efficacy of chemotherapy alone against metastatic breast cancer,

autologous hematopoietic stem cell transplantation has been used to avoid the myelotoxic effects of high-dose chemotherapy

The objective of endocrine therapy is to

block or counter the effect of estrogen. Estrogen plays a central role in the pathogenesis of cancer, and treatment with estrogen deprivation has proven to be effective.

Hormone therapy acts in one of three ways:

blocks estrogen, prevents the body from producing estrogen, and eliminates the hormone receptors on cells, making it impossible for estrogen to properly attached itself to breast cell tissue to grow

growth-stimulating factors, such as epoetin alfa (Procrit) and filgrastim (Neupogen), help keep

blood counts from dropping too low. Counts that are too low can stop or delay the use of chemotherapy.

Immunotherapy treatment has the potential to improve outcomes for clients with breast cancer, and it has several advantages over more conventional chemotherapy-based treatments that directly target the tumor itself. The benefits of immunotherapy include:

bolstering other therapies, such as chemotherapy; it is effective when other treatments aren't; it targets only the client's immune system, so side effects are minimal; and cancer is less likely to return after the client's immune system has learned to target any future cancer cells

The pain is described as a dull, aching feeling of fullness. Masses or nodularity usually appear in

both breasts and are often found in the upper outer quadrants. Some women also experience spontaneous clear to yellow nipple discharge when the breast is squeezed or manipulated.

These decisions are made jointly between the woman and her surgeon. If mastectomy is chosen, because of either tumor characteristics or client preference, then discussion needs to include

breast reconstruction and regional lymph node biopsy versus sentinel lymph node biopsy. The mastectomy techniques are a simple mastectomy with sentinel node biopsy or a radical mastectomy with regional node biopsy. Removal of numerous lymph nodes places the client at high risk for lymphedema.

Teach the woman about the etiology of mastitis and encourage her to continue to

breast-feed, emphasizing that it is safe for her infant to do so. Stress to all breast-feeding mothers to check for medication safety before taking it. Drugs administered to mothers can accumulate in the bodies of their infants and can alter the infant's bowel flora, causing diarrhea.

Breast augmentation with implants is not without risks. Potential complications include

capsular contracture, rippling, implant rupture, asymmetry, breast pain, infection, or hematoma. Capsular contraction occurs when scar tissue forms, contracts, and hardens around the implant. Rippling most often occurs when wrinkles form in the implant or as a complication of contracture

The ACS still recommends annual mammograms and clinical breast exams for women starting at ages 40 to 54 and then biennially, starting at age 55. The ACS also recommends a

clinical breast exam about every 3 years for women in their 20s and 30s and every year for women older than 40. Per the ACS, BSE is an option for women starting in their 20s

Breast fibroadenomas are usually detected incidentally during

clinical or self-examinations and are usually located in the upper outer quadrant of the breast; more than one may be present. Several other breast lesions have similar characteristics, so every woman with a breast mass should be evaluated to exclude cancer.

Fibroadenomas, also classified as proliferative lesions without atypia (cell abnormalities), are

common slow-growing, benign solid breast tumors that occur in about 25% of all women and account for up to half of all breast biopsies. They are the most common mass in women ages 15 to 30 years. They are considered hyperplastic lesions associated with an aberration of normal development and involution rather than a neoplasm.

High-dose brachytherapy is another advance that is an alternative to traditional radiation treatment. A balloon catheter is used to insert radioactive seeds into the breast after the tumor has been removed surgically. The seeds deliver a

concentrated dose directly to the operative site; this is important because most cancer recurrences in the breast occur at or near the lumpectomy site. This allows a high dose of radiation to be delivered to a small target volume with a minimal dose to the surrounding normal tissue. This procedure takes 4 to 5 days as opposed to the 4 to 6 weeks that traditional radiation therapy takes; it also eliminates the need to delay radiation therapy to allow for wound healing.

The only evidence-based predisposing factor that may lead to mastitis is the development of milk stasis. However, other associated factors include

damaged or cracked nipples, especially those colonized with Staphylococcus aureus; irregular or missed feedings; failing to allow the infant to empty one breast completely before moving on to the next breast; poor latch and transfer of milk; illness of mother or infant; oversupply; a tight bra; blocked nipple pore or duct; being a primiparous women; and maternal stress and fatigue

A Mediterranean diet high in fruits, vegetables, and high-fiber carbohydrates and low in animal fat seems to offer some protection against breast cancer while facilitating weight control. Women who follow these dietary guidelines

decrease their risk of breast cancer. In addition, substantial evidence has shown that obesity as measured by body mass index (BMI) is linked to breast cancer outcomes and greater mortality risks because of increased receptor site activity, which synthesizes more estrogen subsequently promoting carcinogenesis

Peripheral nonlactating breast abscesses are less common than periareolar abscesses and are often associated with an underlying condition such as

diabetes, rheumatoid arthritis, steroid treatment, granulomatous lobular mastitis, and trauma. Women with these types of abscesses present with greenish nipple discharge, nipple retraction, and noncyclical pain.

Management of the symptoms of fibrocystic breast changes begins with self-care. For some women,

diet and lifestyle changes help reduce discomfort. Other options include wearing a supportive bra, taking over-the-counter pain relievers, and limiting salt consumption which can cause fluid retention

Mammography can be helpful in distinguishing fibrocystic changes from breast cancer. Ultrasound is a useful adjunct to mammography for breast evaluation because it helps

differentiate a cystic mass from a solid one. Ultrasound produces images of the breasts by sending sound waves through a gel applied to the breasts.

Research has shown that BSE plays a small role in detecting breast cancer compared with self-awareness. However,

doing BSE is one way for a woman to know how her breasts normally feel so that she can notice any changes that do occur

Several advances have taken place in the field of radiation oncology for the treatment of women with early-stage breast cancer that assist in reducing the side effects. The treatment position for external radiation has changed from supine to prone with the arm on the affected side raised above the head so that the treated breast hangs dependently through the opening of the treatment board. Treatment in the prone position improves

dose distribution within the breast and allows for a decrease in the dose delivered to the heart, lung, chest wall, and other breast

In severe cases,

drugs, including bromocriptine, tamoxifen, or danazol, can be used to reduce the influence of estrogen on breast tissue. However, several undesirable side effects, including masculinization, have been documented. Aspiration or surgical removal of breast lumps will reduce pain and swelling by removing space-occupying masses.

MRM of the breast uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the breast structures. It allows for

earlier detection because it can detect smaller lesions and provide finer detail. MRM is a highly accurate (higher than 90% sensitivity for invasive carcinoma) but costly tool. Contrast infusion is used to evaluate the rate at which the dye initially enters the breast tissue.

The diagnosis of mastitis is made clinically on the basis of a

localized, unilateral area of erythema with associated fever. Assess the client for clinical manifestations of mastitis, which include flu-like symptoms of malaise, nausea, headache, leukocytosis, fever, fatigue, and chills.

Breast self-examination (BSE) is a technique that

enables a woman to detect changes in her breasts. BSEs, once thought essential for early breast cancer detection, are now considered optional. Instead, breast awareness is stressed. Breast awareness refers to a woman being familiar with the normal consistency of both breasts and the underlying tissue.

The cause of breast cancer, while not well understood, is thought to be a complex interaction between

environmental, genetic, and hormonal factors. Breast cancer is a progressive rather than a systemic disease, meaning that most cancers grow from a small size with low metastatic potential to a larger size and greater metastatic potential. Tumor stage, size, and lymph node involvement are major predictors of metastatic potential

Women undergoing breast-conserving therapy receive radiation to the entire breast after lumpectomy with the goal of

eradicating residual microscopic cancer cells to reduce the chance of recurrence

Normal breast epithelium has hormone receptors and responds specifically to the stimulatory effects of estrogen and progesterone. Most breast cancers retain

estrogen receptors, and for those tumors, estrogen will retain proliferative control over the malignant cells. It is therefore useful to know the hormone receptor status of the cancer to predict which women will respond to hormone manipulation

Radiation therapy This type of therapy can be given several ways:

external beam radiation, which delivers a carefully focused dose of radiation from a machine outside the body, or internal radiation, in which tiny pellets that contain radioactive material are placed into the tumor.

Fibroadenomas can be stimulated by

external estrogen, progesterone, lactation, and pregnancy

However, severe psychological distress can occur as a result of genetic testing. Distress is related to

family cancer history, relationships, coping strategies, communication patterns, and mutation status

Ask the woman about clinical manifestations of fibroadenomas. These lumps are

felt as firm, rubbery, round, well-circumscribed, freely mobile nodules that might or might not be tender when palpated.

Benign Breast Disorders

fibrocystic breast changes, fibroadenoma, ductal ectasia, intraductal papilloma

The most commonly encountered benign breast disorders in women include

fibrocystic changes of the breasts, fibroadenomas, and mastitis. Although these breast disorders are considered benign, fibrocystic changes of the breasts may carry a cancer risk depending on the type of atypical cells found, with prolific masses and hyperplastic changes occurring within the breasts. Generally speaking, fibroadenomas and mastitis carry little risk for cancer

fibrocystic breast changes

fibrosis, benign cysts, and pain or tenderness in one or both breasts

Breast examination in women with reconstructive surgery is done exactly the same way as for natural breasts. Breasts with implants in place usually feel

firmer than normal breast tissue on palpation due to the formation of a fibrotic band or capsule around the implant. If implants are used, press firmly inward at the edges of the implant to feel the ribs beneath it.

On physical examination of the breasts, a few characteristics might be helpful in differentiating a cyst from a cancerous lesion. Cancerous lesions are typically

fixed and painless and may cause skin retraction (pulling). Cysts tend to be mobile and tender and do not cause skin retraction in the surrounding tissue.

Consuming a low-fat diet with plenty of

fruits, vegetables, legumes, and whole grains can provide all the vitamins and nutrients our bodies need and has been shown to significantly reduce the risk of developing many types of cancer. A plant-based diet can also reduce cancer recurrence; this includes high-fiber, low-fat diets rich in fruits and vegetables and avoiding sugared beverages, calorie-dense foods, and processed meats

Radiation therapy (also called radiotherapy) uses

high-energy rays to destroy cancer cells that might have been left behind in the breast, chest wall, or underarm area after a tumor has been removed surgically. Usually serial radiation doses are given 5 days a week to the tumor site for 6 to 8 weeks postoperatively. Each treatment takes only a few minutes, but the dose is cumulative.

Breast cancer starts in the epithelial cells that line the mammary ducts within the breast. The growth rate depends on

hormonal influences, mainly that of estrogen and progesterone.

A sentinel lymph node biopsy may also be performed since the lymph nodes draining the breast are located primarily in the axilla. Theoretically,

if breast cancer is to metastasize to other parts of the body, it will probably do so via the lymphatic system. If malignant cells are found in the nodes, more aggressive systemic treatment may be needed.

Radiation is administered to the entire breast at daily doses over a period of several weeks and has been found to

increase survival rates over mastectomy without radiation

In contrast to malignant breast lesions, the cysts that develop move freely when palpated, and symptoms decline after menopause when levels of estrogen and progesterone drop (Sabel, 2019). Fibrocystic changes do not

increase the risk of breast cancer for most women except when the breast biopsy shows "atypia" or abnormal breast cells. The cause for concern for many women with fibrocystic changes is that breast examinations and mammography become more difficult to interpret with multiple cysts present, and early cancerous lesions may be overlooked

The best-known SERM is tamoxifen (Nolvadex, 20 mg daily for 5 years). Although it works well in preventing the further spread of cancer, it is also associated with an

increased incidence of endometrial cancer, pulmonary embolus, deep vein thrombosis, hot flashes, vaginal discharge and bleeding, stroke, and cataract formation

Mastitis Physical examination of the breasts reveals

increased warmth, swollen area of one breast, redness, tenderness, and swelling. The nipple is usually cracked or abraded and the breast is distended with milk

Mastitis is an

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

Carcinoma is a malignant tumor that occurs in epithelial tissue; it tends to

infiltrate and give rise to metastases. The incidence of this cancer peaks in the sixth decade of life. It spreads rapidly to axillary and other lymph nodes, even while small. Infiltrating ductal carcinoma may take various histologic forms—well differentiated and slow-growing, poorly differentiated and infiltrating, or highly malignant and undifferentiated with numerous metastases. This common type of breast cancer starts in the ducts, breaks through the duct wall, and invades the fatty breast tissue

Side effects of traditional radiation therapy include

inflammation, local edema, anorexia, swelling, and heaviness in the breast; sunburn-like skin changes in the treated area; and fatigue. Changes to the breast tissue and skin usually resolve in about a year in most women. Radiation induces systemic alterations in a number of innate and adaptive immune cells

Another class of endocrine agents, aromatase inhibitors, works by

inhibiting the conversion of androgens to estrogens. Aromatase inhibitors include letrozole (Femara, 2.5 mg daily), exemestane (Aromasin, 25 mg daily), and anastrozole (Arimidex, 1 mg daily for 5 years), all of which are taken orally. These are usually given to women with advanced breast cancer.

Treatment plans are based on multiple factors, with the primary factors being whether the cancer is

invasive or noninvasive, the tumor's size and grade, the number of cancerous axillary lymph nodes, the hormone receptor status, the woman's overall health, and the ability to obtain clear surgical margins. A combination of surgical options and adjunctive therapy is often recommended.

Women having mastectomies must decide whether to have further surgery to reconstruct the breast. If the woman decides to have reconstructive surgery,

it is ideally performed immediately after the mastectomy. The woman must also determine whether she wants the surgeon to use saline implants or natural tissue from her abdomen (TRAM flap method) or back (LAT flap method).

A core needle biopsy is much like a fine-needle biopsy except that a

larger needle is used to withdraw small cylinders or cores of tissue from the abnormal area of the breast. It takes longer than the fine-needle biopsy, but more tissue is sampled to be tested.

A nurse caring for a woman with fibrocystic breast changes can teach her about the condition, provide tips for self-care, suggest

lifestyle changes, and demonstrate how to perform a monthly breast self-examination (BSE) after her menses to monitor the changes.

Factors such as

lifestyle choices, economic status, and multiple roles need to be taken into consideration when counseling women. Advocate for healthy lifestyles and making sound choices to prevent cancer.

Women diagnosed with breast cancer have many treatments available to them. Generally, treatments fall into two categories:

local and systemic. Local treatments are surgery and radiation therapy. Effective systemic treatments include chemotherapy, hormonal therapy, and immunotherapy.

Adjunctive therapy is supportive or additional therapy that is recommended after surgery. Adjunctive therapies include

local therapy such as radiation therapy and systemic therapies using chemotherapy, hormonal therapy, and immunotherapy.

This diet proved to be a prescription for cancer prevention that has only positive side effects, including

lower cholesterol, weight loss, and a lower risk of heart disease. Adherence to a plant-based diet that limits red meat intake may be associated with reduced risk of breast cancer, particularly in postmenopausal women

Sentinel Lymph Node Biopsy This procedure can be performed under local anesthesia. A radioactive blue dye is injected 2 hours before the biopsy to identify the afferent sentinel lymph node. The surgeon usually removes one to three nodes and sends them to the pathologist to determine whether cancer cells are present. The sentinel lymph node biopsy is usually performed before a

lumpectomy to make sure the cancer has not spread. Removing only the sentinel lymph node can allow women with breast cancer to avoid many of the side effects (lymphedema) associated with a traditional axillary lymph node dissection. This procedure is associated with less morbidity compared to the axillary lymph node dissection, which results in more accurate staging, better axillary tumor control and improved survival.

Ask the woman about common clinical manifestations, which include

lumpy, tender breasts and a feeling of fullness, particularly during the week before menses. Changes in breast tissue produce pain by nerve irritation from edema in connective tissue and by fibrosis from nerve pinching.

Chemotherapy refers to the use of drugs that are toxic to all cells and interfere with a cell's ability to reproduce. They are particularly effective against

malignant cells but affect all rapidly dividing cells, especially those of the skin, the hair follicles, the mouth, the gastrointestinal tract, and the bone marrow. Breast cancer is a systemic disease in which micrometastases are already present in other organs by the time the breast cancer is diagnosed. Chemotherapeutic agents perform a systemic "sweep" of the body to reduce the chances that distant tumors will start growing.

The presence of risk factors, especially several of them, calls for careful ongoing monitoring and evaluation to promote early detection. Even though risk factors are important considerations, many women with newly diagnosed breast cancer have no known risk factors. Although routine

mammography and self-examination are prudent for high-risk women, these precautions may become lifesavers for early detection of cancerous lesions.

breast augmentation

mammoplasty performed to increase breast size, often for cosmetic reasons

The overall survival rate with lumpectomy and radiation is about the same as that with modified radical mastectomy. Research has shown that the survival rates in women who have had

mastectomies versus those who have undergone breast-conserving surgery followed by radiation are the same.

Nonlactational mastitis can be caused by duct ectasia, which occurs when the

milk ducts become congested with secretions and debris, resulting in periductal inflammation. It may be divided into central (periareolar) and peripheral breast lesions.

Chemotherpay typical side effects include

nausea and vomiting, diarrhea or constipation, hair loss, weight loss, stomatitis, fatigue, and immunosuppression. The most serious is bone marrow suppression (myelosuppression). This causes an increased risk of infection, bleeding, and a reduced red blood cell count, which can lead to anemia

Provide women with information about detection and risk factors, inform them about the

new ACS screening guidelines, instruct them on BSEs, and outline dietary changes that might reduce the risk of breast cancer.

Breast cancer is a neoplastic disease in which

normal body cells are transformed into malignant ones. It is the most common cancer in women and the second leading cause of cancer deaths (lung cancer is first) among American women.

Noninvasive (in situ) breast cancers are those that have

not extended beyond the duct, lobule, or other point of origin into the surrounding breast tissue.

Prior to any diagnosis of breast cancer,

nurses can help guide women toward breast cancer prevention through screenings, lifestyle changes, and health care practices to decrease their risks. In the fight against cancer, nurses often assume a variety of roles, such as educator, counselor, advocate, and role model

Nursing assessment consists of a health history, which should include issues having to do with the

onset; frequency; quality and quantity of any pain, discharge, or masses; medications taken; physical activity; family history; reproductive history; any associated symptoms; physical examination of the breasts; and laboratory and diagnostic tests.

Effective milk removal, pain medication, and antibiotic therapy have been the mainstays of treatment. Management of both types of mastitis involves the use of

oral antibiotics (usually a penicillinase-resistant penicillin or cephalosporin), warm compresses to the inflamed area of the breast, continued breast-feeding, and acetaminophen (Tylenol) for pain and fever

invasive (infiltrating) breast cancers have extended into

the surrounding breast tissue with the potential to metastasize. Many researchers believe that most invasive cancers probably originate as noninvasive cancers

Assess the client's health history for risk factors for mastitis, which include

poor hand hygiene ductal abnormalities, nipple cracks and fissures, lowered maternal defenses due to fatigue, tight clothing, poor support of pendulous breasts, failure to empty the breasts properly while breast-feeding, or missing feedings.

Mammography has become an accepted screening procedure that is sanctioned by most cancer organizations and is paid for annually by most health insurance agencies. Mammography can provide a diagnosis while screening for

preclinical disease to prevent adverse outcomes, improve survival, and avoid intensive treatment. Mammography involves taking x-ray pictures of a bare breast while it is compressed between two plastic plates. This can identify and characterize a breast mass and detect an early malignancy. It remains the gold standard screening method for women at average risk for breast cancer.

The risk posed by a BRCA mutation can help women and their teams determine the prognosis and ultimately treatment (Fasching, 2018). Some women may choose to have a

preventative mastectomy. Based on Mendelian genetics, women with BRCA1 and BRCA2 mutations are five to 20 times more likely to develop breast and ovarian cancers

Women with hormone-sensitive cancers can live for long periods without any intervention other than hormonal manipulation, but

quality-of-life issues need to be addressed in the balance between treatment and side effects.

The primary goal of breast cancer surgery is to successfully remove the breast cancer from the woman. A secondary and important goal is to

reconstruct the removed tissue so as to allow the woman to feel whole from a psychological perspective. Both these goals are central to the surgical decision-making of breast cancer treatment

Side effects of brachytherapy include

redness or discharge around catheters, fever, and infection. Daily cleansing of the catheter insertion site with a mild soap and application of an antibiotic ointment will minimize the risk of infection.

An aggressive systemic option, when other treatments have failed or when there is a strong possibility of

relapse or metastatic disease, is high-dose chemotherapy with bone marrow and/or stem cell transplant. This therapy involves the withdrawal of bone marrow before the administration of toxic levels of chemotherapeutic agents.

A simple mastectomy is the

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

A modified radical mastectomy is another surgical option conducive to breast reconstruction and resulting in greater mobility and less lymphedema. This procedure involves

removal of breast tissue, and a few positive axillary nodes. Breast-conserving surgeries do not increase the future risk of death from recurrent disease when compared to mastectomy

The goal of breast-conserving surgery is to

remove the suspicious mass along with tissue free of malignant cells to prevent recurrence. The results are less drastic and emotionally less scarring than having a mastectomy to the woman. Women undergoing breast-conserving therapy may receive radiation after lumpectomy with the goal of eradicating residual microscopic cancer cells to limit locoregional recurrence.

Side effects or complications include

risk of rupture, hardening of the tissues around the implant, infection, and pain. Nurses need to educate the woman about these potential problems and make sure she understands before consenting to breast reconstruction.

Fibroadenomas They are composed of both fibrous and glandular tissue that feels

round or oval, firm, rubbery, and smooth, and they are mobile and may be tender. They are usually unilateral, but may present in both breasts. These masses are frequently larger than 5 cm and occur most often in pregnant or lactating women. These large lesions may reduce in size once hormonal stimulation subsides. Fibroadenomas are rarely associated with cancer.

Screening for breast cancer begins with a

routine history and physical exam. Nurses should take every opportunity to educate and emphasize the goal of breast cancer screening: early detection reduces mortality. Screening also includes a BSE, clinical breast exam, and mammography.

Several different drug classes are used to interfere or block estrogen receptors. They include

selective estrogen receptor modulators (SERMs), estrogen receptor downregulators, aromatase inhibitors, luteinizing hormone-releasing hormone, progestin, and biologic response modifiers

Fine-needle aspiration biopsy is done to identify a solid tumor, cyst, or malignancy. It is a

simple office procedure that can be performed with or without anesthesia. A small (23- to 27-gauge) needle connected to a 10-mL or larger syringe is inserted into the breast mass, and suction is applied to withdraw the contents. The aspirate is then sent to the cytology laboratory to be evaluated for abnormal cells.

Fine-needle aspiration biopsy can also be done to differentiate a

solid tumor, cyst, or malignancy. A fine-needle aspiration biopsy uses a thin needle guided by ultrasound to the mass. In a method called stereotactic needle biopsy, a computer maps the exact location of the mass using mammograms taken from two angles, and the map is used to guide the needle.

In the second part, the tactile examination, the woman should feel the breasts in one of three specific patterns:

spiral, pie-shaped wedges, or a vertical strip (up and down). When using any of the three patterns, the woman should use a circular rubbing motion (in dime-sized circles) without lifting the fingers.

One of estrogen's normal functions is to

stimulate the growth and division of healthy cells in the breasts. However, in some women with breast cancer, this normal function contributes to the growth and division of cancer cells.

Breast augmentation is a surgical procedure by which the breast size is enhanced. It is a common

surgical procedure with women undergoing it with implants for a variety of reasons ranging from aesthetic to reconstructive surgery following a mastectomy. Saline-filled or silicone-filled implants are used in cosmetic enhancement and reconstructive surgeries, but both have an outer silicone shell.

Fibroadenoma of breast Treatment may include a period of "watchful waiting" because many fibroadenomas stop growing or shrink on their own without any treatment. 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 a tumor. In this procedure, extremely cold gas is piped into the tumor using ultrasound guidance. The tumor freezes and dies. The current trend is toward a more conservative approach to treatment after careful evaluation and continued monitoring.

Stereotactic needle-guided biopsy is used to

target and identify mammographically detected nonpalpable lesions in the breast. This procedure is less expensive than an excisional biopsy. The procedure takes place in a specially equipped room and generally takes about an hour. Women are required to lie prone and must be able to remain still for approximately 20 minutes while the biopsy is taken. When proper placement of the breast mass is confirmed by digital mammograms, the breast is locally anesthetized and a spring-loaded biopsy gun is used to obtain two or three core biopsy tissue samples.

Immunotherapy, used as an adjunct to surgery, represents an attempt to stimulate the body's natural defenses to recognize and attack cancer cells. It uses

the immune system to identify and attack cancer cells. Trastuzumab emtansine (Kadcyla), trastuzumab (Herceptin), and pertuzumab (Perjeta) are immunotherapy options that target the HER2 pathway

breast conserving surgery

the least invasive procedure, is the wide local excision (or lumpectomy) of the tumor along with a 1-cm margin of normal tissue

She should check not only the breasts but also between the breast and the axilla, the axilla itself, and the area above the breast up to the clavicle and across the shoulder. The pads of the three middle fingers on the right hand are used to assess

the left breast; the pads of the three middle fingers on the left hand are used to assess the right breast.

The status of the axillary lymph nodes is an important prognostic indicator in early-stage breast cancer. The presence or absence of malignant cells in lymph nodes is highly significant;

the more lymph nodes involved and the more aggressive the cancer, the more powerful chemotherapy will have to be, both in terms of the toxicity of drugs and the duration of treatment

Continued emptying of the breast or pumping improves

the outcome, decreases the duration of symptoms, and decreases the incidence of breast abscess. Thus, continued breast-feeding is recommended in the presence of mastitis

In a lactating woman, severe engorgement can be differentiated from mastitis because engorgement is bilateral with general involvement of the whole breast. Ultrasound scans can be undertaken to differentiate between

the types of mastitis or abscesses, but typically the diagnosis is made based on history and examination.

endocrine therapy

therapy aimed at reducing hormone levels that may continue to foster growth of the tumor;

Intensity-modulated radiation therapy (IMRT) offers another approach to the delivery of treatment to reduce the dose within the target area while sparing surrounding normal structures. A computed tomography scan is used to create a

three-dimensional model of the breast. Based on this model, a series of intensity-modulated beams is produced to the desired dose distribution to reduce radiation exposure to underlying structures. Acute toxicity is thus minimized. Research is ongoing to evaluate the impact of all of these advances in radiation therapy.

The nurse should urge the client to return for reevaluation in 6 months, perform monthly BSEs, and return annually for a clinical breast examination. Recent studies suggest that

women with high breast density and proliferative benign breast disease are at a high risk for future breast cancer. Women with low breast density are at a low risk, regardless of their benign pathologic diagnosis. This is all the more reason for women to have close monitoring over time.