Module 6, Part 1: Breast Cancer

Obesity

Obesity and weight gain during adulthood increases the risk of postmenopausal breast cancer. During menopause, estrogen is primarily produced in fat tissue. More fat tissue can increase estrogen levels, thereby increasing breast cancer risk.

Reconstructive Procedures after Mastectomy

Tissue Expander Followed by Permanent Implant: The skin remaining after a mastectomy and the underlying muscle must gradually be stretched by a process called tissue expansion. The surgeon places a tissue expander (a balloonlike device) through the mastectomy incision underneath the pectoralis muscle. A small amount of saline is injected through a metal port intraoperatively to partially inflate the expander. Then, for about 6 to 8 weeks, at weekly intervals, the patient receives additional saline injections through the port until the expander is fully inflated. It remains fully expanded for about 6 weeks to allow the skin to loosen. The expander is then exchanged for a permanent implant. The patient must be cautioned not to have an MRI while the tissue expander is in place because the port contains metal. This is not an issue once the permanent implant is in place because it does not contain any metal.The patient should be informed that for the rest of her life she should not engage in any exercises that will develop the pectoralis muscle, because this can result in distortion of the reconstructed breast. Tissue Transfer Procedures: Autologous reconstruction is the use of the patient's own tissue to create a breast mound. A flap of skin, fat, and muscle with its attached blood supply is rotated to the mastectomy site to create a mound that simulates the breast. Donor sites may include abdominal, buttocks, or back muscles. Those with medical conditions (e.g., atherosclerosis, pulmonary disease, heart failure) that affect circulation or compromise oxygen delivery are not good candidates. Other candidates who are poor risks include those with poorly controlled diabetes or morbid obesity and those who smoke. Deep breathing and leg exercises are essential because the patient is more limited in her activity and is at greater risk for respiratory complications and deep vein thrombosis. Measures to help the patient reduce tension on the abdominal incision during the first postoperative week include elevating the head of the bed 45 degrees and flexing the patient's knees. Once the patient is able to ambulate, she can protect the surgical incision by splinting it and will gradually achieve a more upright position. The patient is instructed to avoid high-impact activities and lifting (more than 5 to 10 pounds for 6 to 8 weeks after surgery) to prevent stress on the incision. Nipple Areola Reconstruction: Minor surgical procedure carried out either in the physician's office or at an outpatient surgical facility. The most common method of creating a nipple is with the use of local flaps (skin and fat from the center of the new breast mound), which are wrapped around each other to create a projecting nipple. The areola is created using a skin graft. The most common donor site is the upper inner thigh, because this skin has darker pigmentation than the skin on the reconstructed breast. After the nipple graft has healed, micropigmentation (tattooing) can be performed to achieve a more natural color.

Alcohol Intake

Two to five drinks daily increases the risk about one and a half times.

Simulation

A planning session before radiation begins in which the anatomic areas to be treated are mapped out and then identified with small permanent ink markings.

Cystosarcoma Phyllodes

A rare fibroepithelial tumor that tends to grow rapidly. It is rarely malignant and is treated with surgical excision. If it is malignant, mastectomy may follow. Lymph node removal is usually not performed, because metastasis is rare.

Prosthetics

Prostheses are available in different shapes, sizes, colors, and materials, although they are most often made of silicone. They can be placed inside a pocket in a bra or can adhere directly to the chest wall. The nurse can provide the patient with the names of shops where she can be fitted for a prosthesis. Prior to discharge from the hospital, the nurse usually provides the patient with a temporary, lightweight, cotton-filled form that can be worn until the surgical incision is well healed (4 to 6 weeks). After that, the patient can be fitted for a prosthesis.

Modified Radical Mastectomy

Removal of the breast tissue, nipple-areola complex, and a portion of the axillary lymph nodes. In modified radical mastectomy, the pectoralis major and pectoralis minor muscles are left intact, unlike in radical mastectomy, in which the muscles are removed.

Sugical Management

The main goal of surgery is to gain local control of the disease. Modified radical mastectomy Total mastectomy Breast conservation treatment Sentinel lymph node biopsy

Nursing Management Breast Pain (Mastalgia)

The nurse may recommend that the patient wear a supportive bra both day and night for a week, decrease her salt and caffeine intake, and take ibuprofen (Advil) as needed for its anti-inflammatory actions. Vitamin E supplements may also be helpful.

Ultrasonography

Used as a diagnostic adjunct to mammography to help distinguish fluid-filled cysts from other lesions. Used as an adjunct to mammography in women with dense breast tissue. Although it can diagnose cysts with great accuracy, it cannot definitively rule out malignant lesions. Microcalcifications, which are detectable on mammography, cannot be identified on ultrasonography. Examination techniques and interpretation criteria are not standardized.

Potential Problems or Complications from Breast Cancer Surgery

Lymphedema Hematoma/seroma formation Infection

Hormonal Factors

Early menarche - Before 12 years of age Late menopause - After 55 years of age Nulliparity - No full-term pregnancies Late age at first full-term pregnancy - After 30 years of age Hormone therapy (formerly referred to as hormone replacement therapy) - Current or recent use of combined postmenopausal hormone therapy (estrogen and progesterone). Long-term use (several years or more)

Physical Assessment of the Female Breast: Palpation

The breasts are palpated with the patient sitting up (upright) and lying down (supine). In the supine position, the patient's shoulder is first elevated with a small pillow to help balance the breast on the chest wall. Failure to do this allows the breast tissue to slip laterally, and a breast mass may be missed. The entire surface of the breast and the axillary tail is systematically palpated using the flat part (pads) of the second, third, and fourth fingertips, held together, making dime-size circles. Palpation of the axillary and clavicular areas is easily performed with the patient seated. To examine the axillary lymph nodes, the examiner gently abducts the patient's arm from the thorax. With the left hand, the patient's right forearm is grasped and supported. The right hand is then free to palpate the axilla. Any lymph nodes that may be lying against the thoracic wall are noted. Examiner notes any patient-reported tenderness or masses. If a mass is detected, it is described by its location (e.g., right breast, 2 cm from the nipple at 2 o'clock position). Size, shape, consistency, border delineation, and mobility are included in the description. The breast tissue of the adolescent is usually firm and lobular, whereas that of the postmenopausal woman is more likely to feel thinner and fattier. During pregnancy and lactation, the breasts are firmer and larger with lobules that are more distinct. Hormonal changes cause the areola to darken. Obesity may have a proinflammatory effect on the breast that can contribute to increased rates of atypia. Excessive body weight, as reflected by a BMI of 25 kg/m2 or higher, is associated with postmenopausal breast cancer and increases the risk of dying of this disease. Cysts are commonly found in women who are menstruating and are usually well defined and freely movable. In the premenstrual period, cysts may be larger and more tender. Malignant tumors, on the other hand, tend to be hard, poorly defined, and nontender.

Providing Education and Preparation about Surgical Treatments

The nurse plays a key role in reviewing treatment options by reinforcing information provided to the patient and answering any questions. Surgical drains will be inserted in the mastectomy incision and in the axilla if the patient undergoes ALND. A surgical drain is generally not needed after SLNB. The patient should be informed that she will go home with the drain(s) and that complete instructions about drain care will be provided prior to discharge. The drains are usually removed when the output is less than 30 mL in a 24-hour period (approximately 7 to 10 days). In addition, the patient should be informed that she will often have decreased arm and shoulder mobility after ALND and that she will be shown range-of-motion exercises prior to discharge. The patient should also be reassured that appropriate analgesia and comfort measures will be provided to alleviate any postoperative discomfort.

Promoting Decision-Making Ability

The patient may be eligible for more than one therapeutic approach; she may be presented with treatment options and then asked to make a choice. This can be very frightening for some patients, and they may prefer to have someone else make the decision for them (e.g., surgeon, family member). The nurse can be instrumental in ensuring that the patient and family members truly understand their options. The nurse can then help the patient weigh the risks and benefits of each option. The nurse can explore the issues with the patient by asking questions such as the following: How do you think you might feel about losing your breast? Are you considering breast reconstruction? If you choose to retain your breast, would you consider undergoing radiation treatments 5 days a week for 5 to 6 weeks?

Exposure to Ionizing Radiation During Adolescence and Early Adulthood

The risk is highest if breast tissue was exposed while still developing (during adolescence), such as women who received mantle radiation (to the chest area) for treatment of Hodgkin lymphoma in their younger years.

Hormone Therapy

The use of adjuvant hormonal therapy, with or without the addition of chemotherapy, is considered in women who have hormone receptor-positive tumors. Its use can be determined by the results of an estrogen and progesterone receptor assay. About two thirds of breast cancers depend on estrogen for growth and express a nuclear receptor that binds to the estrogen; thus, they are estrogen receptor positive. Similarly, tumors that express the progesterone receptor are progesterone receptor positive. Hormonal therapy involves the use of synthetic hormones or other medications that compete with estrogen by binding to the receptor sites (SERMs), or the use of aromatase inhibitors, which block estrogen production by the adrenal glands. Women who are pre- and perimenopausal are more likely to have non-hormone-dependent lesions, whereas women who are postmenopausal are more likely to have hormone-dependent lesions.

Targeted Therapy

Trastuzumab (Herceptin) is a monoclonal antibody that binds specifically to the HER-2/neu (a protein that suggests an aggressive tumor) protein. Unlike chemotherapy, trastuzumab spares the normal cells and has limited adverse reactions, which may include fever, chills, nausea, vomiting, diarrhea, and headache. However, when trastuzumab is given to patients who have previously been treated with an anthracycline, the risk of cardiac toxicity is increased. The medication has been shown to improve survival rates in women with HER-2/neu-positive metastatic breast cancer and is now regarded as standard therapy. More recently, trastuzumab has been shown to be effective in treating early-stage breast cancer that is HER-2/neu positive.

Breast Self-Examination

Variations in breast tissue occur during the menstrual cycle, pregnancy, and the onset of menopause. Women on HT can also experience fluctuations. Most women notice increased tenderness and lumpiness before their menstrual periods; therefore, BSE is best performed after menses (day 5 to day 7, counting the first day of menses as day 1). In addition, many women have grainy-textured breast tissue, but such areas are usually less nodular after menses. Younger women may find BSE particularly difficult because of the density of their breast tissue. As women age, their breasts become fattier and may be easier to examine. Current practice is shifting from educating about BSE to promoting breast self-awareness, which is a woman's attentiveness to the normal appearance and feel of her breasts. For every woman, knowing how her breasts normally feel helps detect any changes or signs of a problem. BSE may play an important role in screening, especially for women who develop cancer in the interval after a negative result on mammography or clinical breast examination or who have a false-negative imaging or clinical examination result. It can also promote detection in women who have not been screened. Family history can increase the risk of breast cancer in men, particularly if other men in the family have had breast cancer. The risk is also higher if there is a breast cancer gene abnormality in the family. Instructions about BSE should be provided to men if they have a family history of breast cancer.

Contraindications to Breast Conservation Treatment

Absolute Contraindications: First or second trimester of pregnancy Presence of multicentric disease in the breast Prior radiation to the breast or chest region Relative Contraindications: History of collagen vascular disease Large tumor-to-breast ratio Tumor beneath nipple

Physical Assessment of the Male Breast

Breast cancer can occur in men. Assessment of the male breast and axilla is brief but important and should be included in a physical examination. The nipple and areola are inspected for swelling, nodules, ulcerations, and nipple discharge. The flat disc of undeveloped breast tissue under the nipple is palpated. The same procedure for palpating the female axilla is used when assessing the male axilla. Gynecomastia is the firm enlargement of glandular tissue beneath and immediately surrounding the areola of the male.

Ductal Carcinoma in Situ (DCIS)

Characterized by the proliferation of malignant cells inside the milk ducts without invasion into the surrounding tissue. Unlike invasive breast cancer, DCIS does not metastasize and a woman generally does not die of DCIS unless it develops into invasive breast cancer. DCIS can develop into invasive breast cancer if left untreated. DCIS is frequently manifested on a mammogram with the appearance of calcifications and is considered breast cancer stage 0.

Lymphedema

Chronic swelling of an extremity due to interrupted lymphatic circulation, typically from an axillary lymph node dissection. It often affects both the breast and ipsilateral limb. It is associated with a painful swelling of the arm as well as weakness, shoulder pain, and tingling sensations in the arm and shoulder. Risk factors for lymphedema in mixed-age groups include ALND, concomitant radiation therapy, increased age, presence of a concomitant infection, pre-existing cardiovascular conditions, and obesity.

Breast Cancer Incidence

Current statistics indicate that over a lifetime (birth to death), a woman's risk of developing breast cancer is about 12%, or one in eight. Risk of developing breast cancer increases with increasing age. About 5% to 10% of breast cancer cases are thought to be hereditary, resulting directly from gene defects (cell mutations) inherited from a biologic parent. Higher death rates in African Americans have been attributed to later stage at diagnosis and poorer stage-specific survival. Research suggests that racial disparities in cancer mortality are driven in large part by differences in socioeconomic status.

Preoperative Nursing Diagnoses for Patient Undergoing Surgery for Breast Cancer

Deficient knowledge about the planned surgical treatments Anxiety related to the diagnosis of cancer Fear related to specific treatments and body image changes Risk for defensive or ineffective coping related to the diagnosis of breast cancer and related treatment options Decisional conflict related to treatment options

Fibroadenomas

Firm, round, movable, benign tumors. They can occur from puberty to menopause with a peak incidence at 30 years of age. These masses are nontender and are sometimes biopsied or removed for definitive diagnosis.

Assessment of Patient Undergoing Surgery for Breast Cancer

How is the patient responding to the diagnosis? What coping mechanisms does she find most helpful? What psychological or emotional supports does she have and use? Is there a partner, family member, or friend available to assist her in making treatment choices? What are her educational needs? Is she experiencing any discomfort?

Planning and Goals for Patient Undergoing Breast Cancer Surgery

Include increased knowledge about the disease and its treatment; reduction of preoperative and postoperative fear, anxiety, and emotional stress; improvement of decision-making ability; pain management; neurovascular function management; maintenance of a positive body image; improvement in coping abilities; increased self-care abilities; improvement in sexual function; and the absence of complications.

Staging

Involves classifying the cancer by the extent of the disease in the body. It is based on whether the cancer is invasive or noninvasive, the size of the tumor, how many lymph nodes are involved, and if it has spread to other parts of the body. The stage of a cancer is one of the most important factors in determining prognosis and treatment options. The most common system used to describe the stages of breast cancer is the American Joint Committee on Cancer (AJCC) TNM (tumor, nodes, metastasis) system. Other factors considered in staging include hormone receptors and genetic mutations. The extent of testing often depends on the clinical presentation of the disease and may include chest x-rays, computed tomography (CT) scan, MRI scan, positron emission tomography (PET) scan, bone scans, and blood work (complete blood count, comprehensive metabolic panel, and tumor markers [i.e., carcinoembryonic antigen, cancer antigen 15-3]).

Gyenomastia

Most common breast condition in the male. Adolescent boys can be affected because of hormones secreted by the testes. This type of gynecomastia is virtually always benign and resolves spontaneously in 1 to 2 years. Gynecomastia can also occur in older men and usually presents as a firm, tender mass underneath the areola. In these patients, gynecomastia may be diffuse and related to the use of certain medications (e.g., digitalis, ranitidine [Zantac]). It may also be associated with certain conditions, including feminizing testicular tumors, infection in the testes, and liver disease resulting from factors such as alcohol abuse or a parasitic infection. Patients in their late teens to late 40s presenting with idiopathic (unknown cause) gynecomastia should have a testicular examination and possibly a testicular ultrasound. Mammography and ultrasound are utilized if there is a concern about malignancy.

Nipple Discharge

Nipple discharge in a woman who is not lactating may be related to many causes, such as carcinoma, papilloma, pituitary adenoma, cystic breasts, and various medications. Oral contraceptives, pregnancy, HT, chlorpromazine (Thorazine)-type medications, and frequent breast stimulation may be contributing factors. In some women, nipple discharge may occur during running or aerobic exercises. Nipple discharge should be evaluated by a health care provider, but it is not often a cause for alarm. One in three women has clear discharge on expression, which is usually normal. A green discharge could indicate an infection. Any discharge that is spontaneous, persistent, or unilateral is of concern. Although bloody discharge can indicate a malignancy, it is often caused by a benign wartlike growth on the lining of the duct called an intraductal papilloma.

Preoperative Nursing Interventions

Providing education and preparation about surgical treatments Reducing fear and anxiety and improving coping ability Promoting decision-making ability

Fine-Needle Aspiration

Removal of fluid for diagnostic analysis from a cyst or cells from a mass using a needle and syringe. A local anesthetic may or may not be used. A small-gauge needle (25 or 22 gauge) attached to a syringe is inserted into the mass or area of nodularity. Suction is applied to the syringe, and multiple passes are made through the mass. For nonpalpable masses, the same procedure can be performed by a radiologist using ultrasound guidance.

Core Needle Biopsy

Similar to FNA, except a larger-gauge needle is used (usually 14 gauge). A local anesthetic is applied, and tissue cores are removed via a spring-loaded device. This procedure allows for a more definitive diagnosis than FNA, because actual tissue, not just cells, is removed. It is often performed for relatively large tumors that are close to the skin surface, but is also utilized for smaller, deeper lesions that are visible on ultrasound.

Breast Conservation Treatment

Surgery to remove a breast tumor and a margin of tissue around the tumor without removing any other part of the breast; may or may not include lymph node removal and radiation therapy. If the procedure is being performed to treat a noninvasive breast cancer, lymph node removal is not necessary. For an invasive breast cancer, lymph node removal (SLNB or ALND) is indicated.

Risk Factors

A combination of genetic, hormonal, and possibly environmental factors may increase the risk of its development. More than 80% of all cases of breast cancer are sporadic, meaning that patients have no known family history of the disease. The remaining cases are either familial or genetically acquired. There is no evidence that smoking, silicone breast implants, the use of antiperspirants, underwire bras, or abortion (induced or spontaneous) increases the risk of the disease. There is some evidence that long-term smoking, starting before first pregnancy, and night shift work may increase the risk for breast cancer. Factors that may indicate a genetic link include multiple first-degree relatives with early-onset breast cancer, breast and ovarian cancer in the same family, male breast cancer, and Ashkenazi Jewish background. BRCA1 and BRCA2 are tumor suppressor genes that normally function to identify damaged deoxyribonucleic acid (DNA) and thereby restrain abnormal cell growth. Mutations in these genes on chromosome 17 are responsible for the majority of hereditary breast cancer in the United States. BRCA mutations in women have been associated with an overall risk of breast cancer up to 65%. Currently, women who are BRCA positive are counseled to start screening, typically using mammography, once a year and then MRI 6 months after the yearly mammography by 25 years of age, or 5 to 10 years earlier than their youngest affected family member.

Fat Necrosis

A condition of the breast that is often associated with a history of trauma. Surgical procedures such as a breast biopsy, lumpectomy or mastectomy can cause fat necrosis. It may be indistinguishable from carcinoma, and the entire mass may be excised or biopsied. If excision is not indicated, it is followed with regular breast imaging.

Breast Cancer Prevention Strategies in the Patient Who Is at High Risk

A consultation with a breast specialist is of paramount importance prior to embarking on any of the prevention strategies that follow. Once patients have an accurate assessment of their risk, along with the knowledge of the pros and cons of each prevention strategy, they can make a decision that is most appropriate for their situation. Long-Term Surveillance: Focuses on early detection. Women at high risk for breast cancer benefit from additional screening using MRI along with a yearly mammogram. Clinical breast examinations may be performed twice a year starting as early as 25 years of age. Mammograms may also be performed as early as 25 years of age. Ultrasound, in addition may be useful. Chemoprevention: The main modality that aims to prevent the disease. Several national, randomized clinical trials in the past two decades have led to FDA approval of tamoxifen and raloxifene (Evista) as effective chemopreventive agents for use in women who are at high risk. In addition, anastrozole (Arimidex) and exemestane (Aromasin) are now used for chemoprevention. Nurses can help women who are considering chemoprevention by providing them with information about the benefits, risks, and possible side effects of these medications. Prophylactic Mastectomy: Another primary prevention modality that can reduce the risk of breast cancer by 90%. The procedure consists of a total mastectomy (removal of breast tissue) and is usually accompanied by immediate breast reconstruction. Possible candidates include women with a strong family history of breast cancer, a diagnosis of LCIS or atypical hyperplasia, a mutation in a BRCA gene, and previous cancer in one breast. Because of physical and psychological ramifications including anxiety, depression, and altered body image, this procedure should be undertaken only after extensive counseling related to its risks and benefits. The nurse can play a valuable role in providing the patient with information, clarification, and support during the decision-making process.

Contrast Mammography

A diagnostic procedure that involves injection of less than 1 mL of radiopaque material through a cannula inserted into a ductal opening on the areola, which is followed by a mammogram. Performed to evaluate an abnormality within the duct when the patient has bloody nipple discharge on expression, spontaneous nipple discharge, or a solitary dilated duct noted on mammography.

Intraductal Papilloma

A wartlike growth that often involves the large milk ducts near the nipple, causing bloody nipple discharge. Surgery usually involves removal of the papilloma and a segment of the duct where the papilloma is found.

Postoperative Nursing Diagnoses for Patients Undergoing Surgery for Breast Cancer

Acute pain and discomfort related to surgical procedure Peripheral neurovascular dysfunction related to nerve irritation in affected arm, breast, or chest wall Disturbed body image related to loss or alteration of the breast Risk for ineffective coping related to the diagnosis of cancer and surgical treatment Self-care deficit related to partial immobility of upper extremity on operative side Risk for sexual dysfunction related to loss of body part, change in self-image, and fear of partner's responses Deficient knowledge: drain management after breast surgery, arm exercises to regain mobility of affected extremity, hand and arm care after ALND

Radiation Side Effects

Acute side effects consist of mild to moderate erythema, breast edema, and fatigue. Occasionally, skin breakdown may occur in the inframammary fold or near the axilla toward the end of treatment. Fatigue can be depressing, as can the frequent trips to the radiation oncology unit for treatment. The patient needs to be reassured that the fatigue is normal and not a sign of recurrence. Side effects usually resolve within a few weeks to a few months after treatment is completed. Rare long-term effects of radiation therapy include pneumonitis, rib fracture, heart disease, breast fibrosis or necrosis.

Chemotherapy

Adjuvant chemotherapy involves the use of anticancer agents in addition to other treatments (i.e., surgery, radiation) to delay or prevent a recurrence of breast cancer. It is recommended for patients who have positive lymph nodes or who have invasive tumors greater than 1 cm in size, regardless of nodal status. It is considered in patients with tumors that are 0.6 to 1 cm, are moderately to poorly differentiated, or have unfavorable features. Chemotherapy is most commonly initiated after breast surgery and before radiation. Patients who delay initiation of chemotherapy beyond 90 days postsurgery have an increased risk of adverse outcomes. Nurses encourage and assist in facilitating timely treatment to optimize outcomes. Much attention has been focused on dose-dense chemotherapy, which is the administration of chemotherapeutic agents at standard doses with shorter time intervals between each cycle of treatment.

Exercise After Breast Surgery

After ALND, patients are taught arm exercises on the affected side to restore range of motion. Range-of-motion exercises are initiated on the second postoperative day; however, instruction often occurs on the first postoperative day. The patient is instructed to perform range-of-motion exercises at home three times a day for 20 minutes at a time until full range of motion is restored (generally 4 to 6 weeks). If the patient is having any discomfort, taking an analgesic agent 30 minutes before beginning the exercises can be helpful. Taking a warm shower before exercising can also loosen stiff muscles and provide comfort. In general, heavy lifting (more than 5 to 10 pounds) is avoided for about 4 to 6 weeks, although normal household and work-related activities are promoted to maintain muscle tone. Brisk walking, the use of stationary bikes and stepping machines, and stretching exercises may begin as soon as the patient feels comfortable. Once the drain is removed, the patient may begin to drive if she has full arm range of motion and is no longer taking opioid analgesic agents.

Implications of Genetic Testing

Although the actual testing for the BRCA1 and BRCA2 and several other genes that increase risk involves a simple blood or saliva test, ethical and psychosocial issues must first be addressed. Before undergoing genetic testing, a person should meet either with a clinician who has expertise in this area or with a certified genetic counselor to discuss risk factors as well as the benefits, sequelae, and limitations of testing. Nurses play a role in educating and counseling patients and their family members about the implications of genetic testing. Nurses provide support and clarification and make referrals to appropriate specialists when indicated.

Superficial Thrombophlebitis of the Breast (Mondor Disease)

An uncommon condition that is usually associated with pregnancy, trauma, or breast surgery. Pain and redness occur as a result of a superficial thrombophlebitis in the vein that drains the outer part of the breast. The mass is usually linear, tender, and erythematous. Treatment consists of analgesic agents and heat.

Benign Proliferative Breast Disease

Atypical hyperplasia: can be ductal or lobular and is a premalignant lesion of the breast. It is recognized as a precursor lesion to both noninvasive and invasive breast cancer. Imbalance in the normal regulation of cell proliferation is a defining feature. Women with atypical hyperplasia have a fourfold increased risk of breast cancer compared to women in the general population, with a cumulative incidence approaching 30% at 25 years of age. Lobular Carcinoma in Situ (LCIS): an incidental microscopic finding of abnormal tissue growth in the lobules of the breast. LCIS is a risk indicator and some studies describe half of affected women will develop breast cancer within 15 to 30 years. Affected women should undergo rigorous breast cancer surveillance that consists of annual mammography and clinical breast examination every 6 months. Patients should be offered information about chemoprevention with selective estrogen receptor modulators (SERMs), such as tamoxifen (Soltamox, Nolvadex).

Hand and Arm Care After Axillary Lymph Node Dissection Patient Education

Avoid blood pressures, injections, and blood draws in affected extremity. Use sunscreen (higher than 15 SPF) for extended exposure to sun. Apply insect repellent to avoid insect bites. Wear gloves for gardening. Use cooking mitt for removing objects from oven. Avoid cutting cuticles; push them back during manicures. Use electric razor for shaving armpit. Avoid lifting objects heavier than 5-10 pounds. If a trauma or break in the skin occurs, wash the area with soap and water, and apply an over-the-counter antibacterial ointment (Bacitracin or Neosporin). Observe the area and extremity for 24 hours; if redness, swelling, or a fever occurs, call the surgeon or nurse.

Pregnancy and Breast Cancer

Breast cancer during pregnancy is defined as breast cancer diagnosed during gestation or within 1 year of childbirth and occurs in 1 in 3000 women. Because of increased levels of hormones produced during pregnancy and subsequent lactation, the breast tissue becomes tender and swollen, making it more difficult to detect a mass. If a mass is found during pregnancy, ultrasound is the preferred diagnostic method because it involves no exposure to radiation. If indicated, mammography with appropriate shielding, FNA, and biopsy can be performed. Modified radical mastectomy remains the most common form of surgical treatment. SLNB is typically not performed because of the unknown effects of the radioisotope and the blue dye on the fetus. Breast conservation treatment may be considered if the breast cancer is diagnosed during the third trimester. Radiation can then be delayed until after delivery because it is contraindicated during pregnancy. If a woman is close to term, a cesarean section may be performed as soon as maturation of the fetus allows and then treatment is initiated. If aggressive disease is detected early in pregnancy and chemotherapy is advised, termination of the pregnancy may be considered. If a mass is found while a woman is breast-feeding, she is urged to stop to allow the breast to involute (return to its baseline state) before any type of surgery is performed.

Clinical Manifestations

Breast cancers can occur anywhere in the breast but are usually found in the upper outer quadrant, where the most breast tissue is located. In general, the lesions are nontender, fixed rather than mobile, and hard with irregular borders. Complaints of diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease. With the increased use of mammography, more women are seeking treatment at earlier stages of the disease. These women often have no signs or symptoms other than a mammographic abnormality. Some women with advanced disease seek initial treatment after ignoring symptoms. Advanced signs may include skin dimpling, nipple retraction, or skin ulceration.

Radiation Therapy

Breast conservation treatment followed by radiation therapy for stages I and II breast cancer results in a survival rate equal to that of a modified radical mastectomy. If radiation therapy, which is part of breast conservation treatment, is contraindicated, a mastectomy would then be indicated. External-beam radiation (the most common type) typically begins about 6 weeks after breast conservation to allow the surgical site to heal. If systemic chemotherapy is indicated, radiation therapy usually begins after its completion. External-beam radiation is given to the entire breast region (whole breast radiation). Each treatment lasts only a few minutes and is generally given 5 days a week for 5 to 6 weeks. After completion of radiation to the entire breast, many patients receive a "boost"—a dose of radiation to the lumpectomy site where the cancer cells were located. After mastectomy, postoperative radiation may be indicated for women at high risk for cancer recurrence.

Protective Factors

Breast feeding for at least 1 year, regular or moderate physical activity and maintaining a healthy body weight are cited as protective. Some research suggests that the use of extra virgin olive oil regularly in one's diet may be preventive.

Mammography

Breast imaging technique used to visualize the breast to detect small abnormalities that could suggest malignant or benign disease. Two views are taken of each breast. The breast is mechanically compressed from top to bottom (craniocaudal view) and side to side (mediolateral oblique view). May detect a breast tumor before it is clinically palpable (i.e., smaller than 1 cm). The false-negative rate ranges between 5% and 10%. Younger women, or those taking HTs, may have dense breast tissue, making it more difficult to detect lesions with mammography. Healthy women should have mammography every year beginning at age 45 years. Women 55 and older may continue yearly screening or transition to every 2 years.The ACS, however, continues to recommend that women 45 years and older have a mammogram every year and that they continue to do so for as long as they do not have serious, chronic health problems such as congestive heart failure, end-stage kidney disease, chronic obstructive pulmonary disease, and moderate to severe dementia. Age alone should not be the reason to stop having regular mammograms. Digital mammography has been shown to be better at detecting estrogen receptor-negative tumors and cancer in extremely dense breasts.

Total Mastectomy

Like modified radical mastectomy, total mastectomy (i.e., simple mastectomy) also involves removal of the breast and nipple-areola complex but does not include ALND. Total mastectomy may be performed in patients with noninvasive breast cancer (e.g., DCIS), which does not have a tendency to spread to the lymph nodes. It may also be performed prophylactically in patients who are at high risk for breast cancer (e.g., LCIS, BRCA mutation). A total mastectomy may also be performed in conjunction with sentinel lymph node biopsy (SLNB) for patients with invasive breast cancer.

Chemotherapy Side Effects

Common physical side effects of chemotherapy for breast cancer may include nausea, vomiting, bone marrow suppression, taste changes, alopecia (hair loss), mucositis, neuropathy, skin changes, and fatigue. A weight gain of more than 10 pounds occurs in about half of all patients; the cause is unknown. Women who are premenopausal may also experience temporary or permanent amenorrhea. Taxanes can cause peripheral neuropathy, arthralgias, and myalgias, particularly at high doses. During taxane administration, hypersensitivity reactions may occur; therefore, the patient must be premedicated. Alopecia is also common. The side effects of the anthracyclines may be severe and include cardiotoxicity in addition to nausea and vomiting, bone marrow suppression, and alopecia. Their vesicant properties can lead to tissue necrosis if infiltration of the medication infusion occurs.

Managing Postoperative Sensations

Common sensations include tenderness, soreness, numbness, tightness, pulling, and twinges. These sensations may occur along the chest wall, in the axilla, and along the inside aspect of the upper arm. After mastectomy, some patients experience phantom sensations and report a feeling that the breast or nipple is still present. Sensations usually persist for several months and then begin to diminish, although some may persist for as long as 5 years and possibly longer. Patients should be reassured that this is a normal part of healing and that these sensations are not indicative of a problem.

Stereotactic Core Biopsy

Computer-guided method of core needle biopsy that is useful when masses or calcifications in the breast cannot be felt but can be visualized using mammography. A small titanium clip is almost always placed at the biopsy site so that the site can easily be located if further treatment is indicated. Quite accurate and often allows the patient to avoid a surgical biopsy.

Treatment of Recurrent and Metastatic Breast Cancer

Despite the advances made in the treatment of breast cancer, it may recur locally (on the chest wall or in the conserved breast), regionally (in the remaining lymph nodes), or systemically (in distant organs). In metastatic disease, the bone, usually the hips, spine, ribs, skull, or pelvis, is the most common site of spread. Other sites of metastasis include the lungs, liver, pleura, and brain. The overall prognosis and optimal treatment are determined by a variety of factors such as the site and extent of recurrence, the time to recurrence from the original diagnosis, history of prior treatments, the patient's performance status, and any existing comorbid conditions. Patients with bone metastases generally have a longer overall survival compared with metastases in visceral organs. Local recurrence in the absence of systemic disease is treated aggressively with surgery, radiation, and hormonal therapy. Chemotherapy may also be used for tumors that are not hormonally sensitive. Metastatic breast cancer involves control of the disease rather than cure. Treatment includes hormonal therapy, chemotherapy, and targeted therapy. Surgery or radiation may be indicated in select situations. Women who are premenopausal and who have hormonally dependent tumors may eliminate the production of estrogen by the ovaries through oophorectomy (removal of the ovaries) or suppression of estrogen production by medications. Patients with advanced breast cancer are monitored closely for signs of disease progression. Baseline studies are obtained at the time of recurrence. These may include complete blood count; comprehensive metabolic panel; tumor markers (i.e., carcinoembryonic antigen, cancer antigen 15-3); bone scan; CT of the chest, abdomen, and pelvis; and MRI of symptomatic areas. Additional x-rays may be performed to evaluate areas of pain or abnormal areas seen on bone scan (e.g., long bones, pelvis). These studies are repeated at regular intervals to assess for effectiveness of treatment and to monitor progression of disease.

Cysts

Fluid-filled sacs that develop as breast ducts dilate. Do not increase the risk of breast cancer. Fibrocystic Breast Changes: term used to describe certain benign changes in the breast, typically palpable nodularity, lumpiness, swelling, or pain.

Health History

History of medical disorders and previous surgery; family history of diseases, particularly cancer; gynecologic and obstetric history; present medications. past and present use of hormonal contraceptives, hormone therapy, or fertility treatments; and social habits. Psychosocial information, such as the patient's marital status, occupation, and availability of resources and support people, is obtained. Any recent x-rays or other diagnostic tests are noted. Focused questions pertaining to the breast disorder are asked concerning the onset of the disorder and the length of time it has been present. Patient is asked if any masses are palpable and if there is any associated pain, swelling, redness, nipple discharge, or change in the skin. Knowledge and comfort related to breast self-awareness, which can include breast self-examination (BSE), should also be ascertained from the patient.

Managing Side Effects of Adjuvant Hormonal Therapy in Breast Cancer

Hot Flashes: Wear breathable, layered clothing. Avoid caffeine and spicy foods. Perform breathing exercises (paced respirations). Consider medications (vitamin E, antidepressants) or acupuncture. Vaginal Dryness: Use vaginal moisturizers for everyday dryness (e.g., Replens, vitamin E suppository). Apply vaginal lubrication during intercourse (e.g., Astroglide, K-Y Jelly). Nausea and Vomiting: Consume a bland diet. Try to take medication in the evening. Musculoskeletal Symptoms: Take nonsteroidal analgesic agents as recommended. Take warm baths. Risk of Endometrial Cancer: Report any irregular bleeding to a gynecologist for evaluation. Risk for Thromboembolic Events: Report any redness, swelling, or tenderness in the lower extremities, or any unexplained shortness of breath. Risk for Osteoporosis or Fractures: Undergo a baseline bone density scan. Perform regular weight-bearing exercises. Take calcium supplements with vitamin D. Take bisphosphonates (e.g., alendronate) or calcitonin as prescribed.

Invasive Cancer

Infiltrating Ductal Carcinoma: The most common histologic type of breast cancer—accounts for 80% of all cases. The tumors arise from the duct system and invade the surrounding tissues. They often form a solid irregular mass in the breast. Infiltrating Lobular Carcinoma: Accounts for 10% to 15% of breast cancers. The tumors arise from the lobular epithelium and typically occur as an area of ill-defined thickening in the breast. They are often multicentric and can be bilateral. Medullary Carcinoma: Accounts for about 5% of breast cancers, and it tends to be diagnosed more often in women younger than 50 years. The tumors grow in a capsule inside a duct. They can become large and may be mistaken for a fibroadenoma. The prognosis is often favorable. Mucinous Carcinoma: Accounts for about 3% of breast cancers and often presents in women who are postmenopausal and are 75 years and older. A mucin producer, the tumor is also slow growing; thus, the prognosis is more favorable than in many other types. Tubular Ductal Carcinoma: Accounts for about 2% of breast cancers. Because axillary metastases are uncommon with this histology, prognosis is usually excellent. Micropapillary invasive ductal carcinoma is a rare type of aggressive ductal cancer characterized by a high rate of axillary node metastasis and skin involvement. Inflammatory Carcinoma: Rare (1% to 3%) and aggressive type of breast cancer that has unique symptoms. The cancer is characterized by diffuse edema and erythema of the skin, often referred to as peau d'orange (resembling an orange peel). This is caused by malignant cells blocking the lymph channels in the skin. An associated mass may or may not be present; if there is a mass, it is often a large area of indiscrete thickening. Can be confused with an infection because of its presentation. The disease can spread to other parts of the body rapidly. Chemotherapy often plays an initial role in controlling disease progression, but radiation and surgery may also follow. Paget Disease: Accounts for 1% of diagnosed cases of breast cancer. Symptoms typically include a scaly, erythematous, pruritic lesion of the nipple. Paget disease often represents DCIS of the nipple but may have an invasive component. If no lump can be felt in the breast tissue and the biopsy shows DCIS without invasion, the prognosis is very favorable.

Hematoma or Serasoma Formation

May occur after either mastectomy or breast conservation and usually develops within the first 12 hours after surgery. The nurse assesses for signs and symptoms of hematoma at the surgical site, which may include swelling, tightness, pain, and bruising of the skin. The surgeon should be notified immediately if there is gross swelling or increased bloody output from the drain. Compression wrap may be applied to the incision for approximately 12 hours, or the patient may be returned to the operating room so that the incision may be reopened to identify the source of bleeding. The patient may take warm showers (if permitted by the surgeon) or apply warm compresses to help increase the absorption. A hematoma usually resolves in 4 to 5 weeks. A seroma, a collection of serous fluid, may accumulate under the breast incision after mastectomy or breast conservation or in the axilla. Signs and symptoms may include swelling, heaviness, discomfort, and a sloshing of fluid. Seromas may develop temporarily after the drain is removed or if the drain is in place and becomes obstructed. Seromas rarely pose a threat and may be treated by unclogging the drain or manually aspirating the fluid with a needle and syringe. Large, long-standing seromas that have not been aspirated may lead to infection.

Postoperative Nursing Management

Monitoring the effects of the anesthesia and inspecting the surgical dressing for any signs of bleeding. Once the sedation has worn off, the nurse reviews the care of the biopsy site, pain management, and activity restrictions with the patient. Prior to discharge from the ambulatory surgical center or the office, the patient must be able to tolerate fluids, ambulate, and void. The patient must be accompanied home. The dressing covering the incision is usually removed after 48 hours, but the Steri-Strips, which are applied directly over the incision, should remain in place for approximately 7 to 10 days or until they fall off. The use of a supportive bra following surgery is encouraged to limit movement of the breast and reduce discomfort. A follow-up telephone call from the nurse 24 to 48 hours after the procedure can provide the patient with the opportunity to ask any questions and can be a source of great comfort and reassurance. Most women return to their usual activities the day after the procedure but are encouraged to avoid jarring or high-impact activities for 1 week to promote healing of the biopsy site. Discomfort is usually minimal, and most women find acetaminophen (Tylenol) sufficient for pain relief, although a mild opioid analgesic agent may be prescribed if needed. Follow-up after the biopsy includes a return visit to the surgeon for discussion of the final pathology report and assessment of the healing of the biopsy site. Depending on the results of the biopsy, the nurse's role varies.

Pathologic Factors Associated With Favorable Prognosis for Breast Cancer

Noninvasive tumors or invasive tumors <1 cm Negative axillary lymph nodes Estrogen receptor (ER) and progesterone receptor (PR) proteins Well-differentiated tumors Low expression of HER-2/neu oncogene (also known as ERBB2) No vascular or lymphatic invasion Diploid tumors with low S-phase fraction

Preoperative Nursing Management

Nurse assesses the patient for any specific educational, physical, or psychosocial needs. This can be accomplished by reviewing the medical and psychosocial history and encouraging the patient to verbalize fears, concerns, and questions. Patients are often worried not only about the procedure but also about the potential implications of the pathology results. Providing a thorough explanation about what to expect in a supportive manner can help alleviate anxiety. Patients often have difficulty absorbing all the information given to them; therefore, written materials to take home are often provided to reinforce and clarify education. Nurse instructs the patient to discontinue any agents that can increase the risk of bleeding, including products containing aspirin, nonsteroidal anti-inflammatory drugs, vitamin E supplements, herbal substances. Patients on prescription anticoagulants may need to check with the prescriber prior to temporary cessation for the procedure, as biopsies done without cessation of these drugs can result in prolonged bleeding and hematomas. The patient may be instructed not to eat or drink for several hours prior to the procedure or after midnight the night before the procedure, depending on the type of biopsy and anesthesia planned. Most breast biopsy procedures are performed with the use of moderate sedation and local anesthesia.

Nursing Management Chemotherapy

Nurses play an important role in helping patients manage the physical and psychosocial sequelae of chemotherapy. Instructing the patient about the use of antiemetic agents and reviewing the optimal dosage schedule can help minimize nausea and vomiting. Measures to ease the symptoms of mucositis may include rinsing with normal saline or sodium bicarbonate solution, avoiding hot and spicy foods, and using a soft toothbrush. Some patients may require hematopoietic growth factors to minimize the effects of chemotherapy-induced neutropenia and anemia. Granulocyte colony-stimulating factors boost the white blood cell count, helping to reduce the incidence of neutropenic fever and infection. Erythropoietin growth factor increases the production of red blood cells, thus decreasing the symptoms of anemia. The nurse instructs the patient and family on proper injection technique of hematopoietic growth factors and about symptoms that require follow-up with a primary provider. To prevent some of the emotional trauma associated with alopecia, it often helps to have a patient obtain a wig before hair loss begins to occur. The nurse may provide a list of wig suppliers in the patient's geographic region. Familiarity with creative ways to use scarves and turbans may also help minimize the patient's distress. The patient needs reassurance that new hair will grow back when treatment is completed, although the color and texture may be different. Chemotherapy may negatively affect the patient's self-esteem, sexuality, and sense of well-being. This, combined with the stress of a potentially life-threatening disease, can be acute. Providing support and promoting open communication are important aspects of nursing care. Referring the patient to the dietitian, social worker, psychiatrist, or spiritual advisor can provide additional support. Complementary therapies, such as guided imagery, meditation, and relaxation exercises, can also be used in conjunction with conventional treatments.

Nursing Management of Recurrent and Metastatic Breast Cancer

Nurses play an important role in not only educating patients and managing their symptoms but also in providing emotional support. Many patients find that recurrence of the disease is more distressing than the initial cancer diagnosis. The nurse can help the patient identify coping strategies and set priorities to optimize quality of life. Family members and significant others should be included in the treatment plan and follow-up care. Referrals to support groups, as well as psychiatry or psychiatric clinical nurse specialist, social work, and complementary medicine programs (e.g., guided imagery, meditation, yoga), should be made as indicated. Nurses can also be instrumental in providing palliative care, if indicated. The highest priorities include alleviating pain and providing comfort measures. A frank discussion with the patient and family regarding their preferences for end-of-life care should occur before the need arises to ensure a smooth transition without disruption of care. Referrals to hospice and home health care should be initiated as necessary.

Preventing Lymphedema

Once lymphedema develops, it tends to be chronic, so preventive strategies are vital. After ALND, the patient is taught hand and arm care to prevent injury or trauma to the affected extremity, thus decreasing the likelihood for development of lymphedema. The patient is instructed to follow these guidelines for the rest of her life. She is also instructed to contact her primary provider immediately if she suspects that she has lymphedema, because early intervention provides the best chance for control. If allowed to progress without treatment, the swelling can become more difficult to manage. Treatment may consist of a course of antibiotic agents if an infection is present. A referral to a rehabilitation specialist (e.g., occupational or physical therapist) may be necessary for a compression sleeve or glove, exercises, manual lymph drainage, and a discussion of ways to modify daily activities to avoid worsening lymphedema.

SLNB Nursing Management

Patients who undergo SLNB in conjunction with breast conservation treatments are generally discharged the same day. Patients who undergo SLNB with total mastectomy usually stay in the hospital overnight, possibly longer if breast reconstruction is being performed. The patient must be informed that although frozen-section analysis is highly accurate, false-negative results can occur. The patient should also be reassured that the radioisotope and blue dye are generally safe. The nurse informs patients that they may notice a blue-green discoloration in the urine or stool for the first 24 hours as the blue dye is excreted. The incidence of lymphedema, decreased arm mobility, and seroma formation (collection of serous fluid) in the axilla is generally low, but the patient should be prepared for these possibilities. Women who have SLNB alone have neuropathic sensations similar to those who undergo ALND. The nurse must not overlook the psychosocial needs of the patient who has undergone SLNB.

Percutaneous Biopsy

Performed on an outpatient basis to sample palpable and nonpalpable lesions. Less invasive than a surgical biopsy, percutaneous biopsy is a needle or core biopsy that obtains tissue by making a small puncture in the skin.

Physical Assessment of the Female Breast

The American Cancer Society screening guidelines for early detection of cancer state that an annual clinical breast examination for women 40 years and older is preferable. A clinical breast examination every 1 to 3 years for women between the ages of 20 and 39 years is preferable as part of a periodic health examination. A thorough breast examination, including instruction in breast awareness and BSE, takes at least 10 minutes.

Breast Health of Women With Disabilities

Possible barriers to the use of mammography in women with disabilities include physical inaccessibility of office space and medical equipment; limited transportation and parking options; and time and assistance constraints associated with undressing, transferring, and positioning for medical examinations. Lesbian, gay, bisexual, transgender and those questioning their gender may also be uncomfortable with the health care system and avoid screening. An essential role of the nurse is to assist all women, including those with disabilities, to identify accessible health screening and to advocate for greater accessibility of imaging centers and other health care facilities. Reminding women of the need for recommended clinical breast examinations and mammograms is an important part of nursing care.

Expected Outcomes

Preoperative: Exhibits knowledge about diagnosis and surgical treatment options Verbalizes willingness to deal with anxiety and fears related to the diagnosis and the effects of surgery on self-image and sexual functioning Demonstrates ability to cope with diagnosis and treatment Makes decisions regarding treatment options in timely fashion Postoperative: Reports that pain has decreased and states pain and discomfort management strategies are effective Identifies postoperative sensations and recognizes that they are a normal part of healing Exhibits clean, dry, and intact surgical incisions without signs of inflammation or infection Lists the signs and symptoms of infection to be reported to the nurse or surgeon Verbalizes feelings regarding change in body image Discusses meaning of the diagnosis, surgical treatment, and fears appropriately Participates actively in self-care measures Discusses issues of sexuality and resumption of sexual relations Demonstrates knowledge of post discharge recommendations and restrictions Experiences no complications

Discharge Education

Prior to discharge, the nurse must assess the patient's readiness to assume self-care responsibilities and identify any gaps in knowledge. A review of education provided in written and oral forms. The nurse reiterates symptoms that the patient should report, such as infection, seroma, hematoma, or arm swelling. All instruction should be reinforced during office visits and by telephone. Most patients are discharged 1 or 2 days after ALND or mastectomy (possibly later if they have had immediate reconstruction) with surgical drains in place. Initially, the drainage fluid appears bloody, but it gradually changes to a serosanguineous and then a serous fluid over the next several days. The drains are usually removed when the output is less than 30 mL in a 24-hour period (approximately 7 to 10 days). Patient may shower on the second postoperative day and wash the incision and drain site with soap and water to prevent infection. Some surgeons do not permit showers until 48 hours after drains are removed. If immediate reconstruction has been performed, showering may be contraindicated until the drain is removed. A dry dressing may be applied to the incision each day for 7 days.

Brachytherapy

Radiation is delivered by an internal device that is placed close to the tumor within the breast. This technique can lead to an improved quality of life because the treatments are given over 4 to 5 days instead of 5 to 6 weeks.

Postoperative Nursing Interventions

Relieving pain and discomfort Managing postoperative sensations Promoting positive body image Promoting positive adjustment and coping Improving sexual function Monitoring and managing potential complications Promoting home, community, and transitional care

Nursing Management Radiation

Self-care instructions for patients receiving radiation are provided to assist in the maintenance of skin integrity during the treatments and for several weeks after completion. They pertain only to the area being treated and not to the rest of the body. Instructions include: Use mild soap with minimal rubbing. Avoid perfumed soaps or deodorants. Use hydrophilic lotions (Lubriderm, Eucerin, Aquaphor) for dryness. Use a nondrying, antipruritic soap (Aveeno) if pruritus occurs. Avoid tight clothes, underwire bras, excessive temperatures, and ultraviolet light. Follow-up care includes educating the patient to minimize sun exposure to the treated area (i.e., using sunblock with sun protection factor [SPF] of 15 or higher) and reassuring the patient that short-term minor twinges and pain in the breast are normal after radiation treatment.

Physical Assessment of the Female Breast: Inspection

Size and symmetry inspected. The skin is inspected for color, venous pattern, thickening, or edema. Erythema may indicate benign local inflammation or superficial lymphatic invasion by a neoplasm. A prominent venous pattern can signal increased blood supply required by a tumor. Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange peel appearance (peau d'orange)—a classic sign of advanced breast cancer. Nipple inversion of one or both breasts is not uncommon and is significant only when of recent origin. Ulceration, rashes, or spontaneous nipple discharge requires evaluation. The examiner instructs the patient to raise both arms overhead. This maneuver normally elevates both breasts equally. The patient is then instructed to place her hands on her waist and push in. These movements, which cause contraction of the pectoral muscles, do not normally alter the breast contour or nipple direction. Any dimpling or retraction during these position changes suggests an underlying mass. The clavicular and axillary regions are inspected for swelling, discoloration, lesions, or enlarged lymph nodes.

Male Breast Cancer

The lifetime risk of breast cancer in men is about 1 in 1000. Familial cases in men usually have BRCA2 rather than BRCA1 mutations. Klinefelter syndrome, a chromosomal condition reflecting decreased testosterone levels, is the strongest risk factor for developing male breast carcinoma. Presentation is usually a painless lump, but is often late, with more than 40% of individuals having stage III or IV disease. When survival is adjusted for age at diagnosis and stage of disease, outcomes for male and female patients with breast cancer is similar. Early detection is uncommon in male breast cancer because of the rare nature of the disease. Often, neither patient nor provider suspects male breast cancer early in its development. Treatment generally consists of a total mastectomy with either SLNB or ALND. As in women with breast cancer, prognosis depends on the stage of disease at presentation. Involvement of the axillary lymph nodes is the most important prognostic indicator. Male breast cancers are very likely to be ER+, and tamoxifen, although it has several side effects, is a mainstay of treatment.

Medical Management of DCIS

The pathologist analyzes the piece of breast tissue removed to determine the type and grade of the DCIS or how abnormal the cells look when compared with normal breast cells and how fast they are growing. Grade III (high-grade DCIS) cells tend to grow more quickly than grade I (low-grade) and grade II (moderate-grade) cells and look much different from normal breast cells. Accurate grading of DCIS is critical, because high nuclear grade and the presence of necrosis are highly predictive of the inability to achieve adequate margins or borders of healthy tissue around the cancer, of local recurrence, and of the probability of missed areas of invasion. The pros and cons of irradiating patients with DCIS who are treated conservatively should be carefully weighed on a case-by-case basis, considering recent trials have shown that radiation has a beneficial effect on distant recurrence, breast cancer-specific mortality, and overall survival. Breast conservation (treatment of a breast cancer without the loss of the breast) can be curative for well-defined subsets of women with DCIS.

Sentinel Lymph Node Biopsy

The status of the lymph nodes is the most important prognostic factor in breast cancer. The SLNB is a less invasive alternative to ALND and is considered a standard of care for the treatment of early-stage breast cancer. ALND is associated with potential morbidity, including lymphedema, cellulitis, decreased arm mobility, and sensory changes. Studies suggest that SLNB is highly accurate and is associated with a local recurrence rate similar to that of ALND. The sentinel lymph node, which is the first node (or nodes) in the lymphatic basin that receives drainage from the primary tumor in the breast, is identified by injecting a radioisotope and/or blue dye into the breast; the radioisotope or dye then travels via the lymphatic pathways to the node. In SLNB, the surgeon uses a handheld probe to locate the sentinel lymph node, excises it, and sends it for pathologic analysis, which is often performed immediately during the surgery using frozen-section analysis. If the sentinel lymph node is positive, the surgeon can proceed with an immediate ALND, thus sparing the patient a return trip to the operating room and additional anesthesia. If the sentinel lymph node is negative, a standard ALND is not needed, thus sparing the patient the possible complications of the procedure. After the procedure is complete, all specimens are sent to pathology for more thorough analysis.

Tamoxifen

Traditionally, the SERM tamoxifen has been the main hormonal agent used in treatment of pre- and postmenopausal breast cancer and remains the mainstay in women who are premenopausal. As an SERM, tamoxifen has estrogen antagonistic (estrogen-blocking) and agonistic (estrogenlike) effects on certain tissues. Its antagonistic effects in the breast prevent estrogen from binding to the receptor sites, thus preventing tumor growth. Tamoxifen has positive agonistic effects on blood lipid profiles and bone mineral density in women who are postmenopausal. It also has agonistic effects on endometrial tissue and blood coagulation processes, leading to an increased incidence of endometrial cancer and thromboembolic events. Nevertheless, the benefits in most women with breast cancer outweigh the risks. Side effects: Hot flashes, vaginal dryness/discharge/bleeding, irregular menses, nausea, mood disturbances, rashes; increased risk for endometrial cancer; increased risk for thromboembolic events (deep vein thrombosis, pulmonary embolism, superficial phlebitis).

Prognosis

Two of the most important factors are tumor size and whether the tumor has spread to the lymph nodes under the arm. In general, the smaller the tumor appears, the better the prognosis. Doubling time varies, but breast tumors are often present for several years before they become palpable. Nurses can reassure patients that once breast cancer is diagnosed, they have a safe period of several weeks to make decisions regarding treatment; however, a lengthy delay is not advisable. Prognosis also depends on the extent of spread of the breast cancer. The 5-year survival rate is approximately 88% for a stage I breast cancer and 15% for a stage IV breast cancer. The most common route of regional spread is to the axillary lymph nodes. Other sites of lymphatic spread include the internal mammary and supraclavicular nodes. Distant metastasis can affect any organ, but the most common sites are bone, lung, liver, pleura, adrenals, skin, and brain. Excessive number of copies of certain genes (amplification) or excessive amounts of their protein product (overexpression) may represent a poorer prognosis. The HER-2/neu (also known as ERBB2) oncogene is the classic example; approximately 25% of invasive breast cancers, which typically involve the more aggressive tumors, have amplification or overexpression of this gene. The proliferative rate or rapidity in growth rate (S-phase fraction) and DNA content (ploidy) of a tumor are factors that are also associated with overall survival rate.

MRI

Useful diagnostic adjunct to mammography. An intravenous (IV) injection of gadolinium, a contrast dye, is given to improve visibility. The patient lies face down, and the breast is placed through a depression in the table. A coil is placed around the breast, and the patient is placed inside the MRI machine. The entire procedure takes about 30 to 40 minutes. useful for evaluation of contralateral disease, invasive lobular carcinoma, and assessment of chemotherapeutic response. The ACS recommends an annual MRI scan in addition to mammography in women at high risk for breast cancer - candidates include women who have a BRCA1 or BRCA2 mutation, a first-degree relative with either of these mutations, certain rare genetic syndromes, or radiation to the chest between 10 and 30 years of age. MRI should be used in addition to mammography, not instead of it.

Surgical Biopsy

Usually performed using local anesthesia and intravenous (IV) sedation. After an incision is made, the lesion is excised and sent to a laboratory for pathologic examination. Surgical biopsy is usually preceded by a core biopsy or stereotactic biopsy for pathologic determination. Excisional Biopsy: Standard procedure for complete pathologic assessment of a palpable breast mass. The entire mass, plus a margin of surrounding tissue, is removed. This type of biopsy may also be referred to as a lumpectomy. Depending on the clinical situation, a frozen-section analysis of the specimen may be performed at the time of the biopsy by the pathologist, who does an immediate reading intraoperatively and provides a provisional diagnosis. This can help confirm a diagnosis in a patient who has had no previous tissue analysis performed. Incisional Biopsy: Surgically removes a portion of a mass. This is performed to confirm a diagnosis and to conduct special studies. often performed on women with locally advanced breast cancer or on women with suspected cancer recurrence, whose treatment may depend on the results of these special studies. However, pathologic information may be easily obtained from core needle biopsy, and incisional biopsy is becoming less common. Wire Needle Localization : Used to locate nonpalpable masses or suspicious calcium deposits detected on a mammogram, ultrasound, or MRI that require an excisional biopsy. The radiologist inserts a long, thin wire through a needle, which is then inserted into the area of abnormality using x-ray or ultrasound guidance. The wire remains in place after the needle is withdrawn to ensure the precise location. The patient is then taken to the operating room, where the surgeon follows the wire to the tip and excises the area.

Quality of Life and Survivorship

With increased early detection and improved treatment modalities, women with breast cancer have become the largest group of cancer survivors. However, the treatment or simply the diagnosis of breast cancer may have long-term effects that negatively affect the patient and her family. The patient should be prepared early on for the potential long-term effects of the disease so that she has realistic expectations and can make informed decisions. Estrogen withdrawal from chemotherapy-induced menopause and hormonal treatments can lead to a variety of symptoms, including hot flashes, vaginal dryness, urinary tract infections, weight gain, decreased sex drive, and increased risk of osteoporosis. HT to alleviate symptoms is contraindicated in women with breast cancer. Certain chemotherapeutic agents can cause long-term cardiac effects and neuropathy. In addition, patients may experience impaired cognitive functioning, such as difficulty concentrating (often referred to as "chemo brain"). Rare long-term effects of radiation can include pneumonitis, rib fractures, heart disease, and breast fibrosis or necrosis. Long-term sequelae after breast surgery may include lymphedema (mainly after ALND), pain, and sensory disturbances. Once lymphedema develops, it tends to be a chronic problem, so prevention strategies (discussed earlier) are vital. Weight gain and infections are risk factors for lymphedema. Nurses need to encourage patients to maintain an active lifestyle and avoid weight gain. Long-term psychosocial sequelae may include fears of recurrence, mood changes, an increased sense of vulnerability, uncertainty, feelings of loss, concerns about body image, self-concept, and sexuality; emotional distress related to role adjustments and family response; and concerns about finances and employment. Depression and anxiety have been documented in 20% to 30% of women with breast cancer.

Aromatase Inhibitors

anastrozole (Arimidex) letrozole (Femara) exemestane (Aromasin) Important components in the hormonal management of women who are postmenopausal. Most of the circulating estrogens in women who are postmenopausal are derived from the conversion of the adrenal androgen androstenedione to estrone and the conversion of testosterone to estradiol. Aromatase inhibitors work by blocking the enzyme aromatase from performing the conversion, thereby decreasing the level of circulating estrogen in peripheral tissues. Clinical trials have demonstrated that the aromatase inhibitors are superior to tamoxifen in terms of overall response rate and clinical benefit and that inhibitors appear to be effective and feasible compared with tamoxifen as first-line hormonal therapy in women who are postmenopausal with advanced breast cancer. Side effects: Musculoskeletal symptoms (arthritis, arthralgia, myalgia), increased risk of osteoporosis/fractures, nausea/vomiting, hot flashes, fatigue, mood disturbances, rashes. Treatment of Recurrent and Metastatic Breast Cancer