Breast cancer and nursing management of patients

2. 1. It’s a female
reproductive system
2. Lobules consist of alveoli
3. Fibrous tissue support
the granular tissue and
ducts
4. Nipple it’s a small conical
eminance at the center
of breast
ANATOMY & PHYSIOLOGY

3. ● Arterial blood
supply
●venous drain
●nervous supply

4. Arterial blood supply
The breast are supplied
with blood from the
thoracic branches of
the axillary arteries
and from the internal
mammary and inter
costal arteries.

5. Venous drain
This is an anastomotic
circle round the base
of the nipple from
which branches carry
the venous blood to
the circumference and
end in the axillary and
mammary veins

6. Nerve supply
 The breasts are
supplied by branches
from the 4th,5th&6th
thoracic nerves

7. Lymph nodes
 Axillary nodes chest collar bone
functions of lymph nodes

8. LYMPHATIC SYSTEM

9. Functions of lymphatic system
 The lymph system is important to understand
because it is one of the ways in which breast
cancers can spread. This system has several
parts.
 Lymph nodes are small, bean-shaped collections
of immune system cells (cells that are important
in fighting infections) that are connected by
lymphatic vessels. Lymphatic vessels are like
small veins, except that they carry a clear fluid
called lymph (instead of blood) away from the
breast.

10.  They are only active during pregnancy &
after birth of the baby (lactation)
 Lactation is stimulated by prolactin
hormone

11. DEFINATION OF CA BREAST
BREAST cancer is the malignant tumour
that starts from cell of breast. A malignant
tumour is a group of cancer cell that may
invade (grow) into surrounding tissues or
spread (metastasize) to distant areas of
the body.

12. INCIDENCE
World wide breast canser is more common
cancer in women after skin cancer
representing 16 % of female cancer.
The rate is more than twice that of
colorectal cancer & cervical cancer and
about 3 times that of lung cancer
In India – 1 in 22 women (urban areas)
 In USA - 1 in 8 women
1 in 64 women (rural areas)

13. 1 in every 22 woman in India has a lifetime risk
of developing breast cancer
Leading cause of cancer deaths
among women ages 20 to 59.
Incidence in TMH
The average incidence rate varies from 22-28 per
100,000 women per year in urban settings to 6 per
100,000 women per year in rural areas.

14. Epidemiology
 Breast cancer is a major public health concern
through out the world
 In almost all part of Europe and in North
America , Australia & New Zealand
 It most common in women it leads to death an
age group between 35-54yrs
 In US public awareness of breast cancer has
grown considerably in recent year
 180510 newly diagnosed cases estimated in
2007

15. Benign breast lumps
Libroadenomas/intra ductal papillomas
These are abnormal growth but not cancerous.
But it can leads to further malignancies in future

16. ETIOLOGY
1 GENDER
2 AGEING
3 GENATIC RISK FACTORS
• BRCA 1 & BRCA 2
• CHANGE IN OTHER GENES
• GENATIC TESTING
4 PERSONAL HISTORY
5 RACE AND ETHNICITY
6 DENCE BREAST TISSUE

17. 7 FAMILY HISTORY
•1 First degree relative with breast cancer –
increased risk
•>1 First degree relatives with breast cancer –
even higher risk
•5-10% of all breast cancer are hereditary

18. Cont…….
Family History of Breast Cancer Relative
Risk
First-degree relative 1.8
Premenopausal F- relative 3.0
Postmenopausal F- relative 1.5
Premenopausal F-relative
(bilateral breast cancer)
9.0
Postmenopausal f relative
(bilateral breast cancer)
4.0–5.4

19. 8 Personal history of breast cancer
9 Race and ethnicity
10 Dense breast tissue

20. 11 CERTAN BENIGN BREAST CANCER
 NON PROLIFERATING LESIONS
#Fibrocystic disease
#mild hyper plasia
#single papiloma
#fat necrosis
#metastasis
#simple libro adenoma
#other benign tumour

21.  PROLIFARATIVE LESION WITHOUT ATYPIA
#ductal hyper plasia
#sclerosing adenosis
#several papillomas
#radial scan
 PROLIFERATIVE LESIONS WITH ATYPIA
#atypical ductal hyperplasia
#atypical lobular hyperplasia

22. 12 Lobular carcinoma in situ
13 Menstural period
14 Previous chest radition
15 Diethyl stilbestrol exposure

23. 16 Hormonal Factors
 Reproductive Characteristics
 Early menarche (<12 years of age)
 Late menopause (>55 years of age)
 Nulliparity
 Late age at first pregnancy (>35 years)
Recent oral contraceptive use
Hormone therapy after menapause
Combined hormone therpy
Oestrogen therapy

24. Life style related factors
•Having children
•Breast feeding
•Alcohol consumption
•Being overweight/obese
•Physical activicty

25. Uncertain, controversial or
unproven risk factors
1) Diet and vitamine intake
2) Antiperspirants
3) Bras
4) Induced abortion
5) Breast implant
6) Chemical and environment
7) Tobacco smoke
8) Night work

26. General breast cancer terms
1 Carcinoma
2 Adenocarcinoma
3 Carcinoma in situ
4 Invasive (infiltrating) carcinoma
5 Sarcoma

27. TYPES OF CA BREAST
LOBAR CARCINOMA IN SITU
It begins in the milk producing glands but do not grow t
o the wall.
INVASIVE DUCTAL CARCINOMA
its starts in ducts and break through the wall and grows into
fatty tissue. It may spread to other parts of the body through
lymphatic system
INVASIVE LOBULAR CARCINOMA
Its starts in lobules and it can spread to other parts of the
body

28. Cancer cells are inside
the duct but do not
spread through the
wall of the dutcs
DUCTAL CARCINOMA IN SITU

29. TMH Classification of Infiltrating
duct Ca
•Operable Breast Cancer (OBC)
•Small OBC (<5cms)
•Large OBC (>= 5 cms)
•Locally Advanced Breast Cancer
(LABC)
•Metastatic BreastCancer (MBC)

30. •Defn – All cancers that are not LABC or
MBC are OBC.
i.e. in all patients we have to diligently
look for and rule out
LABC and MBC
•TYPES
•Small OBC - <=5 cms in largest
dimension
•Large OBC - >5 cms in largest
dimension

31. • Depending upon cell of origin
• Duct Carcinoma
• Lobular Carcinoma
• Depending upon invasion
In-situ Carcinoma DCIS LCIS
Infiltrating
Carcinoma
IDC ILC
Duct carcinoma Lobular Carcinoma

32. Less common types of ca breast
 INFLAMMATORY
 TRIPPLE NEGATIVE
 MIXED TUMOURS
 MEDULLARY CARCINOMA
 MATAPLASTIC CARCINOMA
 MUCINOUS CARCINOMA
 PEGET CARCINOMA OF THE NIPPLE
 TUBULAR CARCINOMA
 PAPILLARY CARCINOMA
 ADENOID CYSTIC CARCINOMA
 PHYLLODES TUMOURS
 ANGIOSACRCOMA

33. A new lump or a mass and thickning
within the breast
1. hard/soft
2. Painless
3. Irregular edges
4. Tender
5. Rounded
Swelling of all or part of breast
Skin irritation/dimpling
Breast or nipple pain
Redness , scaliness / thickening
of nipple
SIGNS AND SYMPTOMS

34. A discharge from the nipple
A discoloration or change in the
texture of the skin overlying the
breast
A recent change in the nipple
direction, like retraction[inward
turning
Axillary lymph nodes or lump or
swelling
Epsilateral limb pain or edema
Cont…..

36. 1. Medical history
2. Triple test-
A. Palpation
breast will be thoroughly examined for any
lumps or suspicious area also size of lump.
B. Mammography
a) Diagnostic mammography
These are mostly used for screening , but
they can also be used to examine the breast
of women who has a breast problem.
b) Digital mammography
In this x’rays are used to produce an
image of breast.
Investigations

37. C. FNAC
It is performed on palpable
nodules becoz it is quick, it canot
distinguish between DCIS and invasive
cancers

38. 3 Tumour marker
 CA 15-3
Is a Carcinoma Antigen 15-3, is a tumor marker for
breast cancer It is derived from MUC1
 ErbB-2 /neu
(also known asHER2/neu) stands for "Human
Epidermal growth factor Receptor 2" and is a protein
giving higher aggressiveness in breast cancers.
 Receptor tyrosine-protein kinase erbB-3
is an enzyme that in humans is encoded by the ERBB3
gene
 Cathepsin D
is a protein that in humans is encoded by the CTSD
gene.[1][2].This gene encodes a lysosomal aspartyl
protease composed of a dimer of disulfide-linked heavy
and light chains, both produced from a single protein
precursor

39. 4. M.R.I
MRI scan is used to define extent of disease in
the breast and distinguish unifocal from multifocal
disease

40. 6. Breast ultrasound
It is used for highly dence breast
tissue, becoz it can distinguish between
fluid-filled and solid masses
7. PET scan
It is used to stage breast cancer
8. Chest x’ray
It is to see weather breast cancer
has spread to lungs or not
9. Ductogram
It helps to determine the cause of
nipple discharge

41. 10.Biopsies
 FNAC
 Core cutting needle biopsy
 Stereotactic core biopsy
 Mammotome
 Encore biopsy
 Excisional biopsy
 Sentinel lymph node biopsy
11.Bone scan
It is used to show whether cancer has
spread to bones

42. 12. Other tests
 Nipple discharge exam
 Ductal lavage and nipple
aspiration
13. Laboratory tests
 ER PR status
 HER2 status
 Test for cell proliferation rate
 Test for gene patterns
 Oncotype Dx test
 Mamma print
14. CT scan

43. AJCC TNM STAGING
Primary tumor (T)
TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Carcinoma in situ (DCIS, LCIS, or Paget disease of the
nipple with no associated tumor mass)
T1: Tumor is 2 cm (3/4 of an inch) or less across.
T2: Tumor is more than 2 cm but not more than 5
cm(2inches) across.
T3: Tumor is more than 5 cm across.
T4: Tumor of any size growing into the chest wall or skin. This
includes inflammatory breast cancer.

44.  NX: Nearby lymph nodes cannot be assessed
 N0: Cancer has not spread to nearby lymph nodes.
 N1: Cancer has spread to 1 to 3 axillary (underarm)
lymph node
N1mi: Micrometastasis in 1 to 3 lymph nodes under
the arm.
N1a: Cancer has spread to 1 to 3 lymph nodes
under the arm
N1b: Cancer has spread to internal mammary
lymph nodes
N1c: Both N1a and N1b apply.
Near by lymph nodes (N)

45.  N2: Cancer has spread to 4 to 9 lymph
nodes under the arm
N2a: Cancer has spread to 4 to 9 lymph
nodes under the arm
N2b: Cancer has spread to one or more
internal mammary lymph nodes
CONT….

46.  N3: Any of the following:
N3a: either cancer has spread to 10 or more
axillary lymph nodes
OR
Cancer has spread to the lymph nodes under the
clavicle
N3b: either cancer is found in at least one axillary
lymph node
OR
Cancer involves 4 or more axillary lymph nodes
N3c: Cancer has spread to the lymph nodes
above the clavicle
CONT………

47. Metastasis (M):
 MX: Presence of distant spread (metastasis)
cannot be assessed.
 M0: No distant spread is found on x-rays or by
physical exam.
 M1: Spread to distant organs is present. (The
most common sites are bone, lung, brain, and
liver).

48. Evidance based staging
 Stage 0
Stage 0 is used to describe non-invasive
breast cancers, such as DCIS and LCIS. In
stage 0, there is no evidence of cancer
cells or non-cancerous abnormal cells
breaking out of the part of the breast in
which they started, or of getting through
to or invading neighboring normal tissue.

49.  Stage I
 Stage I describes invasive breast cancer
(cancer cells are breaking through to or
invading neighboring normal tissue) in
which:
a) The tumor measures up to 2
centimeters, AND
b) No lymph nodes are involved

50.  Stage IIA
describes invasive breast cancer in which:
1. no tumor can be found in the breast, but cancer cells
are found in the axillary lymph nodes (the lymph nodes
under the arm), OR
2. the tumor measures 2 centimeters or less and has
spread to the axillary lymph nodes, OR
3. the tumor is larger than 2 centimeters but not larger
than 5 centimeters and has not spread to the axillary
lymph nodes
 Stage IIB
describes invasive breast cancer in which:
 the tumor is larger than 2 but no larger than 5
centimeters and has spread to the axillary lymph nodes,
OR
 the tumor is larger than 5 centimeters but has not
spread to the axillary lymph nodes
Stage II
is divided into subcategories known as IIA and IIB.

51. Stage IIIA
describes invasive breast cancer in which either:
 no tumor is found in the breast. Cancer is found in
axillary lymph nodes that are clumped together or
sticking to other structures, or cancer may have spread
to lymph nodes near the breastbone, OR
 the tumor is 5 centimeters or smaller and has spread to
axillary lymph nodes that are clumped together or
sticking to other structures, OR
 the tumor is larger than 5 centimeters and has spread to
axillary lymph nodes that are clumped together or
sticking to other structures
Stage III
Stage III is divided into subcategories known as IIIA, IIIB, and
IIIC.

52.  Stage IIIB
describes invasive breast cancer in which:
 the tumor may be any size and has spread to
the chest wall and/or skin of the breast AND
 may have spread to axillary lymph nodes that
are clumped together or sticking to other
structures, or cancer may have spread to lymph
nodes near the breastbone
 Inflammatory breast cancer is considered at
least stage IIIB.

53. Stage IIIC
describes invasive breast cancer in which:
 there may be no sign of cancer in the breast or,
if there is a tumor, it may be any size and may
have spread to the chest wall and/or the skin of
the breast, AND
 the cancer has spread to lymph nodes above or
below the collarbone, AND
 the cancer may have spread to axillary lymph
nodes or to lymph nodes near the breastbone

54.  the cancer has spread to other organs of the
body -- usually the lungs, liver, bone, or brain
 "Metastatic at presentation" means that the
breast cancer has spread beyond the breast and
nearby lymph nodes, even though this is the
first diagnosis of breast cancer. The reason for
this is that the primary breast cancer was not
found when it was only inside the breast.
Metastatic cancer is considered stage IV.
Stage IV
Stage IV describes invasive breast cancer in which

55. • Principles
• Local Control
• Regional Control
• Control of (assumed) micrometastases
Locoregional Control

56. • Aim
• To obtain a radical resection of the lump with negative
surgical margins and the draining lymph nodes
• Options
• Mastectomy or Breast Conservation Therapy (BCT)
Modified Radical Mastectomy (MRM)
Simple Mastectomy Axillary Clearance (SMAC)
Radical Mastectomy (RM)
W/E Lumpectomy
+ Axillary Clearance
+ Adjuvant Radiation to the breast
Treatment (surgery)

57. SURGERY
1.BCT/ MRM
2.Oncoplasty
3.SNB
4.Reconstruction
5.Palliative surgery

58. • Modified Radical Mastectomy (MRM)
Mastectomy is surgery to remove the entire breast. All
of the breast tissue is removed, sometimes along with other
nearby tissues
• Structures removed
• The whole breast with the axillary tail
• Skin overlying the breast (with nipple & areola)
• Fascia overlying the Pectoralis Major
• All the nodes and fibro-fatty tissue in the axilla

59. • Radical Mastectomy (RM)
In this extensive operation, the surgeon
removes the entire breast, axillary lymph nodes, and the
pectoral (chest wall) muscles under the breast. This
surgery was once very common
Structures removed
The whole breast with the axillary tail
Skin overlying the breast (with nipple & areola)
Fascia overlying the Pectoralis Major
All the nodes and fibro-fatty tissue in the axilla
P Major and P Minor muscles

60. Skin-sparing mastectomy:
For some women considering immediate reconstruction,
a skin-sparing mastectomy can be done. In this procedure, most
of the skin over the breast (other than the nipple and areola) is
left intact. This can work as well as a simple mastectomy. The
amount of breast tissue removed is the same as with a simple
mastectomy.
lumpectomy
Lumpectomy removes only the breast lump and a surrounding
margin of normal tissue.
Choosing between lumpectomy and
mastectomy
The main advantage of a lumpectomy is that it allows a woman
to keep most of her breast. A disadvantage is the usual need for
radiation therapy -- most often for 5 to 6 weeks -- after surgery.

63. • Breast Conservation
Therapy
• W/E lumpectomy (margin at
least 1 cm)
• Axillary Dissection (through a
separate/same incision)
• Radiation to the breast
• Radiation boost to the tumour
bed

64. • AIMS
• To improve survival or time to (further) disease
progression
• To treat only symptomatic patients (except)
• Patients with impending fractures or multiple liver
metastases require treatment (even if not symptomatic at
presentation)
• The choice of therapy should have the least side-effects
(permissible) with the best possible response.
• Locoregional therapy should not be performed unless
patient is symptomatic e.g. fungation etc

65. • Aim –
• To minimize the locoregional recurrence after
surgery and possibly improve survival
• Indications –
• All patients undergoing BCT
• Tumour size > 5 cms
• >= 4 Axillary Nodes positive
• All LABC patients

66. External beam radiation
 This is the most common type of radiation
therapy for women with breast cancer.
The radiation is focused from a machine
outside the body on the area affected by
the cancer.
 The extent of radiation depends on
whether a lumpectomy or mastectomy
was done and whether or not lymph
nodes are involved

67. RADIATION
External beam
radiation

68. Accelerated breast irradiation
The standard approach of giving external
radiation for five day a week over many
weeks can be inconvenient for many
woman .
Such as giving slightly larger daily doses
over only three weeks .
Giving radiation in larger doses using fewer
treatment is known as hypofractionated
radiation therapy.

69. 3D-CONFORMAL RADIO THERAPY
Radiation is given with special machines so
that it is aimed better at the area where
the tumor was.
Treatment was given twice a day for five
days.

70. 3d conformal radio therapy

71. POSSIBLE SIDE EFFECTS OF
EXTERNAL RADIATION
The main side effects of EBRT are swelling
and heaviness.
Sunburn like skin changes in the treated
areas and fatigue.

72. Brachytherapy
 Intracavitary brachytherapy:
This method of brachytherapy consists of a
small balloon attached to a thin tube. The
deflated balloon is inserted into the space
left by the lumpectomy and is filled with a
salt water solution. (This can be done at
the time of lumpectomy or within several
weeks afterward.) The balloon and tube
are left in place throughout treatment

73. Intracavitary applicator

74. Brachytherapy
 Interstitial brachytherapy:
In this approach, several small, hollow
tubes called catheters are inserted into the
breast around the area of the lumpectomy
and are left in place for several days.
Radioactive pellets are inserted into the
catheters for short periods of time each
day and then removed.

75. INTERSTITIAL

76. Chemotherapy
Adjuvant chemotherapy:
When therapy is given to patients with no
evidence of cancer after surgery, it is called
adjuvant therapy. Surgery is used to remove all
of the cancer that can be seen, but adjuvant
therapy is used to kill any cancer cells that may
have been left behind that can't be seen.
Adjuvant therapy after breast-conserving
surgery or mastectomy reduces the risk of
breast cancer coming back. Both chemotherapy
and hormone therapy can be used as adjuvant
treatments.

77. Chemotherapy
Neoadjuvant chemotherapy:
Chemotherapy given before surgery is called
neoadjuvant therapy. Often, neoadjuvant therapy
uses the same chemo that is used as adjuvant
therapy (only it is given before surgery instead of
after). In terms of survival, there is no difference
between giving chemo before or after surgery.
The major benefit of neoadjuvant chemotherapy
is that it can shrink large cancers so that they are
small enough to be removed by lumpectomy
instead of mastectomy

78. Chemotherapy
Chemotherapy for advanced breast cancer:
Chemotherapy can also be used as the main
treatment for women whose cancer has already
spread outside the breast and underarm area at
the time it is diagnosed, or if it spreads after
initial treatments. The length of treatment
depends on whether the cancer shrinks, how
much it shrinks, and how a woman tolerates
treatment.

79. Possible side effects
 Hair loss
 Mouth sores
 Loss of appetite
 Nausea and vomiting
 Increased chance of infections (due to low
white blood cell counts)
 Easy bruising or bleeding (due to low
blood platelet counts)
 Fatigue (due to low red blood cell counts
and other reasons)

80. Long term side effects
Menstrual changes:
For younger women, changes in menstrual
periods are a common side effect of
chemotherapy. Premature menopause
(not having any more menstrual periods)
and infertility (not being able to become
pregnant) may occur and may be
permanent

81. Long term side effects
 Neuropathy:
Several drugs used to treat breast cancer,
including the taxanes (docetaxel and paclitaxel),
platinum agents (carboplatin, cisplatin), and
ixabepilone, can damage nerves outside of the
brain and spinal cord. This can sometimes lead
to symptoms (mainly in the hands and feet) like
numbness, pain, burning or tingling sensations,
sensitivity to cold or heat, or weakness. In most
cases this goes away once treatment is stopped

82. Long term side effects
 Heart damage:
Doxorubicin, epirubicin, and some other
drugs may cause permanent heart
damage if used for a long time or in high
doses, so doctors often check the patient's
heart function before starting one of these
drugs. They also carefully control the
doses and use echocardiograms or other
heart tests to monitor heart function.

83. Long term side effects
 Hand-foot syndrome:
Certain chemo drugs, such as capecitabine
and liposomal doxorubicin, can cause
problems with irritation that affects the
palms of the hands and the soles of the
feet. This is called hand-foot syndrome

84. Long term side effects
 Chemo brain:
Another possible side effect of
chemotherapy is "chemo brain." Many
women who get chemotherapy for breast
cancer report a slight decrease in mental
functioning.

85. Long term side effects
 Increased risk of leukemia:
Very rarely, certain chemotherapy drugs
can permanently damage the bone
marrow, leading to acute myeloid
leukemia, a life-threatening cancer of
white blood cells.

86. • Drugs commonly used
• Cyclophosphamide (C)
• Doxorubicin (A)
• Epirubicin (E)
• Methotrexate (M)
• 5-Fluorouracil (F)
• Taxanes (T) e.g. Docetaxel, Paclitaxel etc
• Mitomycin (M)
• Mitoxantrone (M)
Anthracyclines

87. CAF: D1 only at 3 weekly intervals X 6 cycles
Cyclophosphamide 500 mg/m2
Adriamycin 50 mg/m2
5-fluorouracil 500 mg/m2
CEF: D1 only at 3 weekly intervals X 6 cycles
Cyclophosphamide 500 mg/m2
Epirubicin 90 mg/m2
5-fluorouracil 500 mg/m2
CMF: D1 and D8 at monthly intervals X 6 cycles
Cyclophosphamide 600 mg/m2
Methotrexate 40 mg/m2
5-fluorouracil 600 mg/m2
PROTOCOLS

88.  AC X 4 followed by Paclitaxel X 4: D1 only at 3 weekly intervals
 X 8 cycles
 Cyclophosphamide 600 mg/m2
 Adriamycin 60 mg/m2
 Paclitaxel 175 mg/m216 or 225 mg/m217
 TAC: D1 only at 3 weekly intervals X 6 cycles
 Cyclophosphamide 500 mg/m2
 Adriamycin 50 mg/m2
 Docetaxel 75 mg/m2
 TACT: 3 weekly (4CAF-4T) X 8 cycles
 Cyclophosphamide 600mg/m2
 Adriamycin 60mg/m2
 5-Flurouracil 600mg/m2
 Docetaxel 100mg/m2
B NODE +VE PATIENTS

89. CHEMOTHERAPY

90. Hormone therapy
Hormone therapy is another form of systemic
therapy. It is most often used as an adjuvant
therapy to help reduce the risk of cancer
recurrence after surgery, but it can be used as
neoadjuvant treatment, as well. It is also used to
treat cancer that has come back after treatment
or has spread
Tamoxifen and toremifene (Fareston®):
These anti-estrogen drugs work by temporarily
blocking estrogen receptors on breast cancer
cells, preventing estrogen from binding to them.
They are taken daily as a pill.

91. TARGETED THERAPY
Drugs that target the HER2
I. Herceptin (trastuzumab)
It is a monoclonal antibody a man made version of a very
Specific immune system protein .it attach to a growth
promoting protein known as HER2. It is given by iv as a
Usually once aweek or larger dose every three week.erceptin works
Better cobined with chemotherapy
II. LAPATINIB (TYKERB)
It also target HER2 protein
This drug is given as a pill to woman with advanced HER2
Positive breast cancer.

92. HERCEPTIN

93. TARGETED THERAPY
DRUGS THAT TARGET NEW TUMOR BLOOD
VESSELS(ANGIOGENESIS)
1. Bevacizumab(avastin)
It is a monoclonial antibody that has been used in patient
with metastatic breast cancer. This antibody is directed
against vascular endothelial growth factor,a protein that
helps tumours form new blood vessels.
It is most often used in combination with the chemotherapy
drug paclipaxel(taxol).

94. High-dose chemotherapy
with stem cell transplant
 One way to get around this is to remove
some of the patient's stem cells from
either the peripheral (circulating) blood or
bone marrow, give the high-dose
treatment, and then return the stem cells
into the body through a blood transfusion.
The stem cells are able to find their way
back into the bone marrow, where they
soon re-establish themselves and restore
the body's ability to make new blood cells

95. BISPHOSPHONATES
This drug is used to help strengthen and
reduce the risk of fractures in bones that
have been weakened by metastatic breast
cancer eg.pamidronate (aredia) and
zoledronic acid (zometa).

96. Symptomatic metastases Asymptomatic metastases
Bone pains
Neurological deficit
Impending #
Always consider Sx Fixation 1st
and/or RTh to the local area
Inj. bisphosphonates monthly
ER/PgR status
ER/PgR +ve ER/PgR -ve
INj. Bisphophonates monthly
ER/PgR status
ER/PgR +ve ER/PgR -ve
Observe
Premen – Tam
Postmen – Letroz
If 1st line given,
then 2nd line
Premen – Tam
Postmen – Letroz
If 1st line given,
then 2nd line
Chemo
CAF/Taxanes
Or MMM
BONE MEMETASTASES

97. TREATMENT OF BREAST CANCER DURING
PREGNANCY
BREAST CANCER IS DIAGONISED IN ABOUT 1 PREGNANT
WOMAN OUT OF THREE THOUSAND IN GENERAL
RT DURING PREGNANCY IS KNOWN TO INCREASE THE RISK OF
BIRTH DEFECTS SO IT IS NOT RECOMMENDED FOR PREGNANT
WOMAN WITH BREAST CANCER.FOR THIS REASON BREAST
CONSERVING THERAPY IS ONLY AN OPTION.

98. Nursing management
1. Fear and anxiety
2. Counseling
3. Involve relatives
4. Admission and duration of hospital stay
Pre operative

99. Pre operative counselling

100. Nursing management
Post operative
1) Fear and anxiety
2) Psychological support
3) Positioning
4) Pain
5) Exercise
6) Loss of sensation
7) Care of incision
8) Care of radivac drain
9) Seroma aspiration
10) Suture removal

101. Post operative visitor

102. Positioning

103. Loss of sensation

104. Care of incision

105. Care of drain

106. Seroma aspiration

107. Suture removal

108. Patient Care During Radiation
Therapy
1. Education
 Information about radiation treatment planning
 Symptom Management During Radiation
Therapy
 Skin Reactions
 Fatigue
2. Psychosocial and Family Support

109. Patient Care During
Chemotherapy
1. Symptom Management during
Chemotherapy
2. Bone Marrow Depressions
3. Nausea and Vomiting
4. Mucositis
5. Neurotoxicity
6. Alopecia
7. Arthralgia and Myalgia
8. Hemorrhagic Cystitis
9. Behavioral Symptoms

110. Management Issues in
Chemotherapy
Administration.
1. Minimizing Extravasation
2. Hypersensitivity Reactions
3. Psychosocial Support

111. Palliative care
1. Life style
2. Patient wish
3. Patient desire
4. Spiritual preparation

112. Rehabilitation
Physical
1) exercise
2)Prosthesis
3)Daily activities
4)House hold work
5)Office work

113. Psychological
1. Fear
2. Anxiety
3. Depression
4. Sexual
5. Body image
6. Problem of un employment

114. Economical
1) MSW
2) V care
3) Women initiative

115. Health Education
 Breast Self-examination
 Diet
 Treatment
 Pregnancy
 Follow-up

116. Breast self examination is the is the screening method used
in an attempt to detect early breast cancer
Breast self examination
Definition
When to do?
Examine your breast regularly.
Once a month is enough.
The best time is 7-10 days from the first day
of your period.
If your no longer menstruating choose the same
day of every month.
Also during pregnancy.

117. Arms are relaxed at the sides
Look

118. hands on hips

119. Arms raised above the head

120. Bending forward

121. Check for the nipple and
squeeze it to look for any
discharge or bleeding

122. Lie down
Place pillow under
right shoulder
Check your entire
breast area with finger
Use small circles and
follow an up and down
pattern
Use light, medium
and firm pressure
 repeat these steps
on your other breast

123. IN THE SHOWER;
Raise your left arm.
With soapy hands and fingers flat,
check your left breast.
 Use the method described in the ”lying
down” step.
Repeat on your right breast.

124. Exercises

125. EXERCISES

126. EXERCISES

127. EXERCISES

128. EXERCISES

129. EXERCISES

130. DO’S
 DO WEAR LOOSE RUBBER GLOVE ON YOUR HAND
WHEN WASHING YOUR DISHES OR GARDENING
 DO PROTECT YOUR HAND FROM PIN PRICKS
,SCRATCHES OR CUTS OF ANY KIND
 CAREFUL MANICURE SHOULD BE PRACTICED
 USE AN ELECTRIC RAZOR WITH A NARROW HEAD FOR
UNDER ARMS SHAVING,REDUCE THE RISK OF NICKS
AND SCRATCHES
 USE THIMBLE WHILE STITCHING
 USE LOOSE CLOTHINGS
 USE INSECT REPLLENT TO AVOID BITE

131. DON’TS
 DO NOT ALLOW INJECTIONS OF ANY KIND ON
THE AFFECTED ARM
 DO NOT ALLOW BLOOD TO BE DRAWN FOR
TESTS FROM THE AFFECTED ARM
 DO NOT TAKE BLOOD PRESSURE RECORDINGS
ON THE AFFECTED ARM
 DO NOT WEAR TIGHT CLOTHING OR
JEWELLERY ON THE AFFECTED ARM
 DO NOT EXPOSE THE AFFECTED ARM OR HAND
TO EXTREMES OF TEMPERATURE

132. PLEASE REMEMBER
 EXERCISE SHOULD BE STARTED SECOND
POST OP DAY INSTRUCTED BY SURGEON
 IT SHOULD BE PERFORMED THREE TIMES
A DAY AND REPEAT 10 TIMES
 CONTINUE FOR A MIN.6 MONTH
 IT IS IMPORTANT TO DO YOUR
EXERCISES DURING RT.
 IN CASE OF ANY ABNORMALITIES
CONTACT YOUR DOCTOR

133. Prosthesis
Prosthesis: An artificial substitute or
replacement of a part of the body such as
a tooth, eye, a facial bone, the palate, a
hip, a knee or another joint, the leg, an
arm, etc. A prosthesis is designed for
functional or cosmetic reasons or both
Definition

134. Prosthesis
Types of Breast
Prostheses
• Silicone Breast Prostheses
A silicone breast prosthesis comes the closest to
imitating breast tissue in weight and drape. A good
prosthesis will also have some movement similar to
your real breast.

135. Prosthesis
• Non-Silicone Breast
Prostheses
A non-silicone breast prosthesis may
be made of foam rubber, fiberfill or
cotton. These are lighter in weight
than silicone prostheses, and can be
worn as soon as you'd like after a
mastectomy.

136. Prosthesis
• Partial Breast Prosthesis
If you feel unbalanced after a segmental
mastectomy or lumpectomy, you can use
a small, partial breast prosthesis or
"equalizer" to help fill out your bra on
your surgery side. These are made of
silicone, foam rubber, or fiberfill. A
partial breast prosthesis can be tucked
into your regular bra, or into the pocket
of a mastectomy bra

137. Prosthesis
• Attachable (Contact) Breast
Prosthesis
You might want to try an attachable
prosthesis. Also called a contact prosthesis,
these have adhesive strips or Velcro tabs,
which allow you to attach your prosthesis
directly onto your body. This kind of
prosthesis will move with you, and it can be
worn with a regular bra. Contact prostheses
come in full-breast sizes and partial breast
shapes.

138. Placement of a silicon prosthesis

139. FOLLOW UP
 Bi-annual Physical Examination (PE) for 5
years followed
 Every 3 months first 2-3yrs
 Each follow up Mammography chest x’ray
and bone scan.
 No other investigations in asymptomatic
patients for early detection of metastasis
 Any signs and symptom pt have to come
for assessment
 Husband has to be encourage to come to
follow up with pt for evaluation

140.  Chest radiography
 Ultrasound abdomen
 Liver Function Test
 Radionuclide Bone Scan
 Skeletal survey of suspicious or
weight bearing areas
 CT / MRI, where indicated
If recurrence or symptoms suggestive of metastasis,
relevant investigations to be done

141. THANK YOU