Breast cancer, a prevalent malignancy in women, poses significant global health challenges with over a million new cases diagnosed annually. Factors influencing its risk include genetics, hormonal influences, and lifestyle, while treatment strategies vary based on the cancer stage, including options like surgery, chemotherapy, and hormonal therapy. Effective management requires a multidisciplinary approach, emphasizing early detection and standardized care, particularly in resource-limited settings.

1. KASAMA COLLEGE OF
NURSING
GYNAECOLOGY
BREAST CANCER
BY MR. CHANDA FK

2. The breast

4. Definition of Breast Cancer
• Breast cancer is a cancer that starts in the
tissues of the breast (Conrad M, 2009).
• Breast cancer can either be invasive or non –
invasive

5. Epidemiology
• Breast Cancer constitutes a major public
health issue globally with over 1 million new
cases diagnosed annually, resulting in over
400,000 annual deaths and about 4.4 million
women living with the disease (Veronesi U, et
al, 2005).

6. Cont`
• It is the commonest site specific malignancy
affecting women and the most common cause
of cancer mortality in women worldwide
(Veronesi U, et al, 2005).

7. Cont`
• There is an international/geographical
variation in the incidence of Breast Cancer.
• Incidence rates are higher in the developed
countries than in the developing countries and
Japan.

8. Cont`
• In Africa, Breast Cancer has overtaken cervical
cancer as the commonest malignancy
affecting women and the incidence rates
appear to be rising. (Journal of Clinical
Oncology, 2001).

9. Cont`
• These increases in incidence are due to
changes in the demography, socio-economic
parameters, epidemiologic risk factors, better
reporting and awareness of the disease.
• In Zambia, it is the second largest cancer in
women after cervical cancer (Journal of
Clinical Oncology, 2001).

10. Epidemiologic Risk Factors/Etiology
• Sex: The most obvious risk factor for breast
cancer is being a woman.
• Age: The incidence of breast cancer increases
with age and is rare before the age of 20
years.

11. Cont`
• Genetic: Breast Cancer Genes; Some women
have a very high risk of breast cancer because
they inherited changes in certain genes. The
genes most commonly involved in breast
cancer are known as BRCA1 and BRCA2

12. • BRCA1 and BRCA2 are two tumour
suppressor genes. Normally, these genes help
prevent cancer by producing proteins that
repair damage to DNA. Certain changes
(pathogenetic variants) in these genes disrupt
the function of the protein product and are
associated with hereditary breast and ovarian
cancers.

13. Cont`
• Family History: family history of breast cancer
increases a woman's risk of developing the
disease though up to 80% of women with
breast cancer have no family history of the
illness.
• Geographic variation: A wide difference in age
adjusted incidence and mortality for breast
cancer exists between different countries

14. Cont`
• Hormone/Pregnancy related factors :
The role of estrogen in the causation of
breast cancer has been extensively
studied and the general opinion is that
estrogen is the primary stimulant for
breast epithelial proliferation

15. • Factors that increase exposure to high or
prolonged level of estrogen are therefore
associated with an increased risk of
developing breast cancer.

16. Hormone/Pregnancy related factors cont
These factors include
• early menarche,
• late menopause,
• use of contraceptives and exogenous
estrogen,
• Nulliparity
• increased age at first term pregnancy

17. Cont`
• Pregnancy History: Women who haven’t had a
full-term pregnancy or have their first child
after age 30 have a higher risk of breast cancer
compared to women who gave birth before
age 30.
• Breastfeeding History: Breastfeeding can
lower breast cancer risk, especially if a woman
breastfeeds for longer than 1 year.

18. Cont`
• Menstrual History: Women who started
menstruating (having periods) younger than age
12 have a higher risk of breast cancer later in life.
• The same is true for women who go through
menopause when they're older than 55
• Use of HRT (Hormone Replacement Therapy):
Current or recent past users of HRT have a higher
risk of being diagnosed with breast cancer.

19. Cont`
• Previous Breast Disease: Individuals who have
a prior history of invasive carcinoma or ductal
carcinoma in situ have a 0.5%-1% per year risk
of developing a new invasive breast
carcinoma.
• Environmental Exposures: Exposure to
ionizing irradiation increases the risk of
developing breast cancer.

20. Cont`
• Lifestyle Risks: Height, obesity and high body
mass index are risk factors especially in post
menopausal women and reduced by physical
activity
• Diet, Alcohol and Smoking: Alcohol and Diets
rich in fat especially saturated fat raises the
risk while smoking does not appear to affect
the risk.

21. Pathology
• Breast cancers are derived from the epithelial
cells that line the terminal duct lobular unit.
• Cancer cells that remain within the basement
membrane of the elements of the terminal
duct lobular unit and the draining duct are
classified as in situ or non-invasive.

22. Pathology cont`
• An invasive breast cancer is one in which there
is dissemination of cancer cells outside the
basement membrane of the ducts and lobules
into the surrounding adjacent normal tissue.

23. Breast Cancer Staging
• Staging of Cancer is an attempt to define
characteristics that would reliably define
tumors based on the extent of the disease.
• It is useful for choosing treatment options,
selection of patients and comparing the
outcome of treatment and clinical trials and
for prognosticating

24. Breast Cancer staging
• Its based on the TNM system.
• The breast cancer TNM staging system is the
most common way that of staging breast
cancer. TNM stands for Tumour, Node,
Metastasis.

27. Breast Cancer Stages

28. Signs and Symptoms
• A painless lump in the breast.
• Changes in breast size or shape
• Dimpling or orange peel like appearance.
• Swelling in the armpit.
• Nipple changes or discharge which could be
bloody.
• Breast pain can also be a symptom of cancer,
but this is not common
• Retraction of the nipple

30. Classification of Primary Breast
Cancer
a. Non-invasive Epithelial Cancers
• Lobular Carcinoma in situ (LCIS): Originates
from the terminal duct lobular units and only
develops in the female breast.
• Ductal Carcinoma in situ (DCIS) or intraductal
carcinoma: DCIS: Predominantly seen in the
female breast, it accounts for 5% of male
breast cancers.

31. Cont`
b. Invasive Epithelial Cancers (percentage of
total)
• Invasive lobular carcinoma (10-15)
• Invasive ductal carcinoma
• Invasive ductal carcinoma, (NOS) Not
Otherwise Specified (50-70)
• Tubular carcinoma (2-3)
• Mucinous or colloid carcinoma (2-3)

32. IEC percentage of total Cont`
• Medullary carcinoma (5)
• Invasive cribriform (1-3)
• Invasive papillary (1-2)
• Adenoid cystic carcinoma (1)
• Metaplastic carcinoma (1)
• Paget’s disease (<1)

33. Classification of Primary Breast Cancer
Cont`
c. Mixed Connective and Epithelial Tumors
• Phylloides tumors, benign and malignant
• Carcinosarcoma
• Angiosarcoma

34. Cont`
d. Inflammatory breast cancer: inflammatory
breast cancer is a rare fast growing type of
cancer that often causes no distinct lump.
• breast skin may become thick, red, look pitted
like an orange peel, area may also feel warm
or tender and have small bumps that look
like a rash.

35. Diagnosis
a. Breast self examination

36. Diagnosis
b. Imaging:
• Mammography is the most useful test to
differentiate between benign and malignant
lesions (An X-ray imaging to detect for
presence of tumor or lump in breast.)
• Mammary ductoscopy (MD) is a newly
developed endoscopic technique that allows
direct visualization and biopsy examination of
the mammary ductal epithelium where most
cancers originate

38. Diagnosis cont`
• Ultrasonography method of resolving
equivocal mammography findings, defining
cystic masses,
• MRI is a non invasive, non radiating imaging
technique.
• Plain X-rays and Bone Scan

39. Cont`
c. Biopsy
• Fine needle biopsy for cytology will allow a
diagnosis of malignant cells but will not
differentiate between in situ or invasive disease.
• Tissue biopsy for histology which will allow a
diagnosis of invasive versus in situ cancer due to
the relatively larger tissue samples

40. Treatment
❖Cancer treatment may be local or systemic.
• Local treatments involve only the area of
disease. Radiation and surgery are forms of
local treatment.
• Systemic treatments affect the entire body.
Chemotherapy is a type of systemic
treatment.

41. Cont`
❖Treatment strategy for breast cancer depends
on the stage of the disease such as the
following
• Breast Cancer In situ (DCIS and LCIS)
• Early Breast Cancer

42. Cont`
❖Treatment may also depend on:
• The grade of the lesion, with higher-grade
lesions more likely to recur in a short time
• The youth of the patient, with many more
years at risk for recurrence
• The size of the lesion

43. Cont`
❖Treatment according to stages
• Stage 0 and DCIS - There is some
controversy on how best to treat DCIS
however, Lumpectomy plus radiation or
mastectomy is the standard treatment.

44. • Stage I and II - Lumpectomy plus
radiation or mastectomy with some sort
of lymph node removal is the standard
treatment. Hormone therapy,
chemotherapy, and biologic therapy may
also be recommended following surgery.

45. Cont`
• Stage III - Treatment involves surgery, possibly
followed by chemotherapy, hormone therapy,
and biologic therapy.
• Stage IV - Treatment may involve surgery,
radiation, chemotherapy, hormonal therapy,
or a combination of these treatments.

46. Cont`
❖General Treatment of breast cancer includes:
• Chemotherapy : the administration of
Polychemotherapy - Four to six courses of
treatment (3–6 months) appear to provide
optimal benefit. Popular regimes include CMF
(Cyclophosphamide, Methotrexate and
Fluorouracil)

47. Cont`
• Cyclophosphamide – breast cancer
- Action – interferes with RNA transcription,
causing an imbalance of growth that leads to
cell death.
- Dosoge – 40 – 50mg/kg I.V. In divided doses
over 2 – 5 days
• Fluorouracil – breast cancer
- Action – inhibits DNA synthesis
- Dosage – 12mg/kg I.V. Daily x 4 days

48. Cont`
• Hormonal therapy is prescribed to women
with ER-positive breast cancer to block certain
hormones that fuel cancer growth. E.g.
- Tamoxifen - this drug blocks the effects of
estrogen
- Aromatase inhibitors, such as Exemestane
(Aromasin) block estrogen from being made

49. Cont`
• Radiation - radiation therapy uses high-energy
rays to kill cancer cells.
• Surgical Treatment
- Mastectomy with or without axillary dissection
- removes all or part of the breast and possible
nearby structures.

50. Cont`
- Breast –conserving surgery plus radiotherapy
minimize the risk of local recurrence while
leaving the patient with a cosmetically
acceptable breast
- Lumpectomy – removal of the breast lump
- Breast Reconstruction
- Breast Forms

51. Breast Cancer Surgery

52. Breast Forms

53. Prevention
• Dietary intervention - Dietary fat reduction
and exercise decrease the circulating serum
oestradiol level. Others include;
- Choose foods and portion sizes that promote a
healthy weight
- Choose whole grains instead of refined grain
products

54. Cont`
- Eat 5 or more servings of fruits and vegetables
each day
- Limit processed and red meat in the diet
- Limit alcohol consumption to one drink per
day or not drinking alcohol at all

55. Cont`
• Chemoprevention is defined as the systemic
use of natural or synthetic chemical agents to
reverse or suppress the progression of a
premalignant lesion to an invasive carcinoma
e.g. Tamoxifen
• Surgical prophylaxis - by either a bilateral
Mastectomy or Oophorectomy

56. Screening and control of breast cancer
• Annual screening
• Self Breast Examination
• Clinical Breast Examination
• Incorporation of Breast Awareness programs
and health education into the Primary Health
Care
• Control of risk factors within Control

57. Complications
• Secondary heamorrhage
• Anaemia
• Chronic pain may be due to the disease,
therapy or depression
• Lymphadema
• Respiratoty distress
• Neurological complications i.e. cerebral
metastases, spinal
• physical and psychological distress

58. Nursing management
Problems identified
• Pain-pain relief
• malignant ulcers-wound care
• Depression-psychological care and support
• Low self esteem- psychological care and social
support
• Prone to infections-infection prevention
• Respiratory distress

59. Management after surgery
Problems/potential problems
1. Potential problem of wound complication
and delayed wound healing.
-Check drains
-observe wound for signs of infection
-wound dressing
-Assess nutritional intake( vit C and protein)
-assess amount of sleep and rest
-4hourly temperature checking and pulse

60. Problems/potential problems
2. Anxiety/distress due to altered body image as a result
of mastectomy and diagnosis of cancer
-give pt time and opportunity to express and explore
feelings concerning the diagnosis and breast loss
- encourage pt to discuss feelings with partner were
appropriate
- Give info about scaring e.g. sutures, position
- Assess pt’s reaction at first sight and offer support
- Discuss possibility of breast reconstruction if not done
- Fit temporally prosthesis after removal of drains and
show how to use
- Make fitting appointment for silicon prosthesis

61. Problems/potential problems
3. Difficulty moving the arm due to discomfort
following axillary dissection
-refer the pt for physiotherapy
-encourage pt to practice arm exercises at least
4 times daily
Give written information on the type of
exercises and when to perform them

62. Problems/potential problems
4. Pain
-give regular analgesia and assess effectiveness
-use of pillows to support arm on the affected
side to encourage drainage
-relaxation technique and massage

63. Problems/potential problems
5.Potential problem of lymphadenopathy of the
arm post-op or at some time in future-
-explain to pt what it is,cause,signs etc and
encourage the pt to report if it occurs
-Discuss hand and arm care
-elevate arm prn
-arm and shoulder exercices to reduce possibility of
it’s occurance.

64. Conclusion
• Management of breast cancer is a major
challenge in resource limited countries.
Efforts should be geared towards early
diagnosis, prompt and standardized treatment
to reduce the burden of advanced disease in
African women, majority of who are worse hit
in the most productive part of their life time.

65. Cont`
• The odds of surviving breast cancer are strongly
tied to how early it is found.
• A multi disciplinary approach is important which
will involve psychologists, social welfare/support
groups and various advocacy groups where
survivors of breast cancer can share their
experiences and support one another

66. References
• Breast Cancer-A Review for African Surgeons,
Surgery in Africa- monthly Review (accessed from
http://www.ptolemy.ca/members/index.htm on
07.12.2011 at 10;00 hrs).
• Ca Journal for clinicians (2008), Breast Cancer,
(accessed from
//www.breastcancer.org/symptoms/iphone-app-
breast-cancer-diagnosis-guide.jsp on 19.12.11 at 08:30
hrs).
• Carlson RW, Allred DC, Anderson BO, Carter WB, Edge
SB, et al. (2009 ) Breast cancer, Clinical practice
guidelines in oncology, ( Accessed from
http://health.nytimes.com/health/guides/disease/brea
st-cancer/overview.html- on 07.12.2011 at0942hrs).
• Hamilton D –Faerley (2004), Obstetrics & Gynaecology
2nd Edition Lecture Notes, Blackwell Publications,
London.

67. Cont`
• Oats J (2005), Fundamentals of Obstetrics & Gynaecology,
8th Edition, Elsevier Mosby Edinburgh.
• Veronesi U., Boyle P., Viale G., (2005), Breast cancer-A
review for African surgeons, (accessed from
http://www.ptolemy.ca/members/archives/2007/archives/
2007/Breast cancer/Hisham.pdf on 16.12.11 at 16:50hrs).
• West African Journal of Medicine 2000, (accessed from
http://www.ptolemy.ca/members/archives/2007/archives/
2007/Breast cancer/Hisham.pdf on 16.12.11 at 16:50hrs).
• Conrad M, (2009), The Breast, accessed from
http://www.medicinenet.Com/script/main/art.asp?articlek
ey.
• Stellenberg E and Bruce J(2007), Nursing Practice, medical
surgical nursing for hospitals and community, African
edition, Elsevier, churchill