1. Interventions for Clients with Breast Disorders Jolene Bethune, RN, MSN

2. Anatomy of Breast and Lymph Nodes

3. Objectives Provide an overview of breast disorders, including breast cancer, with key terms you will hear in practice. Describe 3-pronged approach to early detection of breast disorders. Provide a brief outline of pathophysiology and etiology of breast cancer. Describe options available to women at high genetic risk for breast cancer. Use nursing process to describe the care of clients with breast masses.

4. Key Terms

5. Mammogram – x-ray examination of the breast Breast Self Examination – breast examination performed by client (goal is early detection!) Mastectomy – surgical breast removal Fibroadenoma – solid, slowly enlarging benign mass of connective tissue; usually round, firm, easily movable, nontender, clearly delineated from surrounding tissue Chemoprevention – prophylactic use of tamoxifencitrate

6. Fibrocystic breast disease (FBD) – benign breast nodules Ductal ectasia– dilation and thickening of the collecting ducts in the subareolar area Intraductal papilloma – benign process of an outgrowth of tissue in the epithelia lining of the duct Gynecomastia – benign condition of breast enlargement in men Noninvasive – cancer cells remain within the ducts Invasive – cancer cells penetrate the tissue surrounding the ducts

7. Peau d’orange – orange peel appearance of the skin caused by edema Breast biopsy – postoperative examination of the breast tissue Lumpectomy – gross resection of a tumor Partial mastectomy – removal of the portion of the breast that contains the tumor Modified radical mastectomy – affected breast is completely removed

8. EARLY DETECTION: A 3-Pronged Approach Mammography Breast Self-Examination (BSE) Clinical Breast Examination (CBE)

9. Mammography Baseline screening mammogram recommended beginning at age 40 Yearly for women ages 40-50 Barriers include: fear of radiation fear of results concerns about pain knowledge deficit accessibility; client cost

10. Breast Self Examination Inexpensive, encouraged by health care providers for decades Detection before axillary node involvement increases survivability Used in conjunction with mammography, CBE , BSE is extremely effective in early detection and reducing mortality rates Women taught by a health care provider instead of pamphlets or magazines practice BSE more often, more proficiently and more confidently The nurse: Stresses that treatment for breast cancer is more successful the earlier the disease is detected Discusses client’s fears, beliefs and concerns Discusses proper timing of self examinations: 1 week after menstrual period for premenopausal women; postmenopausal women should pick one day each month

11. Clinical Breast Examination Typically performed by advanced-practice nurses, physicians, skilled general practice nurses Can be done before, during, after teaching sessions Breast history is vital Visual inspection Palpation

12. BENIGN BREAST DISORDERS Most breast lumps are benign; related to age. Primary concern is ruling out breast cancer. Benign disorders in age-related order: Fibroadenoma Fibrocystic Breast Disease Ductal Ectasia Intraductal Papilloma Issues of Large Breasted Women Gynecomastia

13. Fibroadenoma Occurs in adolescents; may be in some women in their thirties Solid, slowly enlarging benign mass of connective tissue; usually round, firm, easily movable, nontender Clearly delineated from surrounding tissue Only 0.9% of the masses are malignant Usually located in upper outer quadrant of the breast Multiple masses are possible Health care provider may order a breast ultrasound or needle aspiration to establish whether lesion is cystic or solid If lesion is solid, outpatient excision using local anesthesia is the treatment of choice

14. Fibrocystic Breast Disease Most common breast problem of women between 20-30 years 3 Clinical stages: First stage: premenstrual bilateral fullness and tenderness Second stage: bilateral multicentric nodules Third stage: microscopic, macroscopic cysts

15. Fibroadenoma & Cysts

16. Ductal Ectasia Usually seen in women approaching menopause Masses often difficult to distinguish from breast cancer Microscopic examination of nipple discharge; affected area is excised Nursing care is directed at alleviating the anxiety associated with the threat of breast cancer; supporting the woman through the diagnostic and treatment procedures

17. Intraductal Papilloma Primarily in women 40-55 Intraductal papilloma – benign process of an outgrowth of tissue in the epithelia lining of the duct; ducts become distended, filling with cellular debris, activating an inflammatory response Diagnosis aimed at ruling out breast cancer Microscopic examination of the nipple discharge and surgical excision of the mass and ductal area are usually indicated

18. Issues of Large-Breasted Women Fashion difficulties Discomfort Fungal infections under the breasts Reduction mammoplasty Nursing considerations consistent with those for women undergoing reconstructive surgery

19. Gynecomastia Can be result of a primary cancer like lung cancer Etiologic factors include : Drugs Aging Obesity Underlying diseases causing estrogen excess (malnutrition) Liver disease Hyperthyroidism Androgen deficiency states (age, chronic renal failure) Men are carefully evaluated for breast cancer

21. OVERVIEW Most commonly diagnosed cancer in women Leading cause of cancer deaths in US women age 35-45 Leading cause of cancer mortality in women, second to lung cancer Most women have strong reaction to the threat of breast cancer; influencing their health habits Ultimate goal of early diagnosis: Reduce mortality by identifying women at risk Predicting response to different therapies Early detection the key to survivability Staging the most reliable predictor of prognosis

22. Types of Breast Cancer

23. Infiltrating Ductal Carcinoma Accounts for 80% of most breast cancer cases Epithelial cells of the mammary ducts Can be invasiveor noninvasive Rates of growth depend on hormonal influence Estimates 5-9 years for lesion to be palpable Most breast cancers arise from immediate ducts and are invasive Once invasive, growth occurs in tissue surrounding the ducts and becomes an irregular, poorly defined mass once palpable Tumor continues to grow, becomes fibrotic; causes shortening of the Cooper’s ligaments, resulting in the skin dimpling seen in more advanced disease

24. Ductal Carcinoma Invasive Ductal Carcinoma Noninvasive Ductal Carcinoma

25. Lobular Carcinoma Invasive Lobular Carcinoma Noninvasive Lobular Carcinoma

26. Complications of Breast Cancer Tumor invades lymphatic channels, causing skin edema, peau d’orange (orange peel appearance of the skin) Invasion of lymphatic channels carries tumor cells to nodes, including those in axillary nodes (nodal examination imperative) The tumor replaces the skin itself, ulcerating overlying skin Metastases result from seeding of cancer cell into the blood and lymph system Most common ‘met’ sites are bones, lungs, brain, liver

27. Vascular/Lymphatic Invasion

28. Breast Cancer in Men 1% of breast cancer cases Average age of onset is 60 years Staged the same as women; treatment parallels that of women Prognosis is worse for men Often disseminated disease, accounting for the lower survival rates

29. WOMEN AT HIGH GENETIC RISK FOR BREAST CANCER Family history suggests a predisposition to the disease Multiple relatives with breast cancer Early age at diagnosis Ovarian cancer Inherited genetic mutations Options include: Cancer Surveillance Prophylactic Mastectomy Chemoprevention

30. Cancer Surveillance Referred to as “secondary prevention” Monthly BSE beginning at age 18-21 CBE every 6-12 month beginning at age 25-35 Annual mammography beginning at age 25-35

31. Prophylactic Mastectomy Usually elective An option for decades Small risk that breast cancer will develop in residual breast glandular tissue (no mastectomy reliably removes all mammary tissue)

32. Chemoprevention Tamoxifen (Nolvadax, Tamofen, Tamone) Complaints of side effects Treatment is expensive

33. Etiology: Risk Factors Female gender History of previous breast cancer Age >40 years Menstrual history: early menarche, late menopause or both Reproductive history: nulliparity; 1st child after 30yr Family history: mother, sister or both

34. Etiology: Risk Factors Diet : high fat (?) Alcohol (?) Obesity (?) Ionizing radiation Benign breast disease Oral contraceptives Exogenous hormones

35. COLLABORATIVE MANAGEMENT Assessment Analysis Planning & Implementation Community-Based Care Evaluation

36. Assessment: History Risk factors History of the breast mass Client’s health maintenance practices

37. Assessment:Risk Factors Personal/family histories of breast cancer Age @ menarche Age @ menopause (early menses or late menopause increase risk) Symptoms of menopause Age @ first child’s birth Number of children (nulliparity/birth of first child after age 30 increase risk)

38. Assessment:History of Breast Mass Reveals course of disease, health care-seeking practices BSE or accidental discovery? Time interval between discovery and seeking health care provider Review of systems focusing on the most common areas of metastases

39. Assessment:Health Maintenance Practices Knowledge, practice and regularity of BSE Mammographic history Diet history (High alcohol, fat intake increase risk) Medications – hormone supplements, birth control pills

40. Physical Assessment Focused Assessment of breast mass Shape Size Consistency Fixation to surrounding tissues Any skin change (peau d’orange) Palpate axillary, superclavicular areas for enlarged lymph nodes Pain, soreness? Diagram

41. Psychosocial Assessment Major issues Fear Threats to body image, intimate relationships and survival Decisions regarding treatment options Explore client’s feelings, support system, client’s & family’s knowledge Client’s level of education Sexuality – psychologic, physiologic, relational Evaluate need for additional resources

42. Laboratory Assessment Radioimmunoassay (RIA) Tumor markers Pathologic examination of lymph nodes Liver enzymes (indicate possible liver metastases) Serum calcium levels/alkaline phosphatase levels (indicate possible bone mets)

43. Radiographic Assessment Mammography – can reveal preclinical lesions Chest x-ray Bone, liver, brain scans CT scans of chest & abdomen The nurse prepares client for the procedure

44. Other Assessments Ultrasound (differentiates solid mass from cyst) Breast biopsy Pathologic examination of the tumor The nurse provides pre- and post-procedure care; client teaching

45. Analysis Common Nursing Diagnosis: Anxiety related to diagnosis of breast cancer Collaborative Problem: Potential for Metastasis

46. Analysis: Additional Nursing Diagnoses Anticipatory Grieving r/t loss and possible or impending death Acute Pain r/t tumor compression on nerve endings Disturbed Sleep Pattern r/t pain and anxiety Disturbed Body Image r/t loss of a body part Sexual Dysfunction r/t body image or self-esteem disturbance

47. Planning : Anxiety The client is expected to: Seek information to reduce anxiety Control anxiety responses Use effective coping strategies throughout the treatment period Participate in decision making Discuss concerns Learn self-care measures

48. Implementation: Anxiety Intervention: Anxiety Reduction Allow the client to vent her feelings; listen attentively Use calm, reassuring approach Provide factual information concerning diagnosis, treatment and prognosis Encourage verbalization of feelings, perceptions and fears

49. Implementation: Anxiety Intervention: Anxiety Reduction Identify when level of anxiety changes Support the use of appropriate defense mechanisms Determine client’s decision-making ability Flexibility is the key Suggest support groups

50. Planning: Potential for Metastasis The client with breast cancer is expected to remain free of metastases or recurrence of cancer

51. Implementation: Potential for Metastasis Nonsurgical Management: Late-stage breast cancer; may be only treatment possible Tumor removal with local anesthetic or resection F/U with hormonal therapy, chemotherapy, radiation

52. Implementation: Potential for Metastasis Surgical Management: Halsted radical mastectomy – breast tissue, nipple, underlying muscles, lymph nodes (rarely performed) Modified radical mastectomy – breast tissue, nipple, lymph nodes

53. Implementation: Potential for Metastasis Surgical Management: Simple mastectomy – breast tissue, nipple (lymph nodes left intact)

54. Implementation: Potential for Metastasis Surgical Management: Lumpectomy – only tumor , small amount of surrounding tissue removed

55. Implementation: Potential for Metastasis The nurse provides: Preoperative care – psychologic preparation, preoperative teaching; assess need for drainage tube, mobility restrictions, length of hospital stay, possibility of additional therapy; address body image issues Intra-operative care – circulator, scrub Postoperative care – avoid using affected side for B/P, injections, blood draws; care of drainage tubes, comfort measures, client teaching, ambulation, adls, exercise,

56. Implementation: Potential for Metastasis Breast Reconstruction The nurse: Assesses incision, flap sites Teaches client to avoid pressure flap, suture lines Cares for drainage devices Teaches client to avoid sleeping in prone position Teaches client to avoid contact sports Teaches client to minimize pressure to breast during sexual relations

57. Implementation: Potential for Metastasis Breast Reconstruction The nurse: Teaches client to refrain from driving Reassures client that optimal appearance may not occur for 3-6 months post –surgery Reviews BSE procedure Reminds client that mammograms should be scheduled at least yearly for the rest of her life Refers to ACS Assesses the client’s attitude toward appearance restoration

58. Implementation: Potential for Metastasis Adjuvant Therapy- F/U with radiation, chemotherapy, hormone therapy; stem cell therapy; bone marrow therapy The nurse knows the specific agents to be used and their properties; provides care for client before, during, after procedures

59. Community-Based Care Home Care Management Health Teaching – teaching plan should include: Measures to optimize body image Information to enhance interpersonal relationships Exercises to regain full ROM Measures to prevent infection of incision Health Care Resources The nurse makes referrals to community resources

60. Evaluation The nurse evaluates the care of the client with breast cancer on the basis of the identified nursing diagnoses and collaborative problems.

61. Expected Outcomes The client will demonstrate the correct method of breast self-examination (BSE) and practice BSE on a monthly basis The client will comply with the guidelines for mammography and professional examination The client will be able to cope with the diagnosis, as shown by her use of social support, use of information to deal with uncertainty, absence of physical signs of anxiety and verbal confirmation of feeling calm The client will state that she feels positive about her self-image The client will regain full range of motion of the affected arm The client will remain free from lymphedema or infection

62. References Breastcancer.org Fotosearch.com Googleimages.com Ignatavicius, D. D., & Workman, M. L. (2002). Medical-Surgical Nursing: Critical Thinking for Collaborative Care (4 ed.). Philadelphia, PA: W. B. Saunders Company