Breast cancer is the most common cancer in women, affecting about 1 in 8 women over their lifetime. Risk factors include age, family history, certain genetic mutations, reproductive history, obesity, and alcohol use. Screening mammography can detect breast cancer early when treatment is most effective. Treatment may involve surgery such as lumpectomy or mastectomy, radiation, chemotherapy, hormone therapy, and breast reconstruction. Side effects of treatment can include pain, lymphedema, fatigue, and changes in body image. Long term follow up focuses on monitoring for recurrence and managing side effects.

1. BREAST CANCER

2. Epidemiology Most common cancer affecting ♀ (< 1% in ♂) 1 in 8 ♀ will develop breast CA Commonly develops after age 50 ⇧ reporting & detection r/t screening mammography Incidence ⇧ since 1980s Delay seeking care r/t Fear of cancer Lack of knowledge of success w/ early tx

3. Etiology Unknown r/t estrogen? Probably combination of hormonal, genetic & environmental factors

4. Risk factors Age Race/ethnicity Family history of breast CA—especially 1 st degree relative; mother, sister Genetic mutations in BRCA1 & BRCA2 genes Long menses—early menarche/late menopause Nulliparity 1 st pregnancy after age 30 Obesity/ ? High-fat diet History of unilateral breast CA Hx of benign proliferative breast disease History endometrial or ovarian CA HRT Moderate (1 drink daily) ETOH Hx chest radiation

5. Protective Factors Regular exercise Breast-feeding Pregnancy prior to age 30

6. Prevention Strategies for the high-risk patient Clinical breast exam twice a year Earlier screening mammograms MRI or ultrasound Tamoxifen (anti-estrogen) Evista (SERM) Prophylactic mastectomy with reconstruction Can reduce risk of CA by 90%

7. Pathophysiology Breast CA = malignant tumors that typically begin in ductal-lobular epithelial cells Growth rates vary Spread via lymphatic & bloodstream Other breast Chest wall Lungs Liver Bone Brain Most primary breast CA = adenocarcinoma located in upper outer quadrant of breast

8. Classification cont’d Carcinoma in situ Confined to ductal or lobular units w/o permeation of basement membrane Ductal carcinoma in situ (DCIS) Precursor of infiltrating carcinoma Low-grade, multifocal most common Invasive CA on same side develops w/i 10 yrs ~30% Calcifications on mammogram Lobular carcinoma in situ (LCIS) Solid proliferation of atypical cells Usually found incidentally Less likely to develop into infiltrating CA DCIS & LCIS considered Stage 0 cancers

9. Classification of Invasive Cancers Infiltrating ductal = 75% of cases Infiltrating lobular Tubular ductal Inflammatory (rare)—rapidly growing & causing overlying skin to become edematous, inflamed & indurated. Spreads rapidly Medullary carcinoma—enlarging rapidly Mucinous carcinoma: usually in women over age 75 Paget disease: Scaly itchy lesion of nipple

10. What happens in breast CA? Mutation in cells Lump/mass in breast Hard, stony mass Nontender Irregular shape nonmobile △ breast size/symmetry △ nipple Itching Burning Erosion Retraction Nipple discharge watery Serous Creamy Bloody

11. What happens in breast CA? Fixation of CA to pectoral muscles or underlying fascia Edema △ breast skin Thickening Scaly skin around nipple Dimpling △ skin texture Peau d’orange—sign of inflammatory breast CA

12. What happens in breast CA? Advanced spread w/i breast Metastasis △ skin temp Warm, hot, or pink area Ulceration Edema Pain Pathologic bone fractures Edema of arm

13. Diagnostic tests Primary tests Mammography Breast ultrasound Biopsy Fine needle aspiration (FNA) Sample cells for analysis 1 st step in evaluation Image-guided core needle biopsy Stereotactic (SNB)—target & identify nonpalpable lesions detected by mammography Ultrasound core biopsy—used when lesion can be seen on ultrasound Open biopsy—local anesthetic

14. Staging of breast CA Stage I ≤ 2 cm Confined to breast Stage II up to 5 cm Early metastasis to axillary lymph nodes Stage III > 5 cm Involvement of ipsilateral axillary or internal mammary lymph nodes Stage IV Distant metastasis Ipsilateral supraclavicular lymph node Skin or chest wall; or Inflammatory CA

15. Nursing diagnoses Acute pain r/t breast OR Fear r/t diagnosis of CA Ineffective coping r/t anxiety, lower activity level & inability to perform ADL Activity intolerance r/t fatigue postoperatively Disturbed body image

16. Surgical Management Breast-Preserving Surgery Stage I & Stage II Survival rate equal to mastectomy Lumpectomy (may be combined w/ radiation Lumpectomy & axillary node dissection Quadrantectomy or segmental mastectomy Goal is to excise tumor & obtain clear margins while maintaining acceptable cosmetic appearance

17. Sentinel Lymph Node Biopsy Status of lymph nodes is the most important prognostic factor SLNB less invasive than axillary lymph node dissection (ALND) ALND associated with lymphedema, cellulitis, decreased arm mobility, decreased arm sensation

18. Sentinel Lymph Node Biopsy First node in lymphatic basin that receives drainage from the primary tumor is identified by injecting radioisotope or blue dye into the breast Node is excised & sent for frozen section If positive, ALND is done

19. Comparison of SLNB vs ALND SLNB 15-30 min. with local anesthesia Lower rate of complications ALND 60-90 min. with general anesthesia Higher rate of lymphedema, seroma, decreased ROM & sensation

20. Surgical Management Total Mastectomy Also called “simple” mastectomy Entire breast & nipple-areola removed Used for non-invasive CA Does not include ALND May be done prophylactically for BRCA mutation SLNB may be done with it

21. Surgical Management Modified Radical Mastectomy Used to treat invasive CA Entire breast, nipple-areola removed ALND also done Pectoralis muscles left intact Immediate breast reconstruction may be done Radical Mastectomy Pectoralis muscles also removed, along with entire breast, nipple-areola Rarely done today

22. Reconstructive Surgery after Mastectomy Requires consult with plastic surgeon May be done with mastectomy or delayed Factors to consider Body size & shape Natural breast never precisely duplicated Comorbidities Opposite breast may also require work also to achieve symmetry Does not interfere with CA recurrence or tx

23. Reconstructive Surgery after Mastectomy Most common method is use of tissue expander under pectoralis muscle followed by implant Saline injected into expander weekly for 6-8 weeks then left in place fully expanded x 6 wks. Implant placed as outpatient surgery Not used if had previous radiation to chest

24. Reconstructive Surgery after Mastectomy Tissue Transfer Procedure Longer surgery & recovery time, with 2 incision sites Flap of skin, fat & muscle rotated to mastectomy site Transverse rectus abdominus myocutaneous flap (TRAM) Latissimus dorsi flap Diabetics, smokers, obese patients are poor candidates

25. Reconstructive Surgery after Mastectomy Local flaps from “new breast” tissue can be used to re-create nipple Areola created using skin graft from inner thigh Tattoo procedure to recreate darker pigmentation

26. Prostheses Usually made of silicone; placed into bra Reach to Recovery can provide referrals to shops and prosthetic consultants

27. Post-Op Care Pain control Pain more severe with modified radical mastectomy Changes in sensation may include numbness, pulling, twinges in chest wall or upper arm Phantom breast sensation Usually diminish over months to 2 years

28. Post-Op Care Body image & sexuality Many pts. have difficulty viewing operative site Offer privacy & emotional support Support to partners Referrals to advocacy groups

29. Post-op Complications Transient edema resolves within a month Lymphedema Occurs in 10-30% of patients with ALND Risk factors: Obesity Age Radiation Infection to the extremity

30. Post-op Complications Treatment for Lymphedema Exercises with raising arm above the head Compression sleeve or glove Manual lymph drainage (PT) Protection of affected arm: Avoid BP, blood draws & injections in affected arm Use sunscreen, insect repellant Wear gloves for gardening Electric razor for shaving Avoid lifting more than 5-10 lbs Use care for manicures, cooking

31. Post-op Complications Hematoma Usually develops within 12 hours after surgery Sx include swelling, tightness, pain & bruising Increased bloody drainage from drain---notify MD immediately Return to OR for active bleeding Tx with compression wrap x 12 hours Small hematomas resolve in 4-5 weeks

32. Post-op Complications Seroma Sx include swelling, heaviness, discomfort, sloshing of fluid May occur due to clogged drain Small seromas resolve; large seromas are drained with needle & syringe due to risk of infection

33. Radiation Therapy Decreases chance of local recurrence by eradicating microscopic cancer cells Stage I & II: Radiation after breast-conserving surgery = survival rate of modified radical mastectomy

34. Radiation Therapy External beam tx begins 6 weeks after breast conservation therapy 5 days a week x 6 weeks Anatomic areas mapped out, marked with ink Begins after systemic chemo Other options: Brachytherapy: Radiation source placed into lumpectomy site Intra-operative radiation done in OR immediately after lumpectomy

35. Radiation Side-Effects Erythema Fatigue Skin breakdown near axilla or inframammary fold Rare long-term effects: Pneumonitis, rib fx, fibrosis

36. Care of radiation sites Use mild soap, don’t rub Avoid perfumed soaps or deodorants Hydrophilic lotions (Eucerin, Lubriderm) Aveeno soap for itching Avoid tight clothes, underwire bras Use sunscreen Twinges & shooting pains are expected

37. Chemotherapy Used for tumors greater than 1 cm, or if nodes are positive Initiated after breast surgery, prior to radiation Combine several agents; given over 3-6 months “ CMF” most widely used: Cyclophosphamide, methotrexate, fluorouracil

38. Chemotherapy “ ACT” improves survival in non-operable breast CA & positive lymph nodes: Adriamycin + cyclophosphamide + Taxol

39. Side-Effects of Chemo Nausea/ vomiting Improved anti-emetics (Zofran, Reglan) Bone marrow suppression Hematopoietic growth factors (Epogen or Aranesp; Neupogen/ Neulasta Taste changes Alopecia: Color & texture may change after Mucositis: Saline rinses, soft toothbrush Fatigue Weight gain (? cause) Taxol: Peripheral neuropathy, arthralgia Doxorubicin: Cardiotoxicity; tissue necrosis if infiltrates

40. Hormonal Therapy Considered for hormone-receptor positive tumors Estrogen + or progesterone + Drugs compete with estrogen & bind to receptor sites (SERMs) or block estrogen production (Aromatase inhibitors)

41. Hormonal Therapy SERM (selective estrogen receptor modulator) Tamoxifen Has positive effect on blood lipids & bone density S/E: Hot flashes, vaginal dryness, mood disturbances, increased risk for endometrial CA & DVT

42. Hormonal Therapy Aromatase inhibitors block conversion of testosterone to estradiol Arimadex, Femara S/E: arthritis, myalgia, N/V, fatigue, hot flashes, mood disturbances, increased risk of osteoporosis

43. Targeted Therapy Monoclonal antibody that binds to HER-2/neu protein which is present on the surface of normal breast cells & cancer cells Herceptin inactivates the protein & slows tumor growth without attacking normal cells Fewer S/E

44. Hormonal Therapy Patient Education: Hot flashes: Avoid caffeine & spicy foods; wear layers; antidepressants may help Vaginal moisturizers Bland diet for N/V; meds at nights NSAID’s and warm baths for muscle & joint pain Baseline bone density scan; take Vit. D & calcium; exercise Report abnormal vaginal bleeding and S&S of DVT

45. Evaluation: 5 year Survival Rate Stage 0 Stage I Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IV See Table 48-2 page 1716 100% 98% 88% 76% 56% 49% 16%

46. Which is the single most important predictor of outcome for breast cancer patients? The histological status of the axillary nodes is the single most important predictor of outcome for breast cancer patients.

47. EARLY DETECTION is KEY Nurses should encourage routine breast surveillance and screening mammograms for all women, including those with disabilities