Nrsg 200 breast cancers

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  • Stages II & III are sub-divided into Stage IIA, IIB, IIIA, IIIB, IIIC
  • See Table 48-4 on page 1717
  • See pics of procedures on page 1733.
  • See Chart 48-7 on page 1722.
  • Nrsg 200 breast cancers

    1. 1. BREAST CANCER
    2. 2. Epidemiology <ul><li>Most common cancer affecting ♀ (< 1% in ♂) </li></ul><ul><li>1 in 8 ♀ will develop breast CA </li></ul><ul><li>Commonly develops after age 50 </li></ul><ul><li>⇧ reporting & detection r/t screening mammography </li></ul><ul><li>Incidence ⇧ since 1980s </li></ul><ul><li>Delay seeking care r/t </li></ul><ul><ul><li>Fear of cancer </li></ul></ul><ul><ul><li>Lack of knowledge of success w/ early tx </li></ul></ul>
    3. 3. Etiology <ul><li>Unknown </li></ul><ul><li>r/t estrogen? </li></ul><ul><li>Probably combination of hormonal, genetic & environmental factors </li></ul>
    4. 4. Risk factors <ul><li>Age </li></ul><ul><li>Race/ethnicity </li></ul><ul><li>Family history of breast CA—especially 1 st degree relative; mother, sister </li></ul><ul><li>Genetic mutations in BRCA1 & BRCA2 genes </li></ul><ul><li>Long menses—early menarche/late menopause </li></ul><ul><li>Nulliparity </li></ul><ul><li>1 st pregnancy after age 30 </li></ul><ul><li>Obesity/ ? High-fat diet </li></ul><ul><li>History of unilateral breast CA </li></ul><ul><li>Hx of benign proliferative breast disease </li></ul><ul><li>History endometrial or ovarian CA </li></ul><ul><li>HRT </li></ul><ul><li>Moderate (1 drink daily) ETOH </li></ul><ul><li>Hx chest radiation </li></ul>
    5. 5. Protective Factors <ul><li>Regular exercise </li></ul><ul><li>Breast-feeding </li></ul><ul><li>Pregnancy prior to age 30 </li></ul>
    6. 6. Prevention Strategies for the high-risk patient <ul><li>Clinical breast exam twice a year </li></ul><ul><li>Earlier screening mammograms </li></ul><ul><li>MRI or ultrasound </li></ul><ul><li>Tamoxifen (anti-estrogen) </li></ul><ul><li>Evista (SERM) </li></ul><ul><li>Prophylactic mastectomy with reconstruction </li></ul><ul><ul><li>Can reduce risk of CA by 90% </li></ul></ul>
    7. 7. Pathophysiology <ul><li>Breast CA = malignant tumors that typically begin in ductal-lobular epithelial cells </li></ul><ul><li>Growth rates vary </li></ul><ul><li>Spread via lymphatic & bloodstream </li></ul><ul><ul><li>Other breast </li></ul></ul><ul><ul><li>Chest wall </li></ul></ul><ul><ul><li>Lungs </li></ul></ul><ul><ul><li>Liver </li></ul></ul><ul><ul><li>Bone </li></ul></ul><ul><ul><li>Brain </li></ul></ul><ul><li>Most primary breast CA = adenocarcinoma located in upper outer quadrant of breast </li></ul>
    8. 8. Classification cont’d <ul><li>Carcinoma in situ </li></ul><ul><ul><li>Confined to ductal or lobular units </li></ul></ul><ul><ul><li>w/o permeation of basement membrane </li></ul></ul><ul><ul><li>Ductal carcinoma in situ (DCIS) </li></ul></ul><ul><ul><ul><li>Precursor of infiltrating carcinoma </li></ul></ul></ul><ul><ul><ul><li>Low-grade, multifocal most common </li></ul></ul></ul><ul><ul><ul><li>Invasive CA on same side develops w/i 10 yrs ~30% </li></ul></ul></ul><ul><ul><ul><li>Calcifications on mammogram </li></ul></ul></ul><ul><ul><li>Lobular carcinoma in situ (LCIS) </li></ul></ul><ul><ul><ul><li>Solid proliferation of atypical cells </li></ul></ul></ul><ul><ul><ul><li>Usually found incidentally </li></ul></ul></ul><ul><ul><ul><li>Less likely to develop into infiltrating CA </li></ul></ul></ul><ul><ul><ul><li>DCIS & LCIS considered Stage 0 cancers </li></ul></ul></ul>
    9. 9. Classification of Invasive Cancers <ul><ul><li>Infiltrating ductal = 75% of cases </li></ul></ul><ul><ul><li>Infiltrating lobular </li></ul></ul><ul><ul><li>Tubular ductal </li></ul></ul><ul><ul><li>Inflammatory (rare)—rapidly growing & causing overlying skin to become edematous, inflamed & indurated. Spreads rapidly </li></ul></ul><ul><ul><li>Medullary carcinoma—enlarging rapidly </li></ul></ul><ul><ul><li>Mucinous carcinoma: usually in women over age 75 </li></ul></ul><ul><ul><li>Paget disease: Scaly itchy lesion of nipple </li></ul></ul>
    10. 10. What happens in breast CA? <ul><li>Mutation in cells </li></ul><ul><li>Lump/mass in breast </li></ul><ul><ul><li>Hard, stony mass </li></ul></ul><ul><ul><li>Nontender </li></ul></ul><ul><ul><li>Irregular shape </li></ul></ul><ul><ul><li>nonmobile </li></ul></ul><ul><li>△ breast size/symmetry </li></ul><ul><li>△ nipple </li></ul><ul><ul><li>Itching </li></ul></ul><ul><ul><li>Burning </li></ul></ul><ul><ul><li>Erosion </li></ul></ul><ul><ul><li>Retraction </li></ul></ul><ul><li>Nipple discharge </li></ul><ul><ul><li>watery </li></ul></ul><ul><ul><li>Serous </li></ul></ul><ul><ul><li>Creamy </li></ul></ul><ul><ul><li>Bloody </li></ul></ul>
    11. 11. What happens in breast CA? <ul><li>Fixation of CA to pectoral muscles or underlying fascia </li></ul><ul><li>Edema </li></ul><ul><li>△ breast skin </li></ul><ul><ul><li>Thickening </li></ul></ul><ul><ul><li>Scaly skin around nipple </li></ul></ul><ul><ul><li>Dimpling </li></ul></ul><ul><li>△ skin texture </li></ul><ul><ul><li>Peau d’orange—sign of inflammatory breast CA </li></ul></ul>
    12. 12. What happens in breast CA? <ul><li>Advanced spread w/i breast </li></ul><ul><li>Metastasis </li></ul><ul><li>△ skin temp </li></ul><ul><ul><li>Warm, hot, or pink area </li></ul></ul><ul><li>Ulceration </li></ul><ul><li>Edema </li></ul><ul><li>Pain </li></ul><ul><li>Pathologic bone fractures </li></ul><ul><li>Edema of arm </li></ul>
    13. 13. Diagnostic tests <ul><li>Primary tests </li></ul><ul><ul><li>Mammography </li></ul></ul><ul><ul><li>Breast ultrasound </li></ul></ul><ul><ul><li>Biopsy </li></ul></ul><ul><ul><ul><li>Fine needle aspiration (FNA) </li></ul></ul></ul><ul><ul><ul><ul><li>Sample cells for analysis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>1 st step in evaluation </li></ul></ul></ul></ul><ul><ul><ul><li>Image-guided core needle biopsy </li></ul></ul></ul><ul><ul><ul><ul><li>Stereotactic (SNB)—target & identify nonpalpable lesions detected by mammography </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ultrasound core biopsy—used when lesion can be seen on ultrasound </li></ul></ul></ul></ul><ul><ul><ul><li>Open biopsy—local anesthetic </li></ul></ul></ul>
    14. 14. Staging of breast CA Stage I ≤ 2 cm <ul><li>Confined to breast </li></ul>Stage II up to 5 cm <ul><li>Early metastasis to axillary lymph nodes </li></ul>Stage III > 5 cm <ul><li>Involvement of ipsilateral axillary or internal mammary lymph nodes </li></ul>Stage IV <ul><li>Distant metastasis </li></ul><ul><li>Ipsilateral supraclavicular lymph node </li></ul><ul><li>Skin or chest wall; or </li></ul><ul><li>Inflammatory CA </li></ul>
    15. 15. Nursing diagnoses <ul><li>Acute pain r/t breast OR </li></ul><ul><li>Fear r/t diagnosis of CA </li></ul><ul><li>Ineffective coping r/t anxiety, lower activity level & inability to perform ADL </li></ul><ul><li>Activity intolerance r/t fatigue postoperatively </li></ul><ul><li>Disturbed body image </li></ul>
    16. 16. Surgical Management <ul><li>Breast-Preserving Surgery </li></ul><ul><ul><li>Stage I & Stage II </li></ul></ul><ul><ul><ul><li>Survival rate equal to mastectomy </li></ul></ul></ul><ul><ul><li>Lumpectomy (may be combined w/ radiation </li></ul></ul><ul><ul><li>Lumpectomy & axillary node dissection </li></ul></ul><ul><ul><li>Quadrantectomy or segmental mastectomy </li></ul></ul><ul><ul><li>Goal is to excise tumor & obtain clear margins while maintaining acceptable cosmetic appearance </li></ul></ul>
    17. 17. Sentinel Lymph Node Biopsy <ul><li>Status of lymph nodes is the most important prognostic factor </li></ul><ul><li>SLNB less invasive than axillary lymph node dissection (ALND) </li></ul><ul><ul><li>ALND associated with lymphedema, cellulitis, decreased arm mobility, decreased arm sensation </li></ul></ul>
    18. 18. Sentinel Lymph Node Biopsy <ul><li>First node in lymphatic basin that receives drainage from the primary tumor is identified by injecting radioisotope or blue dye into the breast </li></ul><ul><li>Node is excised & sent for frozen section </li></ul><ul><ul><li>If positive, ALND is done </li></ul></ul>
    19. 19. Comparison of SLNB vs ALND <ul><li>SLNB </li></ul><ul><ul><li>15-30 min. with local anesthesia </li></ul></ul><ul><ul><li>Lower rate of complications </li></ul></ul><ul><li>ALND </li></ul><ul><ul><li>60-90 min. with general anesthesia </li></ul></ul><ul><ul><li>Higher rate of lymphedema, seroma, decreased ROM & sensation </li></ul></ul>
    20. 20. Surgical Management <ul><li>Total Mastectomy </li></ul><ul><ul><li>Also called “simple” mastectomy </li></ul></ul><ul><ul><li>Entire breast & nipple-areola removed </li></ul></ul><ul><ul><li>Used for non-invasive CA </li></ul></ul><ul><ul><li>Does not include ALND </li></ul></ul><ul><ul><li>May be done prophylactically for BRCA mutation </li></ul></ul><ul><ul><li>SLNB may be done with it </li></ul></ul>
    21. 21. Surgical Management <ul><li>Modified Radical Mastectomy </li></ul><ul><li>Used to treat invasive CA </li></ul><ul><li>Entire breast, nipple-areola removed </li></ul><ul><li>ALND also done </li></ul><ul><li>Pectoralis muscles left intact </li></ul><ul><li>Immediate breast reconstruction may be done </li></ul><ul><li>Radical Mastectomy </li></ul><ul><li>Pectoralis muscles also removed, along with entire breast, nipple-areola </li></ul><ul><li>Rarely done today </li></ul>
    22. 22. Reconstructive Surgery after Mastectomy <ul><li>Requires consult with plastic surgeon </li></ul><ul><ul><li>May be done with mastectomy or delayed </li></ul></ul><ul><li>Factors to consider </li></ul><ul><ul><li>Body size & shape </li></ul></ul><ul><ul><ul><li>Natural breast never precisely duplicated </li></ul></ul></ul><ul><ul><li>Comorbidities </li></ul></ul><ul><ul><li>Opposite breast may also require work also to achieve symmetry </li></ul></ul><ul><ul><li>Does not interfere with CA recurrence or tx </li></ul></ul>
    23. 23. Reconstructive Surgery after Mastectomy <ul><li>Most common method is use of tissue expander under pectoralis muscle followed by implant </li></ul><ul><li>Saline injected into expander weekly for 6-8 weeks then left in place fully expanded x 6 wks. </li></ul><ul><li>Implant placed as outpatient surgery </li></ul><ul><li>Not used if had previous radiation to chest </li></ul>
    24. 24. Reconstructive Surgery after Mastectomy <ul><li>Tissue Transfer Procedure </li></ul><ul><ul><li>Longer surgery & recovery time, with 2 incision sites </li></ul></ul><ul><li>Flap of skin, fat & muscle rotated to mastectomy site </li></ul><ul><ul><li>Transverse rectus abdominus myocutaneous flap (TRAM) </li></ul></ul><ul><ul><li>Latissimus dorsi flap </li></ul></ul><ul><ul><li>Diabetics, smokers, obese patients are poor candidates </li></ul></ul>
    25. 25. Reconstructive Surgery after Mastectomy <ul><li>Local flaps from “new breast” tissue can be used to re-create nipple </li></ul><ul><li>Areola created using skin graft from inner thigh </li></ul><ul><ul><li>Tattoo procedure to recreate darker pigmentation </li></ul></ul>
    26. 26. Prostheses <ul><li>Usually made of silicone; placed into bra </li></ul><ul><li>Reach to Recovery can provide referrals to shops and prosthetic consultants </li></ul>
    27. 27. Post-Op Care <ul><li>Pain control </li></ul><ul><ul><li>Pain more severe with modified radical mastectomy </li></ul></ul><ul><li>Changes in sensation may include numbness, pulling, twinges in chest wall or upper arm </li></ul><ul><ul><li>Phantom breast sensation </li></ul></ul><ul><ul><li>Usually diminish over months to 2 years </li></ul></ul>
    28. 28. Post-Op Care <ul><li>Body image & sexuality </li></ul><ul><ul><li>Many pts. have difficulty viewing operative site </li></ul></ul><ul><ul><li>Offer privacy & emotional support </li></ul></ul><ul><ul><li>Support to partners </li></ul></ul><ul><ul><li>Referrals to advocacy groups </li></ul></ul>
    29. 29. Post-op Complications <ul><li>Transient edema resolves within a month </li></ul><ul><li>Lymphedema </li></ul><ul><ul><li>Occurs in 10-30% of patients with ALND </li></ul></ul><ul><ul><li>Risk factors: </li></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul><ul><ul><ul><li>Radiation </li></ul></ul></ul><ul><ul><ul><li>Infection to the extremity </li></ul></ul></ul>
    30. 30. Post-op Complications <ul><li>Treatment for Lymphedema </li></ul><ul><ul><li>Exercises with raising arm above the head </li></ul></ul><ul><ul><li>Compression sleeve or glove </li></ul></ul><ul><ul><li>Manual lymph drainage (PT) </li></ul></ul><ul><ul><li>Protection of affected arm: </li></ul></ul><ul><ul><ul><li>Avoid BP, blood draws & injections in affected arm </li></ul></ul></ul><ul><ul><ul><li>Use sunscreen, insect repellant </li></ul></ul></ul><ul><ul><ul><li>Wear gloves for gardening </li></ul></ul></ul><ul><ul><ul><li>Electric razor for shaving </li></ul></ul></ul><ul><ul><ul><li>Avoid lifting more than 5-10 lbs </li></ul></ul></ul><ul><ul><ul><li>Use care for manicures, cooking </li></ul></ul></ul>
    31. 31. Post-op Complications <ul><li>Hematoma </li></ul><ul><li>Usually develops within 12 hours after surgery </li></ul><ul><li>Sx include swelling, tightness, pain & bruising </li></ul><ul><ul><li>Increased bloody drainage from drain---notify MD immediately </li></ul></ul><ul><ul><li>Return to OR for active bleeding </li></ul></ul><ul><li>Tx with compression wrap x 12 hours </li></ul><ul><li>Small hematomas resolve in 4-5 weeks </li></ul>
    32. 32. Post-op Complications <ul><li>Seroma </li></ul><ul><li>Sx include swelling, heaviness, discomfort, sloshing of fluid </li></ul><ul><li>May occur due to clogged drain </li></ul><ul><li>Small seromas resolve; large seromas are drained with needle & syringe due to risk of infection </li></ul>
    33. 33. Radiation Therapy <ul><li>Decreases chance of local recurrence by eradicating microscopic cancer cells </li></ul><ul><li>Stage I & II: Radiation after breast-conserving surgery = survival rate of modified radical mastectomy </li></ul>
    34. 34. Radiation Therapy <ul><li>External beam tx begins 6 weeks after breast conservation therapy </li></ul><ul><ul><li>5 days a week x 6 weeks </li></ul></ul><ul><ul><ul><li>Anatomic areas mapped out, marked with ink </li></ul></ul></ul><ul><li>Begins after systemic chemo </li></ul><ul><li>Other options: </li></ul><ul><li>Brachytherapy: Radiation source placed into lumpectomy site </li></ul><ul><li>Intra-operative radiation done in OR immediately after lumpectomy </li></ul>
    35. 35. Radiation Side-Effects <ul><li>Erythema </li></ul><ul><li>Fatigue </li></ul><ul><li>Skin breakdown near axilla or inframammary fold </li></ul><ul><li>Rare long-term effects: Pneumonitis, rib fx, fibrosis </li></ul>
    36. 36. Care of radiation sites <ul><li>Use mild soap, don’t rub </li></ul><ul><li>Avoid perfumed soaps or deodorants </li></ul><ul><li>Hydrophilic lotions (Eucerin, Lubriderm) </li></ul><ul><li>Aveeno soap for itching </li></ul><ul><li>Avoid tight clothes, underwire bras </li></ul><ul><li>Use sunscreen </li></ul><ul><li>Twinges & shooting pains are expected </li></ul>
    37. 37. Chemotherapy <ul><li>Used for tumors greater than 1 cm, or if nodes are positive </li></ul><ul><li>Initiated after breast surgery, prior to radiation </li></ul><ul><li>Combine several agents; given over 3-6 months </li></ul><ul><li>“ CMF” most widely used: </li></ul><ul><ul><li>Cyclophosphamide, methotrexate, fluorouracil </li></ul></ul>
    38. 38. Chemotherapy <ul><li>“ ACT” improves survival in non-operable breast CA & positive lymph nodes: </li></ul><ul><ul><li>Adriamycin + cyclophosphamide + Taxol </li></ul></ul>
    39. 39. Side-Effects of Chemo <ul><li>Nausea/ vomiting </li></ul><ul><ul><li>Improved anti-emetics (Zofran, Reglan) </li></ul></ul><ul><li>Bone marrow suppression </li></ul><ul><ul><li>Hematopoietic growth factors (Epogen or Aranesp; Neupogen/ Neulasta </li></ul></ul><ul><li>Taste changes </li></ul><ul><li>Alopecia: Color & texture may change after </li></ul><ul><li>Mucositis: Saline rinses, soft toothbrush </li></ul><ul><li>Fatigue </li></ul><ul><li>Weight gain (? cause) </li></ul><ul><li>Taxol: Peripheral neuropathy, arthralgia </li></ul><ul><li>Doxorubicin: Cardiotoxicity; tissue necrosis if infiltrates </li></ul>
    40. 40. Hormonal Therapy <ul><li>Considered for hormone-receptor positive tumors </li></ul><ul><ul><li>Estrogen + or progesterone + </li></ul></ul><ul><li>Drugs compete with estrogen & bind to receptor sites (SERMs) or block estrogen production (Aromatase inhibitors) </li></ul>
    41. 41. Hormonal Therapy <ul><li>SERM (selective estrogen receptor modulator) </li></ul><ul><ul><li>Tamoxifen </li></ul></ul><ul><li>Has positive effect on blood lipids & bone density </li></ul><ul><li>S/E: Hot flashes, vaginal dryness, mood disturbances, increased risk for endometrial CA & DVT </li></ul>
    42. 42. Hormonal Therapy <ul><li>Aromatase inhibitors block conversion of testosterone to estradiol </li></ul><ul><ul><li>Arimadex, Femara </li></ul></ul><ul><li>S/E: arthritis, myalgia, N/V, fatigue, hot flashes, mood disturbances, increased risk of osteoporosis </li></ul>
    43. 43. Targeted Therapy <ul><li>Monoclonal antibody that binds to HER-2/neu protein which is present on the surface of normal breast cells & cancer cells </li></ul><ul><li>Herceptin inactivates the protein & slows tumor growth without attacking normal cells </li></ul><ul><li>Fewer S/E </li></ul>
    44. 44. Hormonal Therapy <ul><li>Patient Education: </li></ul><ul><ul><li>Hot flashes: Avoid caffeine & spicy foods; wear layers; antidepressants may help </li></ul></ul><ul><ul><li>Vaginal moisturizers </li></ul></ul><ul><ul><li>Bland diet for N/V; meds at nights </li></ul></ul><ul><ul><li>NSAID’s and warm baths for muscle & joint pain </li></ul></ul><ul><ul><li>Baseline bone density scan; take Vit. D & calcium; exercise </li></ul></ul><ul><ul><li>Report abnormal vaginal bleeding and S&S of DVT </li></ul></ul>
    45. 45. Evaluation: 5 year Survival Rate <ul><li>Stage 0 </li></ul><ul><li>Stage I </li></ul><ul><li>Stage IIA </li></ul><ul><li>Stage IIB </li></ul><ul><li>Stage IIIA </li></ul><ul><li>Stage IIIB </li></ul><ul><li>Stage IV </li></ul><ul><li>See Table 48-2 page 1716 </li></ul><ul><li>100% </li></ul><ul><li>98% </li></ul><ul><li>88% </li></ul><ul><li>76% </li></ul><ul><li>56% </li></ul><ul><li>49% </li></ul><ul><li>16% </li></ul>
    46. 46. Which is the single most important predictor of outcome for breast cancer patients? <ul><li>The histological status of the axillary nodes is the single most important predictor of outcome for breast cancer patients. </li></ul>
    47. 47. EARLY DETECTION is KEY <ul><li>Nurses should encourage routine breast surveillance and screening mammograms for all women, including those with disabilities </li></ul>

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