BREAST CANCER

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

Etiology

Unknownr/t estrogen?Probably combination of

hormonal, genetic & environmental factors

Risk factors Age Race/ethnicity Family history of breast CA—especially 1st

degree relative; mother, sister Genetic mutations in BRCA1 & BRCA2 genes Long menses—early menarche/late menopause Nulliparity 1st 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

Protective Factors

Regular exerciseBreast-feedingPregnancy prior to age 30

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

reconstructionCan reduce risk of CA by 90%

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

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 carcinomaLow-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 cellsUsually found incidentallyLess likely to develop into infiltrating CADCIS & LCIS considered Stage 0 cancers

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

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

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

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

Diagnostic testsPrimary tests

Mammography Breast ultrasoundBiopsy

Fine needle aspiration (FNA)Sample cells for analysis1st step in evaluation

Image-guided core needle biopsyStereotactic (SNB)—target & identify

nonpalpable lesions detected by mammography

Ultrasound core biopsy—used when lesion can be seen on ultrasound

Open biopsy—local anesthetic

Staging of breast CAStage 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 metastasisIpsilateral supraclavicular lymph nodeSkin or chest wall; orInflammatory CA

Nursing diagnoses

Acute pain r/t breast ORFear r/t diagnosis of CAIneffective coping r/t anxiety,

lower activity level & inability to perform ADL

Activity intolerance r/t fatigue postoperatively

Disturbed body image

Surgical ManagementBreast-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

Sentinel Lymph Node BiopsyStatus of lymph nodes is the most

important prognostic factorSLNB less invasive than axillary

lymph node dissection (ALND)ALND associated with lymphedema,

cellulitis, decreased arm mobility, decreased arm sensation

Sentinel Lymph Node BiopsyFirst 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

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

Surgical ManagementTotal Mastectomy

Also called “simple” mastectomyEntire breast & nipple-areola

removedUsed for non-invasive CADoes not include ALNDMay be done prophylactically for

BRCA mutationSLNB may be done with it

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

Reconstructive Surgery after Mastectomy

Requires consult with plastic surgeon May be done with mastectomy or

delayed Factors to consider

Body size & shapeNatural breast never precisely

duplicated Comorbidities Opposite breast may also require work

also to achieve symmetry Does not interfere with CA recurrence or

tx

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

Reconstructive Surgery after Mastectomy

Tissue Transfer ProcedureLonger surgery & recovery time,

with 2 incision sites

Flap of skin, fat & muscle rotated to mastectomy siteTransverse rectus abdominus

myocutaneous flap (TRAM)Latissimus dorsi flapDiabetics, smokers, obese patients

are poor candidates

Reconstructive Surgery after Mastectomy

Local flaps from “new breast” tissue can be used to re-create nipple

Areola created using skin graft from inner thighTattoo procedure to recreate

darker pigmentation

Prostheses

Usually made of silicone; placed into bra

Reach to Recovery can provide referrals to shops and prosthetic consultants

Post-Op CarePain control

Pain more severe with modified radical mastectomy

Changes in sensation may include numbness, pulling, twinges in chest wall or upper armPhantom breast sensationUsually diminish over months to 2

years

Post-Op Care

Body image & sexualityMany pts. have difficulty

viewing operative siteOffer privacy & emotional

supportSupport to partnersReferrals to advocacy

groups

Post-op ComplicationsTransient edema resolves within a

monthLymphedema

Occurs in 10-30% of patients with ALND

Risk factors:ObesityAgeRadiationInfection to the extremity

Post-op ComplicationsTreatment for Lymphedema

Exercises with raising arm above the headCompression sleeve or gloveManual lymph drainage (PT)Protection of affected arm:

Avoid BP, blood draws & injections in affected arm

Use sunscreen, insect repellantWear gloves for gardeningElectric razor for shaving Avoid lifting more than 5-10 lbsUse care for manicures, cooking

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

Post-op ComplicationsSeromaSx include swelling, heaviness,

discomfort, sloshing of fluidMay occur due to clogged drainSmall seromas resolve; large

seromas are drained with needle & syringe due to risk of infection

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

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

Radiation Side-EffectsErythemaFatigueSkin breakdown near axilla

or inframammary foldRare long-term effects:

Pneumonitis, rib fx, fibrosis

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

Chemotherapy Used for tumors greater than 1

cm, or if nodes are positiveInitiated after breast surgery,

prior to radiationCombine several agents; given

over 3-6 months“CMF” most widely used:

Cyclophosphamide, methotrexate, fluorouracil

Chemotherapy

“ACT” improves survival in non-operable breast CA & positive lymph nodes:Adriamycin +

cyclophosphamide + Taxol

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

Hormonal Therapy

Considered for hormone-receptor positive tumorsEstrogen + or progesterone +

Drugs compete with estrogen & bind to receptor sites (SERMs) or block estrogen production (Aromatase inhibitors)

Hormonal TherapySERM (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

Hormonal Therapy

Aromatase inhibitors block conversion of testosterone to estradiolArimadex, Femara

S/E: arthritis, myalgia, N/V, fatigue, hot flashes, mood disturbances, increased risk of osteoporosis

Targeted TherapyMonoclonal 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

Hormonal TherapyPatient Education:

Hot flashes: Avoid caffeine & spicy foods; wear layers; antidepressants may help

Vaginal moisturizersBland diet for N/V; meds at nightsNSAID’s and warm baths for muscle & joint

painBaseline bone density scan; take Vit. D &

calcium; exerciseReport abnormal vaginal bleeding and S&S of

DVT

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%

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.

EARLY DETECTION is KEY

Nurses should encourage routine breast surveillance and screening mammograms for all women, including those with disabilities