Breast CancerKatherine MacGillivray & Melissa Poirier
Objectives
Discuss breast cancer statistics in Canada and Nova Scotia. Overview of the breasts anatomy and physiology. Discuss risk factors for breast cancer and how to minimize those
risks. Discuss differences between benign, non-invasive and invasive
breast disease. Brief overview of breast cancer in men. Discuss types of lymph node involvement. Discuss screening options for breast cancer. Discuss diagnostic tests used for breast cancer. Discuss grading & staging of breast cancer. What are the treatment options for breast cancer? Discuss complications and prognosis of breast cancer. Discuss pre/postoperative nursing diagnosis and interventions .
In Canada, 200 men & 23,000 women will be diagnosed with breast cancer in 2012.
Of that, 50 men & 5100 women will succumb to the disease.
Breast cancer accounts for 26% of new cancer cases in Canadian women.
Approximately 62 Canadian women are diagnosed with breast cancer daily.
Approximately 14 Canadian women die daily of breast cancer.
1 in 9 women will develop breast cancer in their lifetime and 1 in 29 will die from it.
Canadian Statistics for 2012
An estimated 740 women will be diagnosed with breast cancer.
An estimated 160 women will die of breast cancer. 100 out of every 100,000 women of NS will be
diagnosed with breast cancer. Of 100,000 deaths, 20 women will die as the result
of breast cancer. In Nova Scotia, there is limited data available for
breast cancer in men. Men succumb to prostate, colorectal and lung cancers.
Statistics in Nova Scotia for 2012
Breast A & P
Male and female breast develop at the same rate till puberty.
Located between the 2nd & 6th ribs.
Tail of Spence extends into the axilla.
Cooper’s ligaments support the breast to the chest wall.
Each breast contains 12-20 lobes.
Personal Health History Family Health History Certain Genome Changes Radiation Therapy to the Chest Reproductive and Menstruation History Race Being Overweight or Obese after Menopause Lack of Physical Activity Alcohol Use Smoking Age
Risk Factors
Lose excess weight. Be physically active. Limit your intake of alcohol. Breastfeed your baby. Quit smoking. Talk to your doctor about the risks and
benefits of hormone replacement therapy (HRT).
Reduce exposure to chemicals
Minimizing Your Risk
Atypical Hyperplasia Benign Abnormal proliferation of cells Increased risk of breast cancer
Lobular Carcinoma in Situ Benign Proliferation of cells in the lobules Unable to be diagnosed with a Mammogram Increased risk of breast cancer
Benign Proliferative Breast Disease
Breast profile:A DuctsB LobulesC Dilated section of duct to hold milkD NippleE FatF Pectoralis major muscleG Chest wall/rib cage
EnlargementA Normal lobular cellsB Lobular cancer cellsC Basement membrane
Lobular Carcinoma in Situ
Types of Breast Cancer:Non-Invasive vs. Invasive
Non-Invasive Cancer Ductal Carcinoma in Situ
Invasive Cancer Infiltrating Ductal Carcinoma Infiltrating Lobular Carcinoma Medullary Carcinoma Mucinous Carcinoma Tubular Ductal Carcinoma Inflammatory Carcinoma Paget’s Disease
Breast profile:A DuctsB LobulesC Dilated section of duct to hold milkD NippleE FatF Pectoralis major muscleG Chest wall/rib cage
EnlargementA Normal duct cellsB Ductal cancer cellsC Basement membrane
D Lumen (center of duct)
Ductal Carcinoma in Situ
Non-invasive cancer is grouped into four subcategories, based on how the cancer cells grow relative to each other, within the center of the milk duct: Solid Cribriform Papillary Comedo
Non-Invasive (In Situ) Cell Growth Subtypes
Solid: There is wall-to wall cell growth
A - Cancer cells B - Basement
membrane
Cribriform: There are holes between groups of cancer cells,
making it look like Swiss cheese.
A - Cancer Cells B - Basement
membrane C - Lumen (center of
duct)
Papillary: The cells grow in fingerlike projections, toward the
inside of the duct.
A - Cancer cells B - Basement
membrane C - Lumen
Comedo: There are areas of “necrosis”, which is debris from dead
cancer cell; this indicates that a tumor is growing so fast that some of the tumor will wither and die because there is not
enough blood to feed all of the cells.
A - Living cancer cellsB - Dying cancer cellsC - Cell debris (necrosis)D - Basement membrane* Referred to as high grade noninvasive cancer- fast growing
Invasive Cancers
Most Common:Infiltrating Ductal CarcinomaInfiltrating Lobular Carcinoma
Invasive Ductal Carcinoma Breast profile: A ducts B lobules C dilated section of duct to
hold milk D nipple E fat F pectoralis major muscle G chest wall/rib cage
Enlargement: A normal duct cells B ductal cancer cells
breaking through the basement membrane
C basement membrane
Invasive Lobular CarcinomaBreast profile:A ductsB lobulesC dilated section of duct to hold milkD nippleE fatF pectoralis major muscleG chest wall/rib cageEnlargement:A normal cellsB lobular cancer cells breaking through the basement membraneC basement membrane
Other Invasive Carcinomas
Medullary Carcinoma Mucinous Carcinoma
Tubular Ductal Carcinoma Inflammatory Carcinoma
Paget’s Disease
Men & Breast Cancer
Less than 1% of breast cancers happen to men in Canada; however the number is increasing
Men over the age of 60 are most often diagnosed with breast cancer
Risk factors, diagnosis, staging and treatment are the same as in women
Risk factors include: mumps, radiation exposure & decreased testosterone levels.
Most common is ductal carcinoma – found in breast ductsSymptoms include a small painless lump, discharge from
nipple, inverted nipple and skin ulcerationAdverse feelings related to “manhood” and sexuality,
having a “women’s disease”
Some breast cancers spread to the lymph nodes under a woman's arm.
Microscopic examination: Lymph node involvement = positive Lymph node clear of cancer = negative
Connection between the number of lymph nodes involved & aggressiveness of cancer's personality.
Knowing how many lymph nodes are involved will help identify appropriate treatment.
Lymph Node Involvement
Three types of lymph node involvement 1. Minimal (or microscopic) lymph node involvement:
- Small number of cancer cells in lymph nodes.2. Significant (or macroscopic) involvement:
-A particular lymph node or group of nodes has become involved with the cancer. Can often
felt by hand or seen without a microscope.3. Extra-capsular extension:
-A breast cancer tumor takes over a whole lymph node and spills beyond the wall of the lymph node into the surrounding fat.
Lymph Nodes
In most cases, the more extensive the lymph node involvement, the more aggressive the cancer. But the extent of disease within a particular lymph node is less important than the total number of lymph nodes affected. The more lymph nodes that are involved, the more threatening the cancer may be.
Doctors use the following categories to describe the overall level of lymph node involvement:
No lymph nodes involved 1–3 nodes involved 4–9 nodes involved 10 or more nodes involved.
Lymph Nodes
Has Cancer Invaded Lymph or
Blood Vessels?
A blood vesselsB lymphatic channels
EnlargementA Normal duct cellB Cancer cellsC Basement membraneD Lymphatic channelE Blood vesselF Breast tissue
Breast Cancer Tissue
Report to Physician ASAP
Screening
1. SBE (self-breast examination) 2. Mammography
Self Breast Examination
Self Breast Exams are an important way to find a breast cancer early.
Not every cancer can be found this way, but it is critical to become familiar with your breasts in order to identify an abnormality
SBE should be done once a month approximately 1wk after your menstrual period
Lumps most women have lumps or lumpy areas in the
breast that may be the result of Fibroadenomas or Cysts
8 out of 10 lumps removed from the breast are benign
Upper/outer area(armpit) - most prominent lumps/bumps
Lower half - sandy/pebbly beach Underneath nipple - collection of large grains Other parts - lumpy bowl of oatmeal
Self Breast Exam cont’d
Studies show that regular breast self-
exams, combined with an annual exam by a doctor, improves the chances of detecting
cancer early.
Look in the mirror, shoulders straight and arms on your hips.
Look for size, shape, and colour of breasts, is there any distortion or swelling present
Changes to report: dimpling, puckering, bulging of the skin, change in nipple position, inverted nipple, redness, soreness, rash or swelling.
Steps to a Self Breast Exam:
Step 1
Raise your arms above your head and look for the same changes.
Step 2
Still standing at the mirror, look for any discharge/fluid coming from your
nipples. Changes to report: any fluid coming
out of 1 or both nipples (unless you are lactating). Could be watery, milky,
yellow or bloody.
Step 3
Lie down on the bed and palpate breasts using pads of a few fingers.
Use a firm smooth touch in a circular motion.
Cover entire breast – collar bone to top of stomach, armpit to sternum.
Make sure to follow a pattern so to cover all area of the breasts.
Step 4
Step 5
Sit or stand and palpate the breast in the same manner as step 4.
Changes to report: lumps, bumps, irregularities
Mammography
Breast imaging technique Identifies non-palpable masses and diagnoses palpable
masses Procedure takes approximately 15 minutes Breast is compressed from top to bottom, and side to
side New and old mammograms are compared Radiation exposure is equivalent to 1 hour in the sun Canadian Cancer Society recommends women to have
a mammogram every 2 years between 50 & 69 years of age.
Women at high risk and under 50 should speak with the HCP
http://www.youtube.com/watch?v=Y-GmNmPeqHQ
EXPERT QUOTE
"The biggest misconception about mammography is that it picks up every breast cancer. In fact, mammography misses at least
10 percent of breast cancer. So if you feel a lump that doesn't show up on a mammogram,
bring it to your doctor's attention. Get it evaluated."
—Susan Orel, M.D.
Diagnosis for Breast Cancer
Procedures for tissue analysis: Percutaneous Biopsy
Fine-Needle Aspiration Core Needle Biopsy Guided Core Biopsy
Surgical Biopsy Excisional Biopsy Incisional Biopsy
Needle Biopsy
Excisional Biopsy
Grading
Grade Description
1 Low grade – slow growing, less likely to spread
2 Moderate grade
3 High grade – tend to grow quickly, more likely to spread
Staging
Stage Description
0 There are two kinds of stage 0 breast cancer:
Ductal carcinoma in situ (DCIS): Abnormal cells are in the lining of a milk duct and have not spread outside the duct.
Lobular carcinoma in situ (LCIS): Abnormal cells are in the lining of a lobule.
1 Tumour is 2 cm or smaller and the cancer has not spread outside the breast.
2 Tumour is 2 to 5 cm, or cancer has spread to the lymph nodes, or both.
3 Cancer has spread to the lymph nodes and may have spread to nearby tissues such as the muscle or skin.
4 Cancer has spread to distant parts of the body.
Surgery Chemotherapy
Radiation Adjunctive Therapy Alternative Therapy
Treatment
Breast Sparing Surgery: Lumpectomy & Partial Mastectomy
Lumpectomy vs. Mastectomy
Modified Radical Mastectomy
Radical Mastectomy
Total Mastectomy
TRAM Flap Reconstruction
Complications
Infection
Lymphedema
Hematoma/Seroma Formation
Allergic Reaction
Lymphedema
Lymphedema is the build-up of fluid in the arm. About 10-20% of women will develop this especially if more than 10 lymph nodes were removed.
Lymphedema
Talk to HCP if experiencing symptoms of lymphedema
Keep skin and nails clean Avoid blocking the flow of fluid through the
body Keep blood from pooling in affected limb Exercise
How to Prevent Lymphedema
Two most important factors when determining the prognosis of breast cancer:
Size of tumour Spread of tumour
Excessive number of copies of certain genes Excessive amounts of the genes protein products
Prognosis
Deficient knowledge Anxiety
Fear Risk for ineffective coping
Decisional conflict
Preoperative Nursing Diagnosis
Provide education and preparation for surgical treatments
Reduce fear and anxiety and improve coping ability
Promote decision-making ability
Preoperative Nursing Interventions
Acute pain Disturbed sensory perception
Disturbed body image Risk for impaired adjustment
Risk for ineffective coping for individual and family
Deficient knowledge Risk for sexual dysfunction
Risk for infection
Postoperative Nursing Diagnoses
Relieving pain and discomfort Managing postoperative sensations Promoting a positive body image
Promote positive adjustment and coping Improving sexual function Monitor for complications
Postoperative Nursing Interventions
Mrs. X, a 59 year old female with a family history of breast cancer recently found a small palpable mass in the upper outer quadrant of her left breast, she also noticed some slight dimpling upon a breast self exam. When she notified her doctor, he preformed a fine needle aspiration biopsy for tissue analysis. Mrs. X’s results showed she had an infiltrating ductal carcinoma, which is an invasive cancer. Mrs. X’s doctor staged her cancer as T1N1M0.
1. How often and when should one perform a breast self exam?
2. If Mrs. X’s breast cancer was genetically inherited, which gene(s)would most likely have a mutation?3. Interpret T1N1M0
Case Study
Mrs. X was scheduled for a modified radical mastectomy (removal of entire breast tissue, nipple – areola complex and axillary lymph nodes). She met with a plastic surgeon to explore the option of breast reconstructive surgery but has decided to wait until after her surgery to decide. Mrs. X’s mother and sister both have undergone the same surgery and she has a very supportive husband. Mrs. X confides in you, the RN, that she is still anxious regarding her upcoming surgery.
1. What are some preoperative nursing interventions you would do?2. What are some postoperative nursing interventions you would do?
Case Study Cont’d
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. G. (2010). Textbook of Canadian medical-surgical nursing (2nd ed). Philadelphia, Pennsylvania: Wolters Kluwer Health/Lippincott Williams & Wilkins.
www.breastcancer.org www.cancer.ca www.cancer.gov
References