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• Breast Cancer Risk Factors


  • Age >65
  • Genetics, Pt Hx of Br Ca or FHx
  • Nulliparity or 1st born after 30
  • Early menarche + late menopause
  • Physical inactivity / obesity
  • Recent OCP or HRT or previous radiation
  • Alcohol consumption
  • High socioeconomic status, Jewish heritage
• Goal of Breast Cancer Treatment

  Maximize cancer treatment and cosmetic outcome with minimal risks
• Breast Conserving Surgery (Lumpectomy)


  • Remove entire tumor and a margin of normal breast tissue around it; May cut some lymph nodes, breast and nipple preserved
  • Needs post-surgery radiation to breast plus boost to tumor bed
• Simple Mastectomy


  • Entire breast is removed and some lymph nodes
• Modified Radical Mastectomy


  • Entire breast + lymph nodes is removed and if necessary, some of the chest wall
• Lymph Node Dissection


  • Auxiliary Node Dissection or ALND: removes 12-20 nodes (done before yr 2000)
  • Sentinel Node Dissection or SLND: remove nodes that drain from tumor and sent for pathology (1-4ish). More nodes removed if cancer cells are found in sentinel nodes; results in lower rates of lymphedema
• Breast Implants and Tissue Expanders

  • Sacs filled with saline or silicone gel inserted under the pectoralis muscle
  • Tissue expanders stretch the skin and muscle before implants can be inserted
• DIEP Flap Reconstruction


  • Fat, skin and blood vessels cut from the lower abdomen and moved up to reconstruct the breast. NO muscle is cut or removed.
  • Blood vessels of the flap are reattached to the blood vessels in the chest wall
• Breast Reconstruction Process


  • Tissue expansion prepares breast for skin or implant placement
  • Autologous tissue reconstruction: skin taken from ass, abdomen or back. Implants: a saline/silicone implant inserted to form a breast
  • Nipple may be reconstructed or tattooed
• Breast Cancer Diagnostic Tests

  • Mammography (every 2 yrs for age 50-74)
  • Breast Self-Exam (BSE) → lump, pulled in nipple, dimpling, dripping, redness/rash, skin changes
  • Clinical Breast Exam
  • MRI, ultrasound, biopsy (to clarify findings)
• Post-Mastectomy Priorities


  • Care for incisions and drains
  • Pain management
  • Restore Arm Ability (prevent lymphedema)
• Lymphedema


  • Pts at risk if the lymph nodes are removed → keep them mobile but gradually
  • Axillary lymph cannot return fluid to central circulation d/t removal of nodes or damage from radiation
  • Fluid accumulates in the affected arm
  • Causes obstruction/pressure; very painful
• Lymphedema Management


  • Massage to mobilize fluid
  • Elevate
  • Compression bandages
  • Pneumatic compression sleeve
  • Diuretics
  • Isometric Exercises
• Drain Care


  • Drains in place to incisions to drain excess fluids to help with healing
  • Pt and fam will be taught how to care for it at home
  • Drains removed after a couple weeks (when less than 30ccs in 24hr for 2-3 consecutaive days)
  • Drainage: red at first → pink → apple juice colour
• Arm Ability Restoration Goals

  • Prevent contractures + muscle shortening
  • Improve lymph + blood circulation → prevent lymphedema
  • Gradual increase of function over 4-6 weeks
• Arm Ability Restoration Interventions

  • Analgesics before exercise
  • Warm water → relaxes muscle
  • Elevate arm post-op
  • NO elastic bandages post-op → interfere with circulation
  • Avoid sun + trauma
  • No BP or venipuncture on that arm → put a sign on the wall or pts door
  • Teach when to seek medical help (infection, pain getting worse)
• Adjuvant Breast Cancer Therapies

  • Chemotherapy
  • Radiation (primary or brachytherapy)
  • Oral Medication (hormonal therapy, estrogen receptor blockers, biological and targeted therapy)
• Leukemia Assessment and Treatment

  • Blood tests + bone marrow bx determine subtype of leukemia and treatment
  • Chemotherapy (Induction, Consolidation, Maintenance)
  • Radiation and Other Targeted Therapies (Drugs)
  • Hematopoietic Marrow & Stem Cell Transplant (Allogenic, Autologous, Syngeneic)
• Leukemia Complications


  • Systemic: Weight loss, fever and frequent infections
  • Psychological: Fatigue + loss of appetite
  • Lymph Nodes: Swelling
  • Lungs: Easy SOB
  • Muscular: Weakness
  • Bones or Joints: Pain or tenderness
  • Spleen or Liver: Enlargement
  • Skin: Night Sweats, Easy bleeding + bruising, Purplish patches or spots
• Chemotherapy


  • Reduce # of Ca Cells
  • Affects mostly → bone marrow (stem cells), epithelial GI tract. Ova or testes and Hair Follicle
• Combination Chemotherapy


  • Multidrug regimen that kills Ca Cells more effectively while allowing normal cells to repair + proliferate
• Extravasation


  • Many chemo drugs are vesicants causing severe tissue breakdown + necrosis if they infiltrate the skin
• Extravasation Prevention


  • Assess IV site for pain (cadinal sign) → pain, swelling, redness
  • Use CVAD if possible → most chemo is done thru a PICC line
  • Often require skin graft for closure → does not heal on its own
• Radiation Therapy


  • Internal Radiation: Radioactive materials are implanted right to the tumor (brachytherapy) – targeted therapy
  • External Radiation: Pt exposed to radiation with a megavoltage treatment machine they lie under
• Internal Radiation


  • Temporary Implants: high radioactive; making pt highly radioactive and must be on precau
  • Permanent Implants: low radioactive + pt can be discharged; wears-off
• Brachytherapy Radiation Precautions


  • Radioactive pt in private rm
  • Pregnant women + children should NOT enter (even with proper PPE)
  • Time: spend little time as possible, no long talks but still be friendly
  • Distance: last BM or assessments but VS go closer
  • Shielding: heavy vest or a badge that detects the amount of radiation the nurse is exposed
• External Radiation


  • Reduce the amount of tissue exposed by breaking up single beam into smaller beams or using 3-D imaging to target exactly where radiation goes sparing as much tissue as possible
  • Identify under fluoroscopy what part of the body needs radiation
• Radiosurgery (Gamma Knife or Cyber Knife)


  • For brain tumors
  • It goes so specifically and delivers high dose of radiation to wherever the tumor is instead of opening the skull
• Chemotherapy and Radiation Complications

  • Myelosuppression (Bone Marrow Suppression)
  • GI Effects: Anorexia and Nausea
  • Fatigue, Pain & Brain Fog
  • Skin Reactions
  • Alopecia
  • Decreased Saliva/Oral Stomatitis/ Mucositis/ Esophagitis
• Myelosuppression Assessments


  • Anemia: HGB, HCT
  • Neutropenia: Absolute Neutrophil Count (ANC)
  • Thrombocytopenia: Assess for petechiae at ecchymosis, signs and symptoms of internal bleeding
• Myelosuppression Interventions


  • Anemia: Encourage foods that promote RBC production
  • Neutropenia: Avoid large crowds/Good handwashing, No fresh fruit/flowers in room, Febrile → ABx therapy immediately, May need reverse isolation, Give colony stimulating factor
  • Thrombocytopenia: Minimize venipuncture + injections, Use electric shaver, not razor, Soft toothbrush, Administer blood products or platelets, Avoid drugs, foods + herbs that effect coagulation, Avoid injury
• GI Effects: Anorexia and Nausea


  • Monitor weight during Tx, Assess for dehydration + alkalosis, Anticipatory vomiting → pt goes to chemo then get sick → their brain starts to associate nausea with the place
• GI Effects Interventions


  • Small, frequent meals, High protein, high calorie foods easy to swallow (ensure, milkshakes), Anti-emetics before Tx, Diarrhea: Low residue diet, meticulous skin care, sitz baths, anti-diarrheals
• Fatigue, Pain & Brain Fog


  • Fatigue: Cause is unclear. Thought to be accumulation of metabolites as cells breakdown. Can cause brain fog (Chemo Brain)
  • Pain and anxiety
• Fatigue, Pain & Brain Fog Interventions


  • Give opioids with extra for breakthrough pain, Hydration + nutrition, Balance mild physical activity (walking) and rest, Encourage client to seek assistance + support from family and friends
• Skin Reactions


  • Erythema
  • Dry + wet desquamation
• Skin Reactions Interventions


  • Use gentle soap (dove) + mild detergents, Avoid tight clothing or harsh fabrics, Avoid sun (1 yr) + extreme heat, Avoid chlorine + salt water pools, Prevent infection, Lubricate dry skin Rx with non-medicated non perfumed lotion, Keep wet reactions clean and protected, Dry desquamation → cover with light cotton tshirt, Wet desquamation → dressing as it will be leaky
• Alopecia


  • Hair may or may not comeback, Hair may comeback curly, straight, black, grey, May be permanent with radiation of head and neck
• Alopecia Interventions


  • Head coverings, Cut hair short, Avoid excessive brushing + shampooing, Avoid hair dryers and other electric appliances for hair, Support client experiencing difficulties coping with change in self image
• Decreased Saliva/Oral Stomatitis/ Mucositis/ Esophagitis


  • Decreased saliva (xerostomia – dry mouth), Oral lesions