BREAST CANCER

• Breast Disorders

  A) benign

  B) fibro

  C) cystic

  D) ectasia

  E) papilloma

  F) tumor

  G) 8

  H) 833

  
• Pathophysiology

  • heterogenous disease with different presentations and therapy response
  • sometimes presents as lump; other times presents only on mammogram
  • non invasive vs. invasive
  • most common sites of metastasis: brain, bone, liver, lung
• Categories of Breast Cancer - Noninvasive (in situ)

  • Ductal carcinoma in situ (DCIS)- a precursor to invasive breast cancer
  • Lobular carcinoma in situ (LCIS)- a risk factor for subsequent IBC
• Invasive Ductal Carcinoma


  • Originates in mammary ducts and break through wall of ducts into surrounding tissue
  • Fibrosis develops around the cancer
  • Peau d'orange
• Inflammatory Breast Cancer (IBC)


  • Diffuse erythema
  • Pain; rapidly growing breast lump; breast itching
  • Peau d'orange
• Triple Negative Breast Cancer (TNBC)


  • Grows rapidly
  • Often found in with BRCA mutation who are premenopausal
• HER2-Positive


  • When breast tissue has extra HER2 receptors (overexpression), breast cells can multiply too quickly
  • Grows rapidly, frequently reoccur
• Paget Disease


  • Disease of the nipple
  • Rarely occurs
  • Scaly, red, irritation
• Risk Factors for Breast Cancer

  • Female
  • Age older than 65 years
  • Race -white greater
  • Early menarche or late menopause
  • Nulliparity or first pregnancy after 30 years
  • Personal history of breast cancer
  • Genetic risk factors (BRACA1, BRACA2, mutated CHEK-2, ATM gene, PHEN gene, p53, CDHI, STK11)
  • Breast density
  • Previous irradiation of chest area
  • Previous abnormal breast biopsy results
  • Long-term hormone replacement therapy with estrogen and progesterone
  • Excessive alcohol consumption
  • Overweight or obesity
  • Physical inactivity
• American Cancer Society (ACS) guidelines for mammogram screening in women


  • Women 40-44 optional mammogram every year
  • Women 45-54 yearly mammogram
  • Women ≥55 mammogram every other year or continue yearly depending on her health
• Assessment

  • History
  • Risk factors
  • Breast mass
  • Health maintenance practices
  • OB/GYN history
  • Alcohol use
  • Medication review
• Clinical Manifestations

  • Nontender lump in breast (most often upper outer quadrant)
  • Inflammatory breast cancer (IBC): typically have pain or enlarged lump as well as erythema and edema
  • Abnormal nipple discharge
  • Rash around nipple area
  • Nipple retraction, dimpling of skin, or change in nipple position
  • May be nipple pain, scaliness, ulceration, skin irritation, discharge may report burning or stinging sensation
  • Dense breast tissue increases risk
  • Many patients have no manifestation
• Diagnostic Assessment

  • Imaging assessment (Mammography, Tomosynthesis, Ultrasonography, MRI, PET scan)
  • Breast scan
  • Genomic tests
  • Laboratory assessment (Pathologic study of breast mass tissue and lymph nodes, Liver enzymes, serum calcium, alkaline phosphatase)
• Therapeutic Management

  • Surgical removal of the tumor plus surrounding tissue and lymph nodes
  • Adjuvant therapy (Radiation therapy, Chemotherapy, Hormonal therapy, Immunotherapy)
  • Complementary and integrative health
• Lumpectomy


  • Excision of primary tumor and some normal breast tissue
• Total (Simple) Mastectomy


  • Removal of the complete breast
• Modified Radical Mastectomy


  • Removes breast tissue, lymph nodes and sometimes part of the underlying chest wall muscle
• Radical Mastectomy


  • Removal of entire affected breast, the underlying chest muscles and the lymph nodes under the arms
• Sentinel Lymph Node Biopsy

  • Analyzes for lymph node involvement
• Perioperative Considerations - Pre-op


  • Education
  • Support
• Perioperative Considerations - Post-op


  • Pain
  • Drains
  • Infection
  • Dressings
  • Mobility
  • Lymphedema precautions
• Chemotherapy


  • Systemic
  • Kill undetected breast cancer cells
• Chemotherapy Side Effects

  • Alopecia
  • Nausea/vomiting
  • Mucositis
  • Bone marrow suppression
• Common Chemotherapy Drugs

  • Anthracyclines, such as doxorubicin (Adriamycin) - damages DNA
  • Taxanes, such as paclitaxel (Taxol or AC-T) - stops cell division
  • 5-fluorouracil (5-FU)- antimetabolites
  • Cyclophosphamide (Cytoxan) - inhibits cells division
  • Trastuzumab- for HER2 positive
• Radiation Therapy


  • Localized
  • Kill cells near original tumor
• Radiation Therapy Side Effects

  • Nausea/vomiting
  • Fibrosis
  • Fatigue
  • Bone marrow suppression
• Hormone Therapy - SERMs


  • Tamoxifen citrate
  • Prevents estrogen from attaching to cancer cells which prevents growth
  • Used in early stage, advanced, and prevention for high risk
• Hormone Therapy - Aromatase Inhibitors


  • Anastrozole, Letrozole
  • Inhibits conversion of androgen to estrogen
  • Closely monitor for osteoporosis
  • First line treatment in postmenopausal women
• Targeted Drugs


  • Counteract specific genetic mutation that promote CA growth
  • Trastuzumab (Herceptin) - Targets HER2/neu gene product in breast cancer cells
• Complementary & Integrative Health

  • Massage
  • Diet
  • Meditation
  • Herbs
  • Acupuncture
  • Guided imagery
• Physical Assessment of Breast Cx

  • location, shape, size, consistency, mobility of mass
  • skin changes
  • enlargement of nodes
  • pain or tenderness
• Psychosocial Assessment of Breast Cx

  • fear, shock, disbelief
  • previous history of mental illness, age and life circumstances can increase distress
  • encourage experession
  • refer to counselor and community resources
  • assess for concerns related to sexuality