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Relatively High estrogen
and
Low progesterone
Development of excess fibrous
tissue
Hyperplasia of the epithelial lining
of the mammary ducts
Proliferation of mammary ducts
Cyst formation
Palpable lumps that are round, welldelineated and freely movable
Lumps increase in size premenstrual
Tenderness
Pain
Nipple discharge
Does having a fibrocystic breast
condition increase a woman’s risk
for development of breast cancer ?
Ultrasound
Biopsy
◊Fine needle Aspiration
◊Excisional
Why is a fine needle aspiration biopsy
preferred over an excisional biopsy?
Patient Teaching
◊Wear good support bra
◊Diet Therapy
 Low salt
 No chocolate or caffeine
◊Medications
 Vitamin E
 Antiestrogen - Danazol
 Diuretics
 Analgesics
◊Remind Patient to have a Yearly follow-up
◊Continue to perform monthly BSE
In teaching the patient with painful fibrocystic
breast changes about the condition, the nurse
explains that
a. All breast lumps must be biopsied to rule out
malignant changes
b. The symptoms will probably subside after
menopause unless you use HRT
c. Restrictions of coffee and chocolate and
supplements of vitamin E may relieve the
discomforts
d. The lumps will become progressively larger and
more painful, eventually necessitating surgical
removal
Breast Cancer
•Significant health concern for women
•1 in 7 chance of being diagnosed
with Breast Cancer
•Intense feelings of shock, fear, denial
•One of the most common
malignancies in American women
◊Female gender; ≥50 years of age
◊Personal History
 Family history
 Personal history of cancer (breast, colon,
endometrial, ovarian)
◊Hormonal factors
 Early menarche or late menopause
 No pregnancies
 First child after 30 years of age
◊Weight gain and obesity after menopause
◊High fat diet, alcohol intake
◊Exposure to ionizing radiation
 BRCA1 and BRCA2 are human genes that belong to a
class of genes known as tumor suppressors.
 In normal cells, BRCA1 and BRCA2 help ensure the
stability of the cell’s genetic material (DNA) and help
prevent uncontrolled cell growth.
 Mutation of these genes has been linked to the
development of hereditary breast and ovarian
cancer.
 A woman’s lifetime risk of developing breast and/or
ovarian cancer is greatly increased if she inherits a
harmful mutation in BRCA1 or BRCA2.
HER-2 receptors are found on the inside and outside of the
Cancer cell. Receptors join together to send messages
telling cancer cells to grow and divide
 Detected as a lump
 Abnormality on mammography
 If palpable, irregular shaped, poorly delineated,
nonmobile (usually attached to chest wall), and
nontender
 May have nipple discharge – bloody
 Nipple retraction

Dimpling
One of the best ways for a woman to become
self-aware of how their breasts normally look
and feel and to detect when something
changes.
Should be done monthly when the breasts
are non tender, right after the end of menses
If no longer have menses – use the first day of
each month
Step 1:
Begin by looking at your breasts
in the mirror with your shoulders
straight and your arms on your
hips.
Here's what you should look for:
Breasts that are their usual
size, shape, and color
Breasts that are evenly
shaped without visible
distortion or swelling
Use a firm, smooth touch with the first few finger pads of your hand,
keeping the fingers flat and together. Use a circular motion, about
the size of a quarter. Go around breast, up and down over breast
and in outward from nipple.
Look at breasts with arms at side and arms raised and on hips
Next, lie down and do same procedure in palpating breasts.
 DNA testing for BRCA – 1 and BRCA-2
 Mammogram / ultrasound
Mammogram showing Bilateral Invasive Ductal Carcinoma
 Biopsy
Lymphatic mapping and sentinel lymph node
dissection (SLND)
◊Helps surgeon identify lymph nodes that
drain first from tumor site
◊Radioisotope and/or blue dye is injected
into tumor site
◊Lymph nodes dissected and sent to lab for
analysis
◊
While discussing risk factors for breast
cancer, the nurse stresses that the greatest
known risk factor for breast cancer is
a. Being a woman over 60 years of age
b. Experiencing menstruation for 40 years or more
c. Using estrogen replacement therapy during
menopause
d. Having a paternal grandmother with
postmenopausal breast cancer
Surgery
Radiation Therapy
Chemotherapy
Hormonal Therapy
Biologic and Targeted Therapy
Most common options for resectable
Breast Cancer
◊Breast conservation surgery with
radiation therapy
◊Modified radical mastectomy with or
without reconstruction
Sentinel lymph node dissection (SLND)
has replaced ALND for patients who do
not have malignant cells
ALND performed when one or more
sentinel lymph nodes contain malignant
cells
Examination of lymph nodes provides
prognosis and treatment information
Involves removal of entire tumor with a
margin of normal tissue
Radiation therapy is delivered to entire
breast, ending with a boost to tumor bed
Evidence of systemic disease may warrant
chemotherapy before radiation
Modified radical mastectomy
◊Removal of breast and axillary lymph nodes
with preservation of the pectoralis major
muscle
◊Patient has the option of breast
reconstruction
Primary radiation therapy
◊Usually performed after local excision of breast
mass
◊Breast is radiated daily over ~5 to 6 weeks
◊“Boost” treatment may be given to full breast
following primary dose
Intraoperative Radiation Therapy
◊Single intense dose delivered to surgery site in the
operating room
High-dose brachytherapy
◊Internal radiation delivered via radioactive
seeds into a balloon catheter
◊Balloon catheter is placed within the
lumpectomy site
◊Treatment is over 4-5 days
Palliative radiation therapy
◊Used to stabilize symptomatic metastatic
lesions in such sites as




Bone
Soft tissue organs
Brain
Chest
◊Relieves pain
◊Successful in controlling recurrent or
metastatic disease for long periods
Radiation therapy side effects
◊Fatigue
◊Skin changes
◊Breast edema
Removes or blocks source of estrogen,
promoting tumor regression
 Estrogen can increase growth of BC cells if
cells are estrogen receptor positive
Most common drug used in estrogen-receptor
positive women is:
 Tamoxifen (Nolvadex) – antiestrogen
 Side effects – decreased visual acuity, and
vascular changes
 Fulvestrant (Faslodex) - antiestrogen
Hormonal therapy (cont'd)
◊2 advances have increased use in BC
 Hormone receptor assays developed to
identify those likely to respond to
treatment
 Drugs have been developed that can
inactivate hormone-secreting glands as
effectively as surgery or radiation
How are these used in treatment?
Trastuzumab (Herceptin) is a monoclonal
antibody to HER-2
Once the antibody attaches to antigen, it
is taken to cells and eventually kills them
It can be used to alone or in combination
with other chemotherapies
Side-effect – monitor for signs of
ventricular dysfunction and congestive
heart failure.
◊Use of cytotoxic drugs to destroy cancer
cells
◊BC is one of the solid tumors that is most
responsive to chemotherapy
◊Given preoperatively in some patients to
decrease size of primary tumor
The patient will:
◊Actively participate in decision-making process
related to treatment options
◊Fully comply with therapeutic plan
◊Manage side effects of therapy
◊Be satisfied with support provided by significant
others and health care providers
Complications;
◊Heaviness
◊Pain
◊Impaired motor function in arm
◊Numbness
◊Paresthesia of the fingers
◊Cellulitis and progressive fibrosis can
result
http://www.youtube.com/watch?v=Di5E_KXbAnU&feature=related
◊Positioning
 Place in a semi-Fowler’s position with arm on
affected side elevated on a pillow, never dependent
◊ Exercise
 Flexing and extending fingers should begin in
recovery room and progressive increase in activity
 Exercises are designed to prevent contractures and
muscle shortening, maintain muscle tone, and
improve lymph and blood circulation
 Postoperative arm and shoulder exercises are
instituted gradually at surgeon’s direction
◊Avoid constriction
 Do not take Blood pressure readings on that arm
 Avoid constrictive clothing
◊Compression
 Wrap arm with bandages going from distal to
proximal
 Use intermittent pneumatic compression sleeve or
a fitted elastic pressure gradient sleeve
◊Massage Therapy
Venipunctures, and injections should not be
done on affected arm
Apply insect repellant
Wear gloves when gardening
Use cooking mitt
Use electric razor for shaving axilla
Avoid cutting cuticles – push back cuticle
No heavy lifting
Keep clean and dry
Relieve postmastectomy pain syndrome:
◊Chest and upper arm pain, tingling down arm
◊Numbness, shooting or prickling pain
◊Unbearable itching persisting beyond
3-month healing time
 Treatment includes
◊Nonsteroidal antiinflammatory drugs
◊Antidepressants
◊Topical lidocaine patches or EMLA
Postoperative discomfort can be minimized
by administering analgesics ~30 minutes prior
to exercises
When showering is appropriate, warm water
has a soothing effect and decreases joint
stiffness
Psychologic care
◊All aspects of care must include sensitivity
to woman’s effort to cope
◊Nurse can help by:
 Assisting her to develop a positive but
realistic attitude
 Helping her identify sources of support
and strength to her
Must be follow-up for rest of life at regular
intervals
Professional examinations every
6 months for 2 years, then annually
Practice monthly breast self examinations
(BSE) on both breasts or remaining breast
A patient had a radical mastectomy with
lymph node dissection. Post op nursing care
focused on restoring arm functioning would
include
a. Use of heating pads or blankets to increase
circulation
b. Daily application of ice packs to minimize the risk
of lymphedema
c. Compression bandaging with sleeves or stocking
for acute swelling
d. Frequent and sustained exercises with the arm in
a dependent position
Chest prior to Implants
Breast implants placed in pocket under
pertoralis muscle and
musculocutaneous skin flap applied
Musculocutaneous flap most often taken from
abdomen or back is used in reconstruction
As part of the final stage of reconstruction,
the nipple and areola are reconstructed
The tissue expander starts out with
minimal inflation.
Gradually filled with water weekly to
stretch the skin and muscle
Tissue expander in place
after mastectomy
Capsular formation
◊Part of bodies natural defense mechanism to
form a fibrous capsule around the implant
Infection
Hematoma
Skin ulceration
Hypertropic scar formation
To prevent capsular formation following
breast reconstruction with implants, the
nurse teaches the patient to
a. Gently massage the area around the implant
b. Bind the breasts tightly with elastic bandage
c. Exercise the arm on the affected side to promote
drainage
d. Avoid strenuous exercise until implant healing
has occurred.