Breast Disorders:

Assessment & Management

 Breast & Female Reproductive Organs
• Play Significant Role In Sexuality
• Disorders Can Cause Great Anxiety
• Requires Good Nursing Assessment: detailed
• Cancer Affects Both Male & Female
• Family History is Important
• Teach individual for any changes in abnormality in breast.
• Teach pt to do breast-self exam at home
- 5-7 days after menses begin for women who are premenopausal & once monthly for
women who are postmenopausal
• Risk factors of breast cancer:
- female gender
- increasing age
- personal hx of breast cancer, family hx of breast cancer
- genetic mutation
- hormonal factors (eaerly menarche, late menopause, hormone therapy)
- exposure to ionizing radiation during adolescence and early adulthood
- hx of benign proliferative breast disease
- obesity
- high-fat diet, alcohol intake
Abnormal assessment findings during inspection of the breasts
• Retractions signs:
- Skin dimpling, creasing, changes in contour of breast or nipple
- may appear only with position changes
• Increased venous prominence
- unilateral localized increase in venous pattern associated w/malignant tumors
• Peau d’Orange (Edema)
- associated with inflammatory breast cancer
- has orange peel appearance
- skin pores enlarge
- skin become thick, hard, and immobile
• Nipple inversion
- associated w/fibrosis & malignancy if recent development
• Acute mastitis (inflammation of the breasts)
- nipple cracks or abrasions noted
- breast skin reddened and warm to touch
- tenderness, fever, increased pulse
• Paget disease (malignancy of mammary ducts)
- early signs: erythema of nipple and areola
- late signs: thickening, scaling, and erosion of nipple and areola
 Breast Infections
• Mastitis: Infection/inflammation of the breast tissue
- Can Pass Infection to Infant During Breast Feeding
- Can Be Blood Born Infection As well
- Skin tough, dull to severe pain, shouldn’t be any discharge
- Any discharge purulent material, serum, or blood from nipple need to be
investigated promptly
- Treatment:
➡Abx and local application of cold compresses to relieve discomfort
➡Broad-spectrum antibiotics 7-10 Days
➡pt should wear a snug bra and perform personal hygiene carefully
➡adequate rest & hydration are important aspects of management
• Lactation Abscess:
- Result of Acute Mastitis.
- Area affected becomes tender & red.
- Purulent matter can be aspirated w/needle, but incision and drainage may be
required
- Specimens of aspirated material are obtained for culture so that an organism-
specifics abx agent can be prescribed
 Breast Disorders
Benign Conditions: not cancerous
• Treatment Focus: Symptom Management & Education
• Classified Into Three Categories: Non-Proliferative, Proliferative, and Atypical
Hyperplasia (can increase the risk for cancer later)
• Breast Pain: Mastalgia (main complaint).
- Eliminate coffee/tea/chocolate. Decreased salt/fat/caffeine intake.
- Education and change diet.
- Recommend the pt to wear a supportive bra both day and night for a wk
- Take ibuprofen (Advil) PRN for its anti-inflammatory actions
- Vit E supplements may also be helpful
• Cysts:
- fluid-filled sac that develop as breast ducts dilate.
- Occur in women 30-55 yrs of age and exacerbated during perimenopause.
- Cause is unknown, usually disappear after menopause, suggesting estrogen is a
factor.
- may report an intermittent shooting sensation or dull ache
- Cyst confirmed on U/S and are not bothersome can often be left alone.
- cyst do not increase risk of breast cancer
- fibrocystic breast changes: array of benign findings include palpable nodularity,
lumpiness, swelling, or pain
 Benign Conditions (Cont)
• Fibroadenomas (firm, round, movable, being tumors). Occur from puberty to
menopause with peak incidence at 30 yrs of age
- Masses are contender, and biopsied or removed for definitive dx
- Proliferative Lesions (atypical, yet noncancerous, breast tissue) found on bx
are atypical hyperplasia and lobular carcinoma in situ
• Atypical Hyperplasia (ductal or lobular is pregmalignant lesion of breast)
- Precursor lesion to both noninvasive & invasive breast cancer
- Requires Pathological Diagnosis
- Have Abnormally Large Ducts
- Increase risk for breast cancer
• Lobular Carcinoma In Situ
- Incidental microscopic finding of abnormal tissue growth in lobules of breast
- Actually A Marker/sign (not a cancer/carcinoma), abnormal tissue growth
in lobules of breast. Increase risk for carcinoma
- Can develop in both breasts
- Undergo rigorous breast cancer surveillance (annual mammography and
clinical breast exam every 6 mths)
- Pt should be offered info about chemoprevention with selective estrogen
receptor modulators (SERMs) (i.e. tamoxifen (Soltamox, Nolvadex))
 Malignant Conditions of the Breast
• Confined to duct??
• Ductal carcinomas in situ (DCIS)
- proliferation of malignant cells inside milk ducts w/o invasion into
surrounding tissue
- does not metastasize. But can develop into invasive breast cancer if left
untreated
- manifested on mammogram with appearance of calcifications and
considered breast cancer stage 0
• Breast Cancer In Situ
• Most Cancers of Breast Are Invasive or Infiltrating
• Prognosis Is Based on How Invasive & When Diagnosed
• High death rate for African American
• 1 in 8 Women Diagnosed
• Risk Factors: family hx of breast cancer, older, genetically acquired, long-
term smoking, night shift work
• BRCA1 and BRCA2: tumor suppressor genes that normally fxn to identify
damaged DNA and restrain abnormal cell growth
 Breast Cancer (Cont)
• Protective Factors
- Avoid Being Overweight, Especially after Menopause
- breast feeding for at least 1 yr
- regular or moderate physical activity & maintain a healthy body wt
- Screening Important: Some Do Baseline At Age 35
- avoid alcohol intake
- prophylactic med to reduce the risk of breast cancer
- breast-self exam at age 20
• Prevention Strategies For High Risk
- Long Term Surveillance:
➡ focuses on early detection
➡ using MRI along with yearly mammogram
- Chemoprevention:
➡ Main modality that aim to prevent disease
➡ Tamoxifen or Raloxifene
➡ provide pt with info about benefits, risks, and possible side effects of these meds
- Prophylactic Mastectomy:
➡ primary prevention modality that can reduce the risk of breast cancer by 90%, “risk-reducing” mastectomy
➡ mastectomy (removal of breast tissue) and accompanied by immediate breast reconstruction
➡ physical & psychological ramification: anxiety, depression, altered body image (need extensive counseling
R/T risks & benefits)
- Total Mastectomy involves removal of breast- nipple-areola complex but does not include ALND
- Breast Conservation Treatment: Lumpectomy
- Sentinel Lymph Node Biopsy (One Lymph Node): first lymph node that see drainage in the tumor ???
 Breast Cancer

• Clinical Symptoms:
• Usually In Upper Outer Quadrant of Breast
• Non-Tender Lesion, fixed rather than mobile
• Breast pain and tenderness with menstruation are usually
associated w/benign breast disease
• Fixed, Hard, With Irregular Borders, immovable
• Advanced Signs: skin dimpling, nipple retraction, skin
ulceration
• Diagnostic Testing: Varied Tests Used:
- Mammogram, Bx, tumor staging and analysis of additional
prognostic factors to determine the prognosis and optimal tx
regimen, ultrasound to determine if it’s lesion or cyst, MRI
 Nursing Intervention/Management

• Preoperative Preparation

• NPO Several Hours Prior To Procedure

• assess knowledge, pt education

• Postoperative Care: relieve pain & discomoft,

• Must Ambulate, Tolerate PO Fluids, & Void Prior to Discharge

• Avoid straining

• Keep fuv, and wear supportive bra

• Steri -Strips In Place 7-10 Days

 Surgery: Mastectomies
• Main Goal of Surgery: gain local control disease/breast cancer Table 58.4
• Modified Radical Mastectomy:
- invasive breast cancer
- remove breast tissue/nipple/ areola/partial of lymph node in axillary lymph node
dissection (ALND).
- Pectoralis major and pectorals minor muscles are left intact
• Total Mastectomy:
- removal breast/nipple-areola complex but does not include ALND
- performed in pt with noninvasive breast cancer, performed prophylactically in pt
who are at high risk for breast cancer
- performed in conjunction with sentinel lymph node bx for pt with breast cancer
• Breast conservation tx:
- lumpectomy, wide excision, partial or segmental mastectomy, quadranectomy
- excise breast tumor completely and obtain clear margins while achieving an
acceptable cosmetic result
• Sentinel Lymph Node Biopsy:
- status of lymph node is most important prognostic factor in breast cancer
- less invasive than ALN, standard of care for tx of early-stage breast cancer
- Can Be Performed At Same Time
 Preoperative Nursing Interventions
• Provide education and preparation about surgical tx
• Reduce fear and anxiety and improve coping ability
• Promoting decision-making ability
• The pt can go home the same day if undergo SLNB in
conjunction with breast conservation tx
• PT undergo SNLB with total mastectomy usually stay in hospital
overnight
• Inform pt the radioisotope and blue dye are generally safe
• Inform the pt that they may notice blue-green discoloration in
urine/stool for first 24 hrs as blue dye is excreted
• With Mastectomy Will Be Discharged With Drains (JP drain)
• Teach Self-Care & ROM Exercises
• Will Have Limited Arm Movement With accessory lymph Node
Dissection
• Instruct Regarding Pain Medication
 Postoperative Management
• Relieve pain and discomfort:
- all pt discharged home with analgesic meds (i.e. oxycodone and
acetaminophen) and encouraged to take it PRN
- Pt who report more than moderate pain must be evaluated to R/O any
potential complications (i.e. infection/hematoma)
- Taking warm showers and using guided imagery
• Manage sensations Post Surgery:
- Pain, Tenderness, Soreness
- May C/O Numbness & Tingling, Pulling & Twinges
- May occur along chest wall, in axilla, along the inside aspect of upper
arm
- With Mastectomy: Phantom Pain and report a feeling that breast or nipple
is still present
- Sensations May Persist As Long As Five Years or Longer
• Promote positive body image
• Promote positive adjustment and coping
• Improve sexual fxn
 Postoperative Management (Cont)
Complications Post Lymph Node Dissection:
• Lymphedema: Chronic Swelling of extremity d/t interrupted lymphatic circulation
- Swelling d/t accumulation of protein-rich fluid in interstitial space and common postoperative complication
after ALND
- After Axillary Node Dissection-
➡ Swelling in Both Arm & Shoulder
➡ Pain & Tingling in Arm & Shoulder
➡ fluid cannot return to systemic circulation
➡ elevate their arm over heart several times, gentle muscle pumping can help reduce transient edema
➡ complication for lymphedema: infection
• Seroma (collection of serous fluid) or hematoma formation (collection of blood inside a cavity)
- S/S of hematoma: swelling, tightness, pain, bruising of the skin
➡ surgeon need to be notified immediately if gross swelling or increased bloody output from the drain
➡ take warm shower for hematoma formation or apply warm compresses to help increase the absorption
➡ Hematoma usually resolves in 4-5 wks
- S/S of seroma: swelling, heaviness, discomfort, sloshing of fluid
➡ develop temporarily after the drain is removed or the drain is in place & become obstructed
➡ treated by unclogging the drain or manually aspirate fluid with needle & syringe
➡ Large, long-standing serums have not been aspirated may lead to infection
• Infection (Rare):
- Higher risk in pt w/DM, immune disorders, advanced age, pt w/poor hygiene
- Monitor for S/S of redness, warmth around incision, tenderness, foul-smelling, drainage, T greater than
100.4, chills
- Contact surgeon/nurse for evaluation
- Treatment- Oral or IV Antibiotics for 1-2 wks; Drains Inserted
- Cultures are taken of any foul-smelling discharge
 Postoperative Management (Cont)
• Self-Care Education:
• Assess the pt’s readiness to assume self-care responsibilities & identify any
gaps in knowledge
• Symptoms to Report (i.e. infection, seroma, hematoma, arm swelling)
• Teach How to Empty & Measure Output (drains removed when output is
less than 30 mL in 24-hr period)
• Pain management and incision Care
• Activity Limitations
• Patient can shower the second day of post-opt and wash incision & drain
site w/soap & water to prevent infection
• dry dressing applied to incision each day for 7 days
• take at least 3 wk for incision to heal, can put lotion/cream on skin, can use
deodorant on affected side

• Continuing Care
• Fuv Every 3-6 months For first several years
• Routine Health Screenings
 Other Therapies For Breast Cancer
• Radiation Therapy (Internal or External): used to decrease the
chance of local recurrence in breast by eradicate residual
microscopic cancer cells
• External-beam radiation (most common type) begins At 6
Weeks After Breast Conservation to allow surgical site to heal
• Before radiation begins, pt undergoes a planning session called
“simulation”, in which anatomic areas to be treated are mapped
out & identified with small permanent ink markings
• If Started On Chemo Initially, Radiation Treatment Follows
Chemotherapy
• Each Treatment Lasts a Few Minutes and given 5 drays a wk
for 5-6 wks.
 Radiation Therapy (Cont)
• Internal Radiation (Brachytherapy)
- Radiation is delivered by internal device that is placed close to tumor within the breast
- Insert Radioactive Material Directly Into Area
• Some Clients Receive Both Types of Radiation
• Side Effects of Radiation
- Fatigue Is Not Uncommon
- Radiation is most tolerated well
- Mild-moderate erythema, breast edema, fatigue
- Edema or skin breakdown but will resolve shortly
- side effect resolve within a few wks to few moths after tx is completed
- rare long-term effects: pneumonitis, rib fracture, heart disease, breast fibrosis or
necrosis
• Self-Care Instructions: maintain skin integrity during tx and for several wks after
completion
- use mild soap w/minimal rubbing
- no perfume soap nor deodorants
- use hydrophilic lotions for dryness
- avoid tight cloth/underwire bra/excessive temperature/UV light
- fuv include educate the pt to minimize sun exposure (use sunblock with sun protection
factor [SPF] of 15 or higher) & reassure pt that short-term twinges and pain in breast
are normal after radiation tx.
 Systemic Therapy
• Chemotherapy:
- Adjuvant chemotherapy: involve use of anticancer agents in
addition to other tx (i.e. surgery, radiation) to delay or prevent a
recurrence of breast cancer
- Chemotherapy is most commonly initiated after breast surgery
and before radiation.
- Chemotherapy regimens for breast cancer combine several agents
(polychemotherapy), generally given over a period of 3-6 mths
- Use Anti-Cancer or Anti-Neoplastic Drugs
• Administer IV or PO
• Types of Chemotherapeutic Drugs Used:
• Non-Adjuvant Therapies: Drugs Given Prior To Surgery
• Shrinks Tumor Prior to Surgery
• get rid of microscopic??
 Biological Therapy
• HER2/neu- Growth Promoting Protein. found in 15-20%
of breast cancer
• Trastuzumab: Monoclonal Antibody
• Reduces Reoccurrence For Easy Cancer and Metastatic
CA
• tamoxifen decrease the recurrence of breast cancer
**
• Are Other Biological Medications In Text
• Hormone Therapy: Block Estrogen Production
 Chemotherapy
• Indicators For Use
• Tumor Size
• Lymph Node Involvement
• Presence or Absence of Hormone Receptors In Tumor
• Amounts of HER2/neu In Breast Cancer Cells
• Chemotherapy Regimes: 3-6 mth regimen
• Nursing Care/Interventions: nutrition is key
 Chemotherapy Nursing Care (Cont)
• Some pt require hematopoietic growth factors to minimize
the effects of Chemotherapy Induced Neutropenia &
Anemia
• Medications Used To Treat Neutropenia:
• Filgrastim (Neupogen) – Short Acting (inject subq or IV
for 7-10 days after chemotherapy administration)
• Pegfilgrastim (Neulasta) - Long Acting (injected once, no
earlier than 24 hrs after chemotherapy)
• Medications To Treat Anemia: Erythropoietin growth factor
(increase production of RBC)
- The short-acting form, epoetin alfa (Epogen) is Given
Weekly. Long Acting Drugs, darbepoetin alfa (Aranesp)
given every 2-3 wks
 Treatment For Recurrent or Metastatic
Breast Cancer
• Recur locally (on chest wall or in conserved breast), regionally
(in remaining lymph nodes), or systemically (in distant organs)
• Other Common Sites: the bone, usually the hips, spine, ribs,
skull, pelvis
• other sites of metastasis: lungs, liver, pleura, brain
• Local Occurrence in absence of systemic disease is treated
aggressively w/surgery, radiation, hormonal therapy
• Use Chemo for Tumors Not Sensitive to Hormone Treatment
• Do Cancer Control Instead of Cure
• Tx: hormonal therapy, chemotherapy, and targeted therapy
• estrogen increase the risk of breast cancer reoccurring
 Nursing Care: Recurrent Breast Cancer
• Education
• Emotional Support
• Teach About Side Effects of Treatment
• Appropriate Referrals
• eliminate pain and provide comfort
• prosthetics
• High Priorities
• End of Life Care
 Special Issues: Breast Cancer
Pregnancy & Breast Cancer: Breast Conservation
• Ultrasound Preferred for Diagnosis
• Can Use Mammogram With Shielding If Needed
• No Chemotherapy First Trimester
• Give During 2nd & 3rd Trimester
 Diseases of the Male Breast
Gynecomastia
• Common in Adolescent. Over development of breast tissue
• Can See In Older Men
• presents as a firm, tender mass underneath the areola
• Can disappear on its own
• Can Be Caused By Certain Medications: ranitidine [Zantac],
digitalis
• Associate with certain conditions (i.e. feminizing testicular
tumors, infection in testes, liver disease resulting from factors
such as alcohol abuse or parasitic infection)
• After Age 40 – If Diagnosed Need Testicular Examination and
possibly a testicular U/S
• Can Treat With Liposuction
 Disease of the male breast (con’t)
Male Breast Cancer
• Familial cases in men have BRCA2 rather than BRCA1
mutations
• Presentation is painless lump, but is often late, with more
than 40% of individuals having stage III or IV disease
• Tx: total mastectomy with SLNB or ALND
• involvement of axillary lymph nodes is most important
prognostic indicator
• Very likely to be ER+ and tamoxifen is a mainstay of tax