MODULE IN BREAST CANCER – MMSU CHS 1

CHAPTER VI: CARE OF CLIENTS WITH CELLULAR ABBERATIONS

Lesson 1: Introduction
Lesson 2: Breast Cancer
Lesson 3: Lung Cancer
Lesson 4: Colorectal Cancer
Lesson 5: Cervical Cancer
Lesson 6: Uterine Cancer
Lesson 7: Prostate Cancer
Lesson 8: Liver Cancer
Lesson 9: Leukemia
Lesson 10: Brain Cancer

LESSON TITLE: CANCER OF THE BREAST

INTRODUCTION
Breast cancer is the number cause of cancer in females. You may already know someone
or may have encountered someone, at least, who have been diagnosed with this condition. The
thing is, the incidence of breast cancer has grown and is still growing. In your clinical encounters
as a student nurse, there is a great possibility that you might be given the responsibility to take
care of an individual with breast cancer. It is therefore, best for you to know the nature of this
disease in order for you to be prepared to take care of not only the sick individual with breast
cancer but also for those who are identified as high risk.

STATEMENT OF OUTCOMES
In this lesson, we will be discussing about the nursing process approach on the care of
clients suffering from cancer of the breast. At the end of this this lesson, the learners will be
able to:
1. Define breast cancer.
2. Differentiate the different types of breast cancer.
3. Explain the pathophysiology of breast cancer.
4. Identify and explain the risk factors for breast cancer.
5. Explain the causes of the manifestations of breast cancer.
6. Identify and explain the diagnostic examinations for breast cancer.
7. Identify and explain the managements for breast cancer.
8. Apply the nursing process in caring for clients with breast cancer.

WARM-UP ACTIVITY
You are assigned as the nurse in-charge of the Out-Patient Clinic and a woman came to
you at the station and says, “I am worried, I think I have breast cancer.” While talking to her,
you learned that she is only 35 years old and single. She said that her aunt has just been
diagnosed with breast cancer and her first degree cousin is a breast cancer survivor as well.
1. What could be the reason why the woman thinks she has breast cancer?
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2. Basing from this scenario, do you think the woman has breast cancer?
Breast Cancer is a malignant new growth that originates from the breast tissues and other
structures of the breast like the milk ducts, lobules or tubules. It is the number one cause of
cancer in females and second only to lung cancer as the leading cause of cancer deaths in
females.
Types of Breast cancer
 Breast Cancer in Situ is a type of breast cancer in which cancer cells remained contained
within their place of origin and haven’t invaded breast tissue around the duct or lobule.
It has two types which includes:
o Ductal carcinoma in situ originates from the linings of milk ducts that haven’t
invaded the surrounding breast tissue. They are sometimes considered as
precancerous tumors in which if detected and treated at an early stage results to
good prognosis and when left untreated might progress to the invasive type of
breast cancer
o Lobular carcinoma in situ (LCIS) originates within a lobule of a breast but haven’t
invaded the surrounding breast tissue
 Invasive breast cancers are the aggressive type of breast cancers wherein they invade
the surrounding tissues that support ducts and lobules of the breast. The tumor cells of
this type can travel to distant parts such as lymph nodes. It also has two types which
include:
o Invasive ductal carcinoma (IDC) forms at the lining of milk duct and accounts for
the majority of the invasive type of breast cancer. Tumor cells break free of
ductal walls and invade surrounding breast tissues
o Invasive lobular carcinoma (ILC) is the less common and acts in similar manner
wherein it starts at milk producing lobules and invades surrounding breast
tissues
Other Types
 Medullary Carcinoma occurs when tumor cells grow in a capsule inside a duct. They can
become large and can be mistaken for a fibroadenoma which is a solid, non-cancerous
breast lump. It accounts for about 5% of breast cancers and women less than 50 years
old are often affected by this type. Medullary carcinomas often have favorable
prognosis.
 Mucinous carcinoma is a slow growing type of breast tumor which has the ability to
produce mucin—the main ingredient of mucus hence the name. It accounts for about
3% of breast cancers. This often presents in post menopausal women 75 years and older
with a favorable prognosis compared to many other types.
 Tubular ductal carcinoma are sometimes considered as a subtype of IDC that starts in
the milk ducts and extends to other parts of the breast. The cancer cells of this type
resemble small tubes when examined under a microscope hence the name. It accounts
for about 2% of breast cancers and although they are considered as invasive types,
axillary metastasis uncommon and prognosis is often excellent.
 Inflammatory carcinoma is an aggressive type of breast cancer which may present as an
indiscrete thickening along with diffused edema and brawny erythema of the skin also
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known as Peau d’orange. This results when cancer cells block lymph channels in the skin.
This is a rare type of breast CA which accounts for only 1-2% of cases.
 Paget disease of the breast is an uncommon type of breast cancer that originates in or
around the nipple. It accounts for 1% of cases and presents as scaly, erythematous and
pruritic lesion of the nipple.
ACTIVITY NO. 1
Copy and paste this table in a separate document and identify the type of breast cancer
described.
1. Sometimes considered as precancerous lesions that
Click or tap here to enter originates in milk ducts.
text.
2. An invasive type of breast CA that starts at the milk
Click or tap here to enter producing lobules.
text.
3. This type of breast CA causes blockage of lymph channels
Click or tap here to enter in the skin.
text.
Click or tap here to enter 4. Cancer cells of this type originates in or around the
text. nipple.
5. It originates within a lobule of a breast but haven’t
Click or tap here to enter invaded the surrounding breast tissue
text.
6. This is an invasive type of cancer wherein tumor cells
Click or tap here to enter resemble small tubes when examined under a
text. microscope.
Click or tap here to enter 7. Tumor cells originates from ducts and are encapsulated.
text.
Click or tap here to enter 8. A slow growing breast tumor that produces mucin.
text.
Click or tap here to enter 9. Most common type of invasive breast cancer.
text.
10. Originates within a lobule of a breast but haven’t invaded
Click or tap here to enter the surrounding breast tissue
text.

Risk Factors
 Gender - women accounts for 99% of breast cancer cases
 Age - majority of breast cancers are found in postmenopausal women; incidence increases
significantly at age 60
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 Reproductive factors - prolonged exposure to unopposed estrogen increases risk for breast
cancer which includes nulliparity and late first pregnancy at after the age of 35 years old
 Hormonal Factors – estrogen exposure in women with early menarche (before age 12) and
late menopause (after age 55) as well as estrogen therapy in post-menopausal women and
contraceptive use have higher risk for the development of breast cancer
 Environmental and lifestyle – exposure to carcinogens including cigarette smoking and
alcohol consumption of more than 1 alcoholic beverage per day increases the risk of breast
cancer; obesity also increases breast cancer risk due to increase in circulating estrogen;
breast CA risk is decreased in physically active women
 Familial factors and tumor related genes – inherited mutations in BRCA1 and BRCA2 genes
as well as p53 genes significantly increases risk; family history of breast cancer in first
degree relatives also increases breast cancer risk
 Previous medical history – history of breast tumors such as moderate or florid mammary
hyperplasia, mammary papilloma and atypical mammary hyperplasia increases breast
cancer risk; prior treatment of Hodgkin’s lymphoma through ionizing radiation damages cell
DNA posing risk for development of breast CA
Protective Factors
Protective factors may include regular vigorous exercise (decreased body fat), pregnancy before
age 30 years, and breastfeeding.

Prevention Strategies
Patients at high risk for breast cancer may consult with specialists regarding possible or
appropriate prevention strategies such as the following:
 Long-term surveillance consisting of twice-yearly clinical breast examinations starting at
age 25 years, yearly mammography, and possibly MRI (in BRCA1 and BRCA2 carriers)
 Chemoprevention to prevent disease before it starts, using tamoxifen (Nolvadex) and
possibly raloxifene (Evista)
 Prophylactic mastectomy (“risk-reducing” mastectomy) for patients with strong family
history of breast cancer, a diagnosis of lobular carcinoma in situ (LCIS) or atypical
hyperplasia, a BRCA gene mutation, an extreme fear of cancer (“cancer phobia”), or
previous cancer in one breast

ACTIVITY NO. 2
Make a list of the possible risk-assessment questions using three languages. Refer to the
example below.
ENGLISH TAGALOG ILOCANO
Are there any members of Mayroon bang miyembro ng Adda kadi miyembro ti
your family or immediate pamilya ninyo o sa mga pamilya yo wennu asideg nga
relatives who have had malapit na kamag-anak ang kabagyan yo nga addaan ti
breast cancer? may kancer sa suso? kanser ti suso?

Clinical Manifestations
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 Presence of fixed, irregular, non- encapsulated and non-tender lump usually in upper
outer quadrants (because it is where the largest breast tissue can be found) is usually
the first sign of breast cancer. It may also be firm, hard and embedded in surrounding
tissues, which may only be palpable after 2 years.
 Asymmetry observed on examination with affected breast being higher
 Retraction or dimpling of the skin over the mass if tumor infiltrates surrounding tissues,
which is secondary to fibrosis or scar formation in the breast. It may appear only with
position changes or with breast palpation.
 Nipple retraction as a result of shortening of mammary gland
 Peau d’orange
 Bloody or clear nipple discharges which may be due to obstruction
 Lymph edema of the affected arm due obstruction of lymphatic circulation
 Unilateral increased venous
 Axillary lymphadenopathy/ nodular axillary mass
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Late manifestations
 Nodule becomes more fixed to the chest wall
 Pain as a result of pressure of the growing tumor
 Ulceration as a result of decreased blood supply leading to necrosis
 Systemic manifestations such as cachexia, weight loss, body malaise, anorexia, body
weakness, pallor

Manifestations of metastasis
 Lung and pleura - productive sputum production; diminished breath sounds; dyspnea;
cough; chest pain
 Liver - hepatomegaly; jaundice; ascites; RUQ pain
 Bone (spine, proximal long bone) - spinal punch; tenderness; aching; fracture;
hypercalcemia
 Brain – Papilledema (swelling of the optic nerve); corresponding abnormality in mental
status; increased ICP; headache; impaired cognitive function; hemiparesis, seizure,
visual changes

Prognosis
 When malignancy is confirmed to breast - 5 years survival, 85 %
 When malignancy has spread to axilla- 5 years survival, 55 %
Important factors to consider:
 Tumor size - the smaller the size, the better the prognosis
 Spread to lymph nodes under the arm (axilla) and surrounding structures – more
lymph nodes and surrounding structures involved, the poorer prognosis; distant
metastases or presence of secondary tumor always lead to poor prognosis

Assessment and Diagnostic Methods

 Breast Self Examination/Clinical breast examination
o Patient should disrobe to the waist and sit in a comfortable position facing the
examiner
o Inspect for size and symmetry, color, venous pattern, thickening or edema
o Palpate for the breast with the patient sitting up (upright) and lying down
(supine)
 In supine position, patient’s shoulder is first elevated with a small pillow
to help balance the breast on the chest wall ( to prevent breast tissue to
slip laterally which may caused a breast mass to be missed)
 Accepted techniques:
 Circular – clockwise direction, following imaginary concentric
circles from outer limits of breast toward the nipple
 Wedge – Palpate from each number in the face of the clock
toward the nipple in an clockwise fashion
 Vertical strip – Imaginary vertical lines on the breast
o Palpate for axillary lymph nodes
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Examiner gently abducts the patient’s arm from the thorax. With left
hand, patient’s left forearm is grasped and supported. Right hand is then
free to palpate the axilla.
 Any lymph nodes that maybe lying against the thoracic wall are noted;
Normally, these lymph nodes are not palpated, but if enlarged, their
location, size, mobility, consistency are noted
o For male, follow the same procedure
o BSE is best performed after menses - days 5-7, counting the first day of menses
as day 1
Note:
*Adolescent breast – firm and lobular
*Postmenopausal – thinner and fattier
*Pregnancy and lactation – firmer and larger with lobules more distinct
*Menstruating – Cysts are common, well defined and freely movable
*Malignant – hard, poorly defined, non-tender
 Mammography
o Can detect non-palpable lesions (<1cm)
o Takes about 15 minutes and can be performed in hospital radiology department/
independent imaging center
o 2 views are taken of each breast – mechanically compressed from top-bottom
(craniocaudal view) and side-side (mediolateral oblique view)
o Women may experience some fleeting discomfort because maximum
compression is necessary for proper visualization
o New mammogram is compared with previous ones and any changes may
indicate a need for further investigation
o False (-) ranges between 5-10%
o Younger women and those taking hormonal therapy – more difficult to detect
lesions due to dense breast tissue
o The radiation exposure is = 1 hour of sunlight exposure
o Those with history of breast cancer – screening should begin 10 years earlier
than the age at which the youngest family member developed breast cancer but
not before 25 years of age
 Galactography
o Involves injection of <1ml of radiopaque material through a canula inserted into
a ductal opening on areola, followed by mammogram
o To evaluate abnormality within duct when patient has bloody nipple discharge
on expression, spontaneous nipple discharge or solitary dilated duct on
mammogram
 Ultrasound
o Diagnostic adjunct to mammogram to help distinguish fluid-filled cysts from
other lesions
o A thin coating of lubricating jelly is spread over the area, transducer
o Accurate but can’t definitively rule out malignant lesions
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o Can’t detect microcalcification which mammogram can do

 Magnetic Resonance Imaging
o Adjunct to mammogram
o Involves injection of gadolinium (contrast dye) to improve visibility
o Patient face/lie down and breast is placed through a depression in the table
o Coil is placed around the breast – inside the MRI machine
o Takes about 30-40 minutes
o To assess multifocal (>1 tumor in same quadrant) and multicentric (>1 tumor in
different quadrants) disease3, chest wall involvement, tumor recurrence,
response to chemotherapy
o To identify occult/undetectable breast cancer
 Percutaneous biopsy
o Fine needle aspiration
 Non-invasive biopsy technique that is generally well tolerated by most
women
 May/may not use local anesthesia
 22 or 25-gauige needle is attached to a syringe is inserted into the mass
or area of nodularity
 Cellular material is placed in a glass slide and send to lab for analysis
o Core needle biopsy
 More definitive because actual tissue and not just cells are removed
 For relatively large tumor close to skin surface
o Surgical biopsy under local anesthesia/IV sedation
 Sentinel lymph node biopsy
o Sentinel lymph node is the first node in the lymphatic basin that receives
drainage from primary tumor in breast (first lymph node through which breast
cancer cells would spread to regional LN in axilla)
o It involves injecting radioisotope/blue dye in breast – which travels via the
lymphatic pathways to the node
o Surgeon uses hand-held probe to locate the SLN, excise – pathologic analysis
(which is performed immediately during the surgery using frozen section analysis)
 If (+), the surgeon proceeds with ALND (Axillary lymph node dissection,
sparing the patient a return trip to OR and additional anesthesia
 If (-), ALND not done, sparing the patient with sequelae of procedure
 No cancer cells in SLN suggests that all LN are free of cancer
cells – preserve more breast, axillary and chest muscle
 Leaving many normal LN intact decreases potential for
complications – lymphedema, poor wound healing
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ACTIVITY NO. 3
Copy and paste the table in a separate document and label the images according to what
method of BSE is used.

Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.

Staging of Breast Cancer

Classifying tumors as stage 0, I, or IV is fairly straightforward. Stage II and III tumors represent a
wide spectrum of breast cancers and are subdivided into stage IIA, IIB, IIIA, IIIB, and IIIC. Factors
determining stages include number and characteristics of axillary lymph nodes, status of other
regional lymph nodes, and involvement of the skin or underlying muscle.

T – Primary
Tumor Size
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: intraductal carcinoma, lobular carcinoma in situ,
or Paget disease of the nipple with node
T1 Tumor 2 cm or less in greatest dimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest
dimension
T3 Tumor more than 5 cm in greatest dimension
T4 Tumor of any size with direct extension to chest wall or skin
N – Regional
Lymph Nodes
Nx Regional lymph nodes cannot be assessed ( e.g., previously removed)
N0 No regional lymph node metastasis
N1 Metastasis to movable ipsilateral axillary lymph node or nodes
N2 Metastasis to ipsilateral axillary lymph node(s) fixed to one another
or to other structures
N3 Metastasis to ipsilateral internal mammary lymp node or nodes
M- Distant
Metastasis
Mx Presence of distant metastasis can not be assessed
M0 No distant metastasis
M1 Distant metastasis (includes metastasis to ipsilateral supraclavicular
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lymph node or nodes

Stage Grouping
Stage 0 Tis N0 M0
Stage 1 T1 N0 M0
Stage IIa T0 N0 M0
T1 N1 M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0
Stage IIIA T0 N2 M0
T1 N2
T2 N2
T3 N1
T3 N2
Stage IIIB T4 Any N M0
Any T N3
Stage IV Any T Any N M1

Management
 Surgical – the goal of surgery is to obtain local control of the disease
Types of Surgical Intervention:
o Breast conservation
 Lumpectomy (tylectomy, tumorectomy) is the removal of circumscribed area
around and including tumor
 Quadrantectomy is the removal of breast quadrant that includes the tumor
 Partial/ segmental mastectomy is the removal of the tumor and 2-3 cm
wedge of normal tissue surrounding it and also a portion of the overlying skin
and underlying fascia that envelops the breast and chest muscle
o Total mastectomy is the removal of the entire breast but pectoralis muscles are left
intact
o Modified radical mastectomy is the removal of the entire breast including pectoralis
minor muscle, some or most of the axillary lymph nodes. This is used to treat
invasive breast cancer. A drain is inserted to remove serous fluid that collects under
skin --- promotes healing and decreases potential infection.
o Classical radical mastectomy (Halsted) is the removal of breast, underlying muscles
of the chest wall, nodules and lymphatic of axilla

 Radiation Therapy – the goal of RT is 1) to decrease the chance of local recurrence on breast
by eradicating residual microscopic cancer cells; 2) serves as an adjunct therapy with
surgery; 3) to shrink large tumor to operable size; 4) to alleviate pain caused by metastasis;
and 5) as primary therapy
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Methods:
o External Beam Radiation starts at about 6 weeks after surgery to allow surgical site
to heal or after completion of chemotherapy. Each treatment lasts for 5 minutes, 5
days/week, for 5-6 weeks then a “boost” dose of RT is given after completion.
o Brachytherapy involves placing a radioactive source within lumpectomy site. It is
administered for 4-5 days.
o Intra operative RT (IORT) is the use of single intense dose of RT that is delivered in
surgical site in OR immediately following lumpectomy
Side Effects
 Mild to moderate erythema, breast edema, fatigue
 Skin breakdown in inflammatory fold or near axilla which occurs few weeks to few
months after treatment is completed
 Pneumonitis, rib fracture, breast fibrosis
Nursing Management
 Use mild soap with minimal rubbing
 Avoid perfumed soap or deodorant
 Use hydrophilic lotion (Aquaphor, Lubriderm) for dryness
 Avoid tight clothes, under wire bras, excessive temperature, UV light
 Minimize sun exposure to the treated area

 Chemotherapy - Adjuvant therapy; for patient with lymph nodes involvement or invasive
tumor >1 cm, regardless of nodal status. It is given for 3-6 months and may include single or
combined antineoplastic drugs :
o Cyclophosphamide, Methotrexate, Fluorouracil (CMF)
o Taxanes (Paclitaxel, docetaxel)
Side Effects: Nausea/vomiting, BM suppression, taste changes, fatigue, weight gain >10 lbs,
permanent or temporary amenorrhea causing sterility

 Hormonal Therapy is indicated for women who have hormone receptor-positive tumors,
which is determined by the results of an estrogen and progesterone receptor assay. About
2/3 of breast cancer are dependent on estrogen for growth and express a nuclear receptor
that binds to estrogen [ESTROGEN RECEPTOR (+)/ER (+)]. HT involves the use of medications
that compete with estrogen by binding to receptor sites. Similarly, tumor that express
progesterone receptor that are called progesterone receptor (+)/ PR (+). Tumors which are
ER (+)/ PR (+) – greatest likelihood to respond to HT with more favorable prognosis than ER
(-)/ PR (-). It is more commonly for used in postmenopausal women.
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 Selective estrogen receptor modulator (SERM)

o Tamoxifen (Nolvadex) - has estrogen antagonistic (estrogen blocking) and
agonistic (estrogen-like) effects on certain tissues.
 Antagonistic – in breast, prevents estrogen from binding to receptor
sites, prevents tumor growth.
 Agonistic – in blood lipid profile and bone mineral density in post
menopausal
- In endometrial tissue and blood coagulation process --- increases incidence
of endometrial cancer and thromboembolic events (DVT, pulmonary
embolism)
 Aromatase inhibitors
o Anastrazole (Arimidex)
o Letrozole (Femara)
o Exemestane (Aromasin)
 Most circulating estrogen in postmenopausal women is derived from
conversion of adrenal androgen androstenedione to estrone and
testosterone = estradiol
 MOA: Blocks the enzyme Aromatase from performing the conversion ---
thus, decreasing the level of circulating estrogen in peripheral tissues
 Antiprogestin
o Mifepristone (RU 486) – blocks progesterone dependent breast cancer as
determined by progesterone assay in excised tissue
 Androgen therapy
o Testolactone (teslac) – for advanced breast cancer in postmenopausal
women

 Targeted Therapy
o Trastuzumab (Herceptin) is a monoclonal antibody that binds especially to HER –
2/neu protein. It regulates cell growth; (+) in small amount in surface of normal
breast cells and most breast cancers. Approximately 25-30% of tumors over express
it and are associated with rapid growth and poor prognosis. Trastuzumab targets
and inactivates the HER – 2/neu protein --- slowing tumor growth. Unlike
chemotherapy, it spares normal cells and has limited adverse reactions including
fever, chills, nausea/vomiting, diarrhea and headache. It may be administered as
single agent or in combination with chemotherapy.
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Nursing Process Approach to Management

The Patient Undergoing Surgery for Breast Cancer
Assessment
 Perform a health history.
 Assess the patient’s reaction to the diagnosis and ability to cope with it.
 Ask about coping skills, support systems, knowledge deficit, and presence of
discomfort.
Diagnosis
Preoperative Nursing Diagnoses
 Deficient knowledge about the planned surgical treatments
 Anxiety related to cancer diagnosis
 Fear related to specific treatments and body image changes
 Risk for ineffective coping (individual or family) related to the diagnosis of breast
cancer and treatment options
 Decisional conflict related to treatment options
Postoperative Nursing Diagnoses
 Pain and discomfort related to surgical procedure
 Disturbed sensory perception related to nerve irritation in affected arm, breast,
or chest wall
 Disturbed body image related to loss or alteration of the breast
 Risk for impaired adjustment related to the diagnosis of cancer and surgical
treatment
 Self-care deficit related to partial immobility of upper extremity on operative
side
 Risk for sexual dysfunction related to loss of body part, change in self-image, and
fear of partner’s responses
 Deficient knowledge: drain management after breast surgery
 Deficient knowledge: arm exercises to regain mobility of affected extremity
 Deficient knowledge: hand and arm care after an ALND
Collaborative Problems/Potential Complications
 Lymphedema
 Hematoma/seroma formation
 Infection
Planning and Goals
 The major goals may include increased knowledge about the disease and its
treatment; reduction of preoperative and postoperative fear, anxiety, and emotional
stress; improvement of decision-making ability; pain management; improvement in
coping abilities; improvement in sexual function; and the absence of complications.
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Preoperative Nursing Interventions

 Providing Education and Preparation about Surgical Treatments
o Review treatment options by reinforcing information provided to the patient and
answer any questions.
o Fully prepare the patient for what to expect before, during, and after surgery.
o Inform patient that she will often have decreased arm and shoulder mobility after
an ALND; demonstrate range-of-motion exercises prior to discharge.
o Reassure patient that appropriate analgesia and comfort measures will be provided.
 Reducing Fear and Anxiety and Improving
Coping Ability
 Help patient cope with the physical and emotional effects of surgery.
 Provide patient with realistic expectations about the healing process and
expected recovery to help alleviate fears (eg, fear of pain, concern about inability
to care for oneself and one’s family).
 Inform patient about available resources at the treatment facility as well as in
the breast cancer community (eg, social workers, psychiatrists, and support
groups); patient may find it helpful to talk to a breast cancer survivor who has
undergone similar treatments.
Promoting Decision-Making Ability
 Help patient and family weigh the risks and benefits of each option.
 Ask patient questions about specific treatment options to help her focus on
choosing an appropriate treatment (eg, How would you feel about losing your
breast? Are you considering breast reconstruction? If you choose to retain your
breast, would you consider undergoing radiation treatments 5 days a week for 5
to 6 weeks?).
 Support whatever decision the patient makes.
Postoperative Nursing Interventions
 Relieving Pain and Discomfort
o Carefully assess patient for pain; individual pain varies.
o Encourage patient to use analgesics.
o Prepare patient for a possible slight increase in pain after the first few days of
surgery; this may occur as patients regain sensation around the surgical site and
become more active.
o Evaluate patients who complain of excruciating pain to rule out any potential
complications such as infection or a hematoma.
o Suggest alternative methods of pain management (eg, taking warm showers,
using distraction methods such as guided imagery).
 Managing Postoperative Sensations
o Reassure patients that postoperative sensations (eg, tenderness, soreness,
numbness, tightness, pulling, and twinges; phantom sensations after a
mastectomy) are a normal part of healing and that these sensations are not
indicative of a problem.
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 Promoting Positive Body Image

o Assess the patient’s readiness to see the incision for the first time and provide
gentle encouragement; ideally, the patient will be with the nurse or another
health care provider for support.
o Maintain the patient’s privacy.
o Ask the patient what she perceives, acknowledge her feelings, and allow her to
express her emotions; reassure patient that her feelings are normal.
o If desired, provide patient who has not had immediate reconstruction with a
temporary breast form to place in her bra.
 Promoting Positive Adjustment and Coping
o Provide ongoing assessment of how the patient is coping with her diagnosis and
treatment.
o Assist patient in identifying and mobilizing her support systems; the patient’s
spouse or partner may also need guidance, support, and education; provide
resources (eg, Reach to Recovery program of the American Cancer Society [ACS],
advocacy groups, or a spiritual advisor).
o Encourage the patient to discuss issues and concerns with other patients who
have had breast cancer.
o Provide patient with information about the plan of care after treatment.
o If patient displays ineffective coping, consultation with a mental health
practitioner may be indicated.
 Improving Sexual Function
o Encourage the patient to discuss how she feels about herself and about possible
reasons for a decrease in libido (eg, fatigue, anxiety, self-consciousness).
o Suggest that the patient vary the time of day for sexual activity (when the
patient is less tired), assume positions that are more comfortable, and express
affection using alternative measures (eg, hugging, kissing, manual stimulation).
o If sexual issues cannot be resolved, a referral for counseling (eg, psychologist,
psychiatrist, psychiatric clinical nurse specialist, social worker, sex therapist) may
be helpful.
 Monitoring and Managing Potential Complications
o Promote collateral or auxiliary lymph drainage by encouraging movement and
exercise (eg, hand pumps) through postoperative education.
o Elevate arm above the heart.
o Obtain referral for patient to therapist for compression sleeve and/or glove,
exercises, manual lymph drainage, and a discussion of ways to modify daily
activities.
o Teach patient proper incision care and signs and symptoms of infection and
when to contact surgeon or nurse.
o Monitor surgical site for gross swelling or drainage output, and notify surgeon
promptly.
o If ordered, apply compression wrap to the incision.
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Home- and Community-Based Care

 Teaching Patients Self-Care
o Assess patient’s readiness to assume self-care. Focus on teaching incision care, signs
to report (infection, hematoma/seroma, arm swelling), pain management, arm
exercises, hand and arm care, drainage management, and activity restriction.
Include family member.
o Provide follow-up with telephone calls to discuss concerns about incision, pain
management, and patient and family adjustment.
 Continuing Care
o Reinforce earlier teaching as needed.
o Encourage patient to call with any questions or concerns.
o Refer patient for home care as indicated or desired by patient.
o Remind patient of the importance of participating in routine health screening.
o Reinforce need for follow-up visits to the physician (every 3 to 6 months for the first
several years).
Evaluation
 Expected Patient Outcomes
o Exhibits knowledge about diagnosis and treatment options
o Verbalizes willingness to deal with anxiety and fears
o Demonstrates ability to cope with diagnosis and treatment
o Makes decisions regarding treatment options in a timely manner
o Reports pain has decreased and states pain management strategies
o Identifies postoperative sensations and recognizes that they are a normal part of
healing
o Exhibits clean, dry, and intact surgical incision without signs of inflammation or
infection
o Lists signs and symptoms of infection to be reported
o Verbalizes feelings regarding change in body image
 Participates actively in self-care activities
 Demonstrates knowledge of post-discharge recommendations and restrictions
 Experiences no complications
MODULE IN BREAST CANCER – MMSU CHS 17

WRAP-UP ACTIVITY
Instruction: Choose the letter that best answers the question.

1. Which of the following is NOT a risk factor for breast cancer?

A. Family history of ovarian cancer
B. A weight of 55 kg and a height of 170 cm
C. Use of contraceptive pills for 8 years
D. Menarche at 9 years old
2. The patient who is high risk for developing breast cancer asks you what can she do to
prevent breast cancer, which statement made by the nurse is correct?
A. You should avoid conceiving a child before the age of 30
B. Breastfeeding increases your risk of developing breast cancer
C. Prophylactic surgeries are not necessary at this stage
D. Regular exercise has shown protective effect against breast cancer
3. Which among the types of breast cancer manifest as orange discoloration of the breast?
A. Infiltrating ductal carcinoma
B. Medullary carcinoma
C. Inflammatory carcinoma
D. Mucinous carcinoma
4. For patients who are high risk in developing breast cancer, which of the following drugs
are usually given as chemoprevention?
A. Methotrexate
B. Iodine 131
C. Cobalt
D. Tamoxifen
5. As a member of the health care team, it is the responsibility of the nurse to identify high
risk clients. Which of the following clients should the nurse consider as high risk?
A. Menopause at 50 years old
B. Menarche at 13 years old
C. 65 years old female nulliparous
D. 30 years old female G5P4
6. The client who is scheduled for modified radical mastectomy asks you how the
procedure will be done, your best response is:
A. They will remove the breast tissue including pectoralis muscle
B. They will remove the breast tissue including 4-6 surrounding lymph nodes
C. They will remove breast tissue, nipple-areola complex and perform axillary
lymph node dissection
D. They will remove both breast including axillary lymph nodes
MODULE IN BREAST CANCER – MMSU CHS 18

Continuation…
7. The client is to receive Cyclophosphamide for chemotherapy, which of the following
medications are given to prevent side-effects?
A. Leucovorin Calcium
B. Amifostine
C. Nitroomidazoles
D. MESNA
8. This drug inhibits the conversion of estradiol to estrogen in post-menopausal thereby
decreasing circulating estrogen in the body and minimizing breast cancer risk.
A. Transtuzumab
B. Tamoxifen
C. 5-Fluorouracil
D. Anastrazole
9. One of the general side-effects of chemotherapy is alopecia or loss of hair, as the nurse
in charge, when should you advise the client to buy her wig?
A. When there is minimal loss of hair
B. Before she starts losing her hair
C. Until all of her hair falls off
D. When she is half bald 
10. The patient is for modified radical mastectomy, right breast. Which of the following is an
appropriate health teaching?
A. Use protective gloves when gardening
B. Avoid doing the laundry
C. Use arm sling for at least 4 weeks
D. Limit movement on your right hand
11. Which of the following manifestations would suggest metastasis of breast cancer?
A. Significant weight loss
B. Severe anemia
C. Difficulty of breathing
D. Orange discoloration of breast
12. Which of the following is an appropriate management for a non-invasive ductal
carcinoma?
A. Total mastectomy
B. Breast conservation treatment
C. Modified radical mastectomy
D. None of the above
MODULE IN BREAST CANCER – MMSU CHS 19

Continutation…
13. The patient worries that her husband won’t find her attractive after her mastectomy,
which of the following is an appropriate nursing diagnosis?
A. Decisional conflict related to lack of knowledge about treatment options and
their effects
B. Fear and anxiety related to diagnosis of breast cancer
C. Disturbed body image related to anticipated physical and emotional effects of
treatment modalities
D. Risk for infection related to immunosuppression
14. Which of the following is NOT included in the CAF chemotherapy protocol for high risk
breast cancer patients?
A. Cyclophosphamide
B. Adriamycin
C. Cisplatin
D. Fluorouracil
15. The patient asks you why should the chemotherapy be given in sessions, your best
response is:
A. It will minimize the occurrence of nadir
B. It will allow your normal cells to repair
C. It will maintain therapeutic serum level of the drugs
D. It will prevent the occurrence of side-effects

POST-ASSESSMENT
(A post-assessment quiz will be administered via MVLE.)

REFERENCES
Borromeo, A.R. Lewis, S.L. Dirksen, S. (2014). Lewis’s Medical Surgical Nursing: Assessment and
Management of Clinical Problems Philippine Edition (8th ed) Singapore: Elsevier
(Singapore) Pte Ltd
Hinkle, J.L. Cheever, K.H. (2014). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
(13th ed). Philadelphia: Lippincot Williams & Wilkins

Handbook for Brunner and Suddarth's textbook of medical-surgical nursing. (2010). Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins.