CASE STUDY (Cellular Aberration)

Breast Cancer

1. Discuss the various hispathologic types of breast cancer.

Phyllodes tumors
 Account for less than 1% of all breast cancers. Even though the tumor
may be benign, it is still considered a type of breast cancer, because it
has the potential to become malignant.
 Also Known As:
phylloides tumor, PT, cystosarcoma phyllodes, cystosarcoma
phylloides and sometimes called "giant fibroadenomas"
 Surgery to remove a Phyllodes tumor is the standard treatment. This
type of tumor does not respond well to radiation, chemotherapy or
hormonal therapies.
 Prognosis, or outlook after treatment, is very good for a benign
Phyllodes tumor. There is a low chance of recurrence for a Phyllodes
tumor, if 45 or older. For patients with a diagnosis of borderline or
malignant tumors, prognosis will vary

Paget disease of the nipple

 Paget disease of the nipple was named after Sir James Paget, a
scientist who noted an association between changes in the
appearance of the nipple and underlying breast cancer
 an uncommon type of cancer that forms in or around the nipple
 More than 95 percent of people with Paget disease of the nipple also
have underlying breast cancer; however, Paget disease of the nipple
accounts for less than 5 percent of all breast cancers
 Most patients diagnosed with Paget disease of the nipple are over age
50, but rare cases have been diagnosed in patients in their 20s. The
average age at diagnosis is 62 for women and 69 for men. The
disease is rare among both women and men.
 One theory proposes that cancer cells, called Paget cells, break off
from a tumor inside the breast and move through the milk ducts to the
surface of the nipple, resulting in Paget disease of the nipple
 The other theory suggests that skin cells of the nipple spontaneously
become Paget cells. This theory is supported by the rare cases of
Paget disease in which there is no underlying breast cancer, and the
cases in which the underlying breast cancer is found to be a separate
tumor from the Paget disease
 Symptoms of early Paget disease of the nipple include redness and
mild scaling and flaking of the nipple skin. Early symptoms may cause
only mild irritation and may not be enough to prompt a visit to the
doctor. Improvement in the skin can occur spontaneously, but this
 should not be taken as a sign that the disease has disappeared. More
advanced disease may show more serious destruction of the skin. At
this stage, the symptoms may include tingling, itching, increased
sensitivity, burning, and pain. There may also be discharge from the
nipple, and the nipple can appear flattened against the breast.

Male breast cancer

 It happens most often to men between the ages of 60 and 70. Risk
factors for male breast cancer include exposure to radiation, a family
history of breast cancer and having high estrogen levels
 Symptoms of male breast cancer include lumps, changes to the nipple
or breast skin, or discharge of fluid from the nipple. Treatment for male
breast cancer is usually a mastectomy, which is surgery to remove the
breast. Other treatments include radiation, chemotherapy and/or
hormone therapy

Ductal carcinoma in situ (DCIS)

 The most common type of non-invasive breast cancer.
 Ductal means that the cancer starts inside the milk ducts, carcinoma
refers to any cancer that begins in the skin or other tissues (including
breast tissue) that cover or line the internal organs, and in situ means
"in its original place." DCIS is called "non-invasive" because it hasn’t
spread beyond the milk duct into any normal surrounding breast tissue.
DCIS isn’t life-threatening, but having DCIS can increase the risk of
developing an invasive breast cancer later on.
 Most recurrences happen within the 5 to 10 years after initial
diagnosis. The chances of a recurrence are under 30%.

 DCIS generally has no signs or symptoms. A small number of people

may have a lump in the breast or some discharge coming out of the
nipple. According to the National Cancer Institute, about 80% of DCIS
cases are found by mammography.

Lobular carcinoma in situ (LCIS)

 LCIS is an area (or areas) of abnormal cell growth that increases a
person’s risk of developing invasive breast cancer later on in life.
 Lobular means that the abnormal cells start growing in the lobules, the
milk-producing glands at the end of breast ducts. Carcinoma refers to
any cancer that begins in the skin or other tissues that cover internal
organs — such as breast tissue. In situ or “in its original place” means
that the abnormal growth remains inside the lobule and does not
spread to surrounding tissues. People diagnosed with LCIS tend to
have more than one lobule affected
  Despite the fact that its name includes the term “carcinoma,” LCIS is
not a true breast cancer. Rather, LCIS is an indication that a person is
at higher-than-average risk for getting breast cancer at some point in
the future. For this reason, some experts prefer the term “lobular
neoplasia” instead of “lobular carcinoma.” A neoplasia is a collection of
abnormal cells.

 LCIS is usually diagnosed before menopause, most often between the

ages of 40 and 50. Less than 10% of women diagnosed with LCIS
have already gone through menopause. LCIS is extremely uncommon
in men

 LCIS usually does not cause any signs or symptoms, such as a lump
or other visible changes to the breast. LCIS may not always show up
on a screening mammogram. One reason is that LCIS often lacks
microcalcifications, the tiny specks of calcium that form within other
types of breast cancer cells. On a mammogram, microcalcifications
show up as white specks. It’s believed that many cases of LCIS simply
go undiagnosed, and they may never cause any problems.

Inflammatory breast cancer (IBC)

 IBC is a rare and aggressive form of breast cancer. According to the
National Cancer Institute, about 1-5% of all breast cancer cases in the
United States are inflammatory breast cancers
 Inflammatory breast cancer usually starts with the reddening and
swelling of the breast instead of a distinct lump. IBC tends to grow and
spread quickly, with symptoms worsening within days or even hours

 The average age at diagnosis for inflammatory breast cancer in the

United States is 57 for white women and 52 for African American
women. These ages are about 5 years younger than the average ages
at diagnosis for other forms of breast cancer. According to the
American Cancer Society, inflammatory breast cancer is more
common in African American women. A 2008 study found that being
overweight makes a person more likely to develop IBC. Like other
forms of breast cancer, IBC can also affect men

 Although most breast cancers begin as lumps or tumors, inflammatory

breast cancer usually starts with a feeling of thickness or heaviness in
the breast. You also may develop red, inflamed skin on the breast. IBC
tends to grow in the form of layers or “sheets” of tissue, which doctors
sometimes call “nests.”

The breasts swell and become inflamed because the cancer cells clog
the vessels that carry lymph. Lymph is a clear, watery fluid that
 transports white blood cells and removes bacteria and proteins from
the tissues.

Common symptoms of IBC include:

 Redness of the breast: Redness involving part or the entire breast is

a hallmark of inflammatory breast cancer. Sometimes the redness
comes and goes.
 Swelling of the breast: Part of or all of the breast may be swollen,
enlarged, and hard.
 Warmth: The breast may feel warm.
 Orange-peel appearance: Your breast may swell and start to look like
the peel of a navel orange (this is called “peau d’orange”).
 Other skin changes: The skin of the breast might look pink or bruised,
or you may have what looks like ridges, welts, or hives on your breast.
 Swelling of lymph nodes: The lymph nodes under your arm or above
the collarbone may be swollen.
 Flattening or inversion of the nipple: The nipple may go flat or turn
inward.
 Aching or burning: Your breast may ache or feel tender

Invasive lobular carcinoma (ILC)

 Sometimes called infiltrating lobular carcinoma, is the second most
common type of breast cancer after invasive ductal carcinoma (cancer
that begins in the milk-carrying ducts and spreads beyond it).
 According to the American Cancer Society, more than 180,000 women
in the United States find out they have invasive breast cancer each
year. About 10% of all invasive breast cancers are invasive lobular
carcinomas. (About 80% are invasive ductal carcinomas.)

 Invasive means that the cancer has “invaded” or spread to the

surrounding breast tissues. Lobular means that the cancer began in
the milk-producing lobules, which empty out into the ducts that carry
milk to the nipple. Carcinoma refers to any cancer that begins in the
skin or other tissues that cover internal organs — such as breast
tissue. All together, “invasive lobular carcinoma” refers to cancer that
has broken through the wall of the lobule and begun to invade the
tissues of the breast. Over time, invasive lobular carcinoma can spread
to the lymph nodes and possibly to other areas of the body.

 Although invasive lobular carcinoma can affect women at any age, it is

more common as women grow older. According to the American
Cancer Society, about two-thirds of women are 55 or older when they
are diagnosed with an invasive breast cancer
  There are different subtypes of invasive lobular carcinoma (ILC) that
are based on how the cancer cells look under the microscope. In its
most typical or “classic” form, ILC is made up of small cancer cells that
invade the stroma.

If the cancer cells grow in a different pattern than classic ILC — that is,
not in a single-file formation — you may hear your doctor refer to one
of these subtypes of invasive lobular carcinoma:

 Solid: The cells grow in large sheets with little stroma in between
them.
 Alveolar: The cancer cells grow in groups of 20 or more.
 Tubulolobular: This subtype has some of the “single-file” growth
pattern of classic invasive lobular carcinoma, but some of the cells
also form small tubules (tube-like structures).

If the cancer cells themselves look different from classic invasive

lobular carcinoma cells, you may hear your doctor refer to one of these
subtypes:

 Pleomorphic: The cancer cells are larger than they are in classic
ILC, and the cells’ nuclei look different from each other.
 Signet ring cell: In this type of ILC, the tumor contains some cells
that are filled with mucus that pushes the nucleus (the core of the
cell that contains genetic material) to one side. Because of their
appearance, these cells have come to be known as signet ring
cells.

Invasive ductal carcinoma (IDC)

 Sometimes called infiltrating ductal carcinoma, is the most common
type of breast cancer. About 80% of all breast cancers are invasive
ductal carcinomas.
 Invasive means that the cancer has “invaded” or spread to the
surrounding breast tissues. Ductal means that the cancer began in the
milk ducts, which are the “pipes” that carry milk from the milk-
producing lobules to the nipple. Carcinoma refers to any cancer that
begins in the skin or other tissues that cover internal organs — such as
breast tissue. All together, “invasive ductal carcinoma” refers to cancer
that has broken through the wall of the milk duct and begun to invade
the tissues of the breast. Over time, invasive ductal carcinoma can
spread to the lymph nodes and possibly to other areas of the body.
 Although invasive ductal carcinoma can affect women at any age, it is
more common as women grow older. According to the American
Cancer Society, about two-thirds of women are 55 or older when they
are diagnosed with an invasive breast cancer. Invasive ductal
carcinoma also affects men.
Tubular carcinoma of the breast
 Is a rare subtype of invasive ductal carcinoma (cancer that begins
inside the milk duct and spreads beyond it). Tubular carcinoma
accounts for about 1-2% of all breast cancer cases. In this type of
cancer, the tumor is usually small and made up of tube-shaped cells
that are low grade. “Low grade” means they look somewhat similar to
normal, healthy cells and tend to grow slowly.
 Tubular carcinoma of the breast is less likely to spread outside the
breast than other types of breast cancer. It’s also easier to treat.
 Studies have found that the average age of diagnosis for tubular
carcinoma ranges from the mid-40s to late 60s.

Medullary carcinoma
 Medullary carcinoma of the breast is a rare subtype of invasive ductal
carcinoma (cancer that begins in the milk duct and spreads beyond it),
accounting for about 3-5% of all cases of breast cancer. It is called
“medullary” carcinoma because the tumor is a soft, fleshy mass that
resembles a part of the brain called the medulla.
 can occur at any age, but it usually affects women in their late 40s and
early 50s
 more common in women who have a BRCA1 mutation
 Studies have shown that medullary carcinoma is also more common in
Japan than in the United States.
 Medullary carcinoma cells are usually high-grade in their appearance
and low-grade in their behavior. In other words, they look like
aggressive, highly abnormal cancer cells, but they don’t act like them.
Medullary carcinoma doesn’t grow quickly and usually doesn’t spread
outside the breast to the lymph nodes. For this reason, it’s typically
easier to treat than other types of breast cancer.

Mucinous carcinoma of the breast

 Sometimes called colloid carcinoma — is a rare form of invasive ductal
carcinoma (cancer that begins in the milk duct and spreads beyond it).
 Accounts for about 2-3% of all breast cancer cases. In this type of
cancer, the tumor is formed from abnormal cells that “float” in pools of
mucin, a key ingredient in the slimy, slippery substance known as
mucus.
 Normally, mucus lines most of the inner surface of our bodies, such as
our digestive tract, lungs, liver, and other vital organs. Many types of
cancer cells — including most breast cancer cells — produce some
mucus. In mucinous carcinoma, however, the mucus becomes a main
part of the tumor and surrounds the breast cancer cells.
  Tends to affect women after they’ve gone through menopause. Some
studies have found that the usual age at diagnosis is 60 or older.
 Less likely to spread to the lymph nodes than other types of breast
cancer. It’s also easier to treat

Invasive papillary carcinomas

 Rare, accounting for less than 1-2% of invasive breast cancers. In
most cases, these types of tumors are diagnosed in older women who
have already been through menopause.
 usually has a well-defined border and is made up of small, finger-like
projections
 Often it is Grade 2, or moderate grade, on a scale of 1 to 3 — with
Grade 1 describing cancer cells that look and behave somewhat like
normal, healthy breast cells, and Grade 3 describing very abnormal,
fast-growing cancer cells. In most cases of invasive papillary
carcinoma, ductal carcinoma in situ (DCIS) is also present

Invasive cribriform carcinoma

 The cancer cells invade the stroma (connective tissues of the breast)
in nestlike formations between the ducts and lobules.
 Within the tumor, there are distinctive holes in between the cancer
cells, making it look something like Swiss cheese.
 Usually low grade, meaning that its cells look and behave somewhat
like normal, healthy breast cells. In about 5-6% of invasive breast
cancers, some portion of the tumor can be considered cribriform.
Usually, some ductal carcinoma in situ (DCIS) of the cribriform type is
present as well.

2. Discuss etiologies for breast cancer.

1. Lesions to DNA such as genetic mutations. Mutations that can lead to

breast cancer have been experimentally linked to estrogen exposure.
2. exposure to carcinogens
3. The failure of the cells to die or what is called apoptosis. The cell suicides
rather than risk becoming deranged and potentially dangerous.
4. Failure of immune defenses

Unfortunately, the immune defenses are not always effective. The immune
system may be unable to recognize cancer cells as foreign or to mount an
immune response for several reasons.

An immature, old, or weak immune system may contribute to this. People who
are malnourished or chronically ill may also be immunocompromised. The
tumor burden (number of cancer cells) may be too small to stimulate an
immune response. Alternatively, the tumor burden may be so great as to
overwhelm the immune system.

Some cancer cells may escape detection because they resemble normal
cells. Other cancer cells may produce substances that shield them from
recognition. Cancer cells may also escape detection by becoming coated with
fibrin. Tumor invasion of the bone marrow can result in decreased production
of the lymphocytes needed to destroy the tumor mass.

5. Abnormal growth factor signaling in the interaction between stromal cells

and epithelial cells can facilitate malignant cell growth.
6. Inherited defects in DNA repair genes, such as ''BRCA1'', ''BRCA2'' and
''TP53''. People in less-developed countries report lower incidence rates
than in developed countries.

Predisposing Factors

 Age and Ethnicity: risk increases with age, although the rate of increase
slows after menopause. Women above 50 years old have higher risk of
breast cancer incidence. Although there early detection of breast cancer
are common 30 and above.
There is a high incidence of breast cancer found in white North America
than in Asia and Africa. Although a study was also found that African
American women are less likely to be cured than their non-African women
counterparts, but they also survive for a shorter time until death from
breast cancer. Even when matched for tumor stage, they are more at risk
for micrometastatic disease and early death. This may be related to ability
to access for medical management. Still, the high incidence rate is with
white women.

However, it was studied before that Asia has the lower risk for breast
cancer. But then according to the DOH of the Philippines, the Philippines
have poor survival rate of breast cancer now in the year 2010 and have
high risk of incidence compared to other countries.

 Gender—studies have found that women have more incidence of breast

cancer. Men are also affected but rarely.
 Menstrual history—early menarche (first menstruation) and late
menopause (cessation of menstruation) lead to an increased risk of breast
cancer of 30% to 50%. The woman who experiences natural menopause
before age 45 years has a risk for breast cancer that is half that of the
woman whose menopause occurs after age 55 years.
 Birthing history—both nulliparity (no births) and age 30 years at first live
birth are associated with a nearly doubled risk of subsequent breast
cancer.
 Health history—nonproliferative lesions of breast (such as cysts, duct
ectasia, mild hyperplasia, and fibdroadenoma) do not increase the risk of
breast cancer; however, cellular atypia or atypical hyperplasia (a
proliferative disease) is an example of a histologic change associated with
a higher risk. Nearly 40% of women with a family history of breast cancer
and atypical hyperplasia subsequently have breast cancer.
 Family history—breast cancer due to the inheritance of a specific germline
mutation form either maternal or paternal relative is rare. But depending
on the familial context, the lifetime risk of breast cancer associated with
carrying a mutation ranges from 50% to 80%. Families with several
affected first-degree relatives and clients with early-onset disease have
been found to harbor mutations at a higher frequency. Women who have
the BRCA2 mutation tend to have early-onset (before age 50) breast
cancer. Identification of the BRCA1 gene makes it possible to identify
women who have a 90% to 95% lifetime, likelihood of developing breast
cancer (with a 70% risk of breast cancer by age 60).
 Radiation therapy—an increased incidence of breast cancer has been
reported in women who received mantle radiation for the treatment of
Hodgkin’s disease, particularly if they were younger than 20 years of age.
The disease in this group typically presents more aggressively, with a high
rate of nodal involvements and bilaterality. It is for this reason that all
persons who receive mantle radiation for Hodgkin’s disease, especially
those treated prior to age 20, receive a regular mammography follow-up
examination in order to detect these lesions early.

Precipitating Factors

 Smoking—most studies have found no link between cigarette smoking

and breast cancer. Some studies have suggested smoking increases the
risk of breast cancer, but this remains controversial.
 Dietary factor—alcohol intake is the best established dietary risk factor for
breast cancer in epidemiologic studies. The positive correlation of alcohol
intake with breast cancer risk has been established, and it appears that
moderate alcohol intake (2 drinks per day) increases the risk of breast
cancer by altering estrogen metabolism.
 Hormonal therapy—the use of hormonal replacement therapy (HRT) has
also demonstrated a small but significant increase in risk for breast cancer
in women who used it for more than 10 years.

There is no convincing evidence that oral contraceptives use affects the

risk of breast cancer. The question is difficult to address because the oral
contraceptive in use today are vastly different (in that dosages are much
lower) from those used 15 and 20 years ago.
  DES (diethylstilbestrol)―the drug DES was given to some pregnant
women in the United States between 1940 and 1971 to prevent
miscarriage. Women who took DES during pregnancy may have a slightly
increased risk of breast cancer. The effects of DES exposure on breast
cancer risk in their daughters are unclear and still under study.
 Body weight—studies have found that the chance of getting breast cancer
after menopause is higher in women who are overweight or obese.
 Physical activity level—women who are physically inactive throughout life
may have an increased risk of breast cancer. Being active may help
reduce risk by preventing weight gain and obesity.

3. Discuss cultural and ethnic consideration for breast cancer

There is a high incidence of breast cancer found in white North America

than in Asia and Africa. Although a study was also found that African
American women are less likely to be cured than their non-African women
counterparts, but they also survive for a shorter time until death from breast
cancer. Even when matched for tumor stage, they are more at risk for
micrometastatic disease and early death. This may be related to ability to
access for medical management. Still, the high incidence rate is with white
women.

However, it was studied before that Asia has the lower risk for breast
cancer. But then according to the DOH of the Philippines, the Philippines
have poor survival rate of breast cancer now in the year 2010 and have high
risk of incidence compared to other countries.

Breast cancer culture, or pink ribbon culture, is the set of activities,

attitudes, and values that surround and shape breast cancer in public. The
dominant values are selflessness, cheerfulness, unity, and optimism.
Appearing to have suffered bravely is the passport into the culture.

The woman with breast cancer is given a cultural template that constrains
her emotional and social responses into a socially acceptable discourse: She
is to use the emotional trauma of being diagnosed with breast cancer and the
suffering of extended treatment to transform herself into a stronger, happier
and more sensitive person who is grateful for the opportunity to become a
better person. Breast cancer thereby becomes a rite of passage rather than a
disease. To fit into this mold, the woman with breast cancer needs to
normalize and feminize her appearance, and minimize the disruption that her
health issues cause anyone else. Anger, sadness and negativity must be
silenced.
 As with most cultural models, people who conform to the model are given
social status, in this case as cancer survivors. Women who reject the model
are shunned, punished and shamed.

The culture is criticized for treating adult women like little girls, as
evidenced by "baby" toys such as pink teddy bears given to adult women.

The primary purposes or goals of breast cancer culture are to maintain

breast cancer's dominance as the preëminent women's health issue, to
promote the appearance that society is "doing something" effective about
breast cancer, and to sustain and expand the social, political, and financial
power of breast cancer activists.

Breast cancer culture, or pink ribbon culture, is the set of activities,

attitudes, and values that surround and shape breast cancer in public. The
dominant values are selflessness, cheerfulness, unity, and optimism.
Appearing to have suffered bravely is the passport into the culture.

The woman with breast cancer is given a cultural template that constrains
her emotional and social responses into a socially acceptable discourse: She
is to use the emotional trauma of being diagnosed with breast cancer and the
suffering of extended treatment to transform herself into a stronger, happier
and more sensitive person who is grateful for the opportunity to become a
better person. Breast cancer thereby becomes a rite of passage rather than a
disease. To fit into this mold, the woman with breast cancer needs to
normalize and feminize her appearance, and minimize the disruption that her
health issues cause anyone else. Anger, sadness and negativity must be
silenced.

As with most cultural models, people who conform to the model are given
social status, in this case as cancer survivors. Women who reject the model
are shunned, punished and shamed.

The culture is criticized for treating adult women like little girls, as
evidenced by "baby" toys such as pink teddy bears given to adult women.

The primary purposes or goals of breast cancer culture are to maintain

breast cancer's dominance as the preëminent women's health issue, to
promote the appearance that society is "doing something" effective about
breast cancer, and to sustain and expand the social, political, and financial
power of breast cancer activists.

4. Discuss clinical manifestations for breast cancer

 Initially, breast cancer may not cause any symptoms. A lump may be too
small for you to feel or to cause any unusual changes you can notice on your
own. Often, an abnormal area turns up on a screening mammogram (x-ray of
the breast), which leads to further testing.

In some cases, however, the first sign of breast cancer is a new lump or
mass in the breast that you or your doctor can feel. A lump that is painless,
hard, and has uneven edges is more likely to be cancer. But sometimes
cancers can be tender, soft, and rounded. So it's important to have anything
unusual checked by your doctor.

According to the American Cancer Society, any of the following unusual

changes in the breast can be a symptom of breast cancer:

 swelling of all or part of the breast

 skin irritation or dimpling
 breast pain
 nipple pain or the nipple turning inward
 redness, scaliness, or thickening of the nipple or breast skin
 a nipple discharge other than breast milk
 a lump in the underarm area

These changes also can be signs of less serious conditions that are not
cancerous, such as an infection or a cyst. It’s important to get any breast
changes checked out promptly by a doctor.

5. Discuss the diagnostic studies used to confirm breast cancer.

Laboratories

 Blood tests for cancer/tumor markers to detect cancer activity in the body.
Proteins and circulating tumor cells are two types of markers that can be
measured. A cancer tumor often produces a specific protein in the blood that
serves as a marker for the cancer. Circulating tumor cells are cells that break
off from the cancer and move into the blood stream. Protein markers and
circulating tumor cells can be measured with simple blood tests.

Blood marker tests may be done before treatment, to help diagnose the
breast cancer and determine whether it's moved to other parts of the body;
during treatment, to assess whether the cancer is responding; and after
treatment, to see if the cancer has come back (recurrence).

Blood Test for cancer/tumor markers include:

1. Cancer Antigen 15.3: used to find breast and ovarian cancers

2. TRU-QUANT and CA 27.29: may mean that breast cancer is present
3. Cancer Antigen 125: may signal ovarian cancer, ovarian cancer
recurrence, and breast cancer recurrence
4. CEA (carcinoembryonic antigen): a marker for the presence of colon,
lung, and liver cancers. This marker may be used to determine if the
breast cancer has traveled to other areas of the body.
5. Circulating tumor cells: cells that break off from the cancer and move
into the blood stream. High circulating tumor cell counts may indicate that
the cancer is growing.

Some doctors use marker test results as early indicators of breast cancer
progression (the cancer getting worse) or recurrence. They may use this
information to make decisions about when to change therapies — if current
treatment does not appear to be working — or to start treatment for
recurrence. If you have an elevated marker, your doctor may check that
marker periodically to assess your response to chemotherapy or other
treatments.

While breast cancer blood marker tests are promising, they're not
absolutely conclusive. When a breast cancer blood marker test comes
back negative, it doesn't necessarily mean you're free and clear of breast
cancer. And a positive result doesn't always mean that the cancer is growing.
These tests may help with diagnosis, but using cancer marker tests to find
metastatic breast cancer hasn't helped improve survival yet.

 BRCA Test—a human tumor suppressor gene. This test detects common
mutations in the genes, mutations that are known to increase the risk of
breast and ovarian cancer development specifically BRCA1 and BRCA 2
mutations.
 Estrogen and progesterone receptor status—A score of Estrogen
Receptor positive (ER+) means that estrogen is causing tumor to grow,
and that the cancer should respond well to hormone suppression
treatments. If the score is Estrogen Receptor negative (ER-), then tumor is
not driven by estrogen, and results will need to be evaluated along with
other tests. This is the same with progesterone.
 HER-2 gene test – tests for the human epidermal growth factor-2 (HER-2)
gene that indicates how fast a tumor may grow. Oncogenes are bits of
genetic information inside the body's cells that usually work to protect us
from cancer, by keeping cell growth in check.

Oncogene overexpression happens when an oncogene (such as the one

called HER2/neu) malfunctions and "overexpresses" itself (like screaming
instead of talking) by making excess normal or abnormal proteins and
receptors. This can lead to cancer. Cancers that result from overexpressed
oncogenes such as HER2/neu tend to be more nasty or belligerent and are
more likely to recur than other cancers. They also may respond to different
types of treatment than other breast cancers.

Knowing that a cancer is derived from oncogene overexpression may help

your doctor choose a more effective form of treatment for you. For example,
overexpression of the HER2/neu protein or receptor may:

 predict a good response to Herceptin (trastuzumab), a specialized

medicine used to combat the HER2/neu protein
 predict a poor response to CMF chemotherapy and tamoxifen

 indicate a need for a higher dose of CAF chemotherapy to get the best
response

Procedures

 Physical examination of the breasts – the doctor may be able to feel a

small lump in the breast during a physical examination, although a
noticeable lump is rare with DCIS. In cases when DCIS cannot be felt
during a physical exam, it can often be detected using mammography.

 Mammography – It is a specific type of imaging that uses a low-dose x-ray

system to examine breasts. A mammography exam, called a
mammogram, is used to aid in the early detection and diagnosis of breast
diseases in women. Also used as a screening tool to detect early breast
cancer in women experiencing no symptoms and to detect and diagnose
breast disease in women experiencing symptoms such as a lump, pain or
nipple discharge. American Cancer Society (ACS) and the National
Cancer Institute recommend screening mammography every year for
women, beginning at age 40.

An x-ray (radiograph) is a noninvasive medical test that helps

physicians diagnose and treat medical conditions. Imaging with x-rays
involves exposing a part of the body to a small dose of ionizing radiation to
produce pictures of the inside of the body. X-rays are the oldest and most
frequently used form of medical imaging.

Two recent advances in mammography include digital

mammography and computer-aided detection.

Digital mammography, also called full-field digital mammography

(FFDM), is a mammography system in which the x-ray film is replaced by
solid-state detectors that convert x-rays into electrical signals. These
detectors are similar to those found in digital cameras. The electrical
signals are used to produce images of the breast that can be seen on a
 computer screen or printed on special film similar to conventional
mammograms. From the patient's point of view, having a digital
mammogram is essentially the same as having a conventional film screen
mammogram.

Computer-aided detection (CAD) systems use a digitized

mammographic image that can be obtained from either a conventional film
mammogram or a digitally acquired mammogram. The computer software
then searches for abnormal areas of density mass, or calcification that
may indicate the presence of cancer. The CAD system highlights these
areas on the images, alerting the radiologist to the need for further
analysis.

Mammogram should not be scheduled before menstruation

because the breast the breast is usually tender at that time. The best time
for a mammogram is one week after menstruation. The x-ray technologist
should be informed of any possibility of pregnancy.

The ACS also recommends:

 Not to wear talcum powder or lotion under the arms or on the

breasts on the day of the exam. These can appear on the
mammogram as calcium spots.
 Describe any breast symptoms or problems to the technologist
performing the exam.
 If possible, obtain prior mammograms and make them available to
the radiologist at the time of the current exam.
 Fine needle aspiration—Fine needle aspiration (FNA) is a percutaneous
("through the skin") procedure that uses a fine gauge needle (22 or 25
gauge) and a syringe to sample fluid from a breast cyst or remove clusters
of cells from a solid mass. With FNA, the cellular material taken from the
breast is usually sent to the pathology laboratory for analysis. The needle
used during FNA is smaller than a needle that is normally used to draw
blood. If the radiologist or surgeon just drains fluid from a cyst and does
not send the sample to the pathology laboratory for analysis, the
procedure is simply called cyst aspiration.
 Open biopsy—surgical biopsy requires a 1.5 to 2.0 inch incision
(approximately 3.8 centimeters to 5.1 centimeters) in the breast. Surgical
biopsy does not require general anesthesia. Instead, the patient will be
given a local anesthetic (to the breast only), or a combination of
intravenous (through the vein) sedation with local anesthetic.

During an excisional surgical biopsy, the surgeon will attempt to

completely remove the area of concern (lesion), often along with a
surrounding margin of normal breast tissue. If the lesion is palpable (can
 be felt by examination), excisional biopsy is generally a brief,
straightforward surgery performed in an operating room.

An incisional surgical biopsy is similar to an excisional biopsy

except that the surgeon only removes part of the breast lesion. Incisional
breast biopsy is usually only performed on large lesions.

 Breast ultrasound – this may done after mammogram to take an even

closer look of the breast. In particular, this is done for patients with dense
breast to detect the slightest abnormalities. Breast ultrasound also helps
to determine whether a lump is a cyst (sac containing fluid) or a solid
mass. It can also be used to precisely locate the position of a known tumor
in order to guide the physician during a biopsy or aspiration procedure.
Ultrasound helps confirm correct needle placement.

Ultrasound testing works by transmitting high-frequency waves,

inaudible to the human ear, through the breast. The sound waves bounce
off surfaces in the breast (tissue, air, fluid) and these “echoes” are
recorded and transformed into video or photographic images.

 MRI – Another breast imaging tool may be use is magnetic resonance

imaging (MRI). MRI uses strong fields and radio waves to produce
exceptionally detailed images. MRI excels at imaging soft tissue
structures, including breasts. The MRI is more likely to pick up tumors that
may be missed with a mammogram. Also when metastasis is strongly
suspected MRI is ordered to further define and measure extent of disease.
While this diagnostic process takes longer, the patient will be able to lie
down and the scan is more comfortable than a mammogram.

 CT Scan—also called a CAT scan, or computerized tomography scan is

an x-ray technique that gives information about the body’s internal organs
in 2-dimensional slices, or cross-sections. During a CT scan, the patient
lie on a moving table and pass through a doughnut-shaped machine that
takes x-rays of the body from many different angles. A computer puts
these x-rays together to created detailed pictures of the inside of the body.
Before the test the patient need to have a contrast solution (dye) injected
into your arm through an intravenous line. Because the dye can affect the
kidneys, the doctor may perform kidney function tests before giving you
the contrast solution.
 PET Scan—short for Positron Emission Tomography, can detect areas of
cancer by obtaining images of the body’s cells as they work. First, you are
injected with a substance made up of sugar and a small amount of
radioactive material. Cancer cells tend to be more active than normal
cells, and they absorb more of the radioactive sugar as a result. A special
camera then scans the body to pick up any “highlighted” areas on a
computer screen. This helps radiologists identify areas where cells are
 suspiciously active, which can indicate cancer. Once doctors know where
to look, further evaluation can be done with other techniques.Bone scan-
to check for bone metastasis. The PET scan is not used as screening test
but used to define or measure extent of metastasis.

6. Discuss common nursing diagnosis for breast cancer.

NURSING DIAGNOSIS: Acute pain

May be related to
1. Inflammation
2. Advancement of disease process
3. Obstruction or enlargement of tumor
Possibly evidenced by
1. Verbalization of pain
2. Guarding behavior

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

1. Verbalize relief of pain.

NURSING INTERVENTION
1. Provide quiet environment and uninterrupted rest periods
2. Provide complimentary intervention for relaxation
3. Opiod/nonopiod analgesic per doctor’s order

NURSING DIAGNOSIS: Body image disturbance

May be related to
Impending changes in breast and sexuality

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Coping/emotional Status
Exhibit presurgical or baseline positive body image
Possibly evidenced by
Wearing usual make-up and using usual feminine attire after surgery.

NURSING INTERVENTION
1. assessing individual and family coping ability and concerns
2. Identify coping mechanism.
3. provide time for individual and family consultation

NURSING DIAGNOSIS: ineffective individual coping and ineffective family

coping
 May be related to
Diagnosis of cancer and surgical changes in breast.

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Coping/emotional Status
Family and individual will cope with the diagnosis of cancer and surgical
changes in breast
Possibly evidenced by
1. statement of acceptance and decisions about treatment
2. Family members will provide support to the patient.

NURSING INTERVENTION
1. Develop rapport; utilize active listening skills
2. assessing individual and family coping ability and concerns
3. Provide consistent, emphatic, and positive regard.
4. Support client’s expression of feelings.
5. Identify coping mechanism.
6. provide time for individual and family consultation
7. Guide the client to community resources such as support groups.
8. Refer client to appropriate and qualified professional for further
intervention as indicated.

NURSING DIAGNOSIS: Nutrition: imbalanced, risk for less than body

requirements
Risk factors may include
Loss of appetite, fatigue, nausea/vomiting; stomatitis as side effect of
treatment (chemotherapy) and disease process.

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Nutritional Status
Maintain/regain weight as indicated by individual situation and maintain
nutrition.
Possibly evidenced by
1. Absence of nausea and vomiting, control of stomatitis, intake of adequate
calories daily, and no or minimal weight loss.

NURSING INTERVENTION
1. Provide small frequent meals.
2. Provide complete nutritious food.
3. Provide oral hygiene.
4. Instruct to eat slowly or calmly.
5. Provide bland diet or dry foods.

7. What are the purposes for prescribed medications?

 1. Doxorubicin Hydrochloride (Adriamycin)

Indication: Breast Carcinoma. May interfere with DNA-dependednt RNA

synthesis intercalation.

2. Cyclophosphamide (Cytoxan)

Indication: Breast Carcinoma. Corss-links strands of cellular DNA and

interferes with RNA transcription, cacusing an imbalance of growth that leads
to cell death. Not specific to cell cycle.

3. Ondansetron Hydrochloride (Zofran)

Indication: prevention of nausea and vomiting from emetogenic

chemotherapy. Selective antagonist of a specific type of serotonin receptor
(5-HT3) located in the CNS at the chemoreceptor trigger zone and in the
peripheral nrvous system on nerve terminals of the vagus nerve.

4. Dexamethasone (Decadron)

Indication: a prophylaxis to prevent allergic reaction with Taxotere. It

decreases inflammation mainly by stabilizing leukocyte lysomal membranes;
suppresses immune response; stimulates bone marrow; and influences
protein, fat, and carbohydrate metabolism.

5. Docetaxel (Taxotere)

Indication: locally advanced or metastatic breast cancer. It promotes

stabilization of nonfunctional microtubules. This prevents mitosis and leads to
cell death.

8. What are the most common adverse reactions, drug-to-drug,

drug-to-food/herbal interactions of the prescribed medications?

1. Doxorubicin Hydrochloride (Adriamycin)

Adverse reactions

CV: cardiac depression, arrhythmias, acute left ventricular failure, irreversible

cardiomyopathy
EENT: conjunctivitis.
GI: nausea, vomiting, diarrhea, stomatitis, esophagitis, anorexia.
GU: transient red urine.
Hematologic: leucopenia, thrombocytopenia, myelosuppression.
Metabolic: hyperuricemia.
Skin: severe cellulites, tissue sloughing with drug extravasation, urticaria,
facial flushing, complete alopecia within 3 to 4 weeks, hyperpigmentation of
nail beds and dermal creases, radiation recall effect.
Other: fever, chills, anaphylaxis.

Interactions

Drug-drug:
—aminophylline cephalothin, dexamethasone, fluororacil, heparin,
hydrocortisone: may form a precipitate. Don’t mix together.
 Calcium channel blockers: may potentiate cardiotoxic effects. Monitor
patient’s ECG closely.
 Digoxin: may decrease degoxin levels. Monitor diogoxin levels closely.
 Fosphenytoin, phenytoin: decerased levels of phenytoin or fosphenytoin.
Check levels.
 Streptozocin: increased and prolonged blood levels. Dosage may have to
be adjusted.

2. Cyclophosphamide (Cytoxan)

Adverse reactions

CV: cardiotoxic with very high doses and with doxorubicin, flushing.
GI: nausea, vomiting and anorexia beginning within 6 hours, abdominal pain,
stomatis, mucositis.
GU: hemorrhagic cystitis, impaired fertility.
Hematologic: leucopenia, thrombocytopenia, anemia.
Hepatic: hepatotoxicity.
Metabolic: hyperurecemia, SIADH.
Respiratory: pulmonary fibrosis with high doses.
Skin: reversible alopecia, rash, pigmentation, nail changes, itching.
Other: secondary malignant disease, anaphylaxis, hypersensitivity reactions.

Interactions

Drug-drug:
—allopurinol: increased myelosuppression. Monitor toxicity.
 Aspirin, NSAID: increased risk of bleeding. Avoid using together.
 Barbiturates: increased pharmacologic effect and enhanced
cyclophosphamide toxicity form induction of hepatic enzymes. Monitor
patient closely.
 Cardiotoxic drugs: increased adverse cardiac effects.
 Chloramphenicol, corticosteroids: reduced activity of cyclophosphamide.
 Digoxin: may decrease digoxin levels.
3. Ondansetron Hydrochloride (Zofran)

Adverse reactions

CNS: headache, malaise, fatigue, dizziness, sedation

CV: chest pain
GI: diarrhea, constipation, abdominal pain, xerostomia.
GU: urine retention, gynecologic disorders.
Musculoskeletal: pain.
Respiratory: hypoxia
Skin: rash, pruritus
Other: chills, injection site reaction, fever.

Interactions

Drug-drug:
—Drugs that alter hepatic drug metabolizing enzymes such as cimetidine,
Phenobarbital: may alter pharmacokinetics of ondansetron. No dosage
adjustment appears necessary.

Drug-herb:
 Horebound: may enhance serotoninergic effects. Discourage use
together.

4. Dexamethasone (Decadron)

Adverse reactions

CNS: euphoria, insomnia, psychotic behavior, pseudotumor cerebri, vertigo,

headache, paresthesia, seizures.
CV: heart failure, hypertension, edema, arrhythmias, thrombophlebitis,
thromboembolism.
EENT: cataracts, glaucoma.
GI: peptic ulceration, GI irritation, increased appetite, pancreatitis, nausea,
vomiting
GU: menstrual irregularities, increased urine glucose and calcium levels.
Musculoskeletal: muscle weakness, osteoporosis.
Skin: hirsuitism, delayed wound healing, acne, various skin eruptions

Interactions

Drug-drug:
—Aminoglutethimide: may cause loss of dexamethasone-induced adrenal
suppression.
 Antidiabetics, including insulin: decreased response.
  Aspirin, indomethacin, other NSAID: increase d risk of bleeding.
 Cardiac glycosides: increased risk of arrhythmia resulting from
hypokalemia.
 Ephedrine: a decreased half-life and increased clearance of
dexamethasone may occur.

Drug-herb:
 Echinacea: increased immune-stimulating effects.
 Ginseng: potentiates immune-modulating response.

Drug-lifestyle:
 Alcohol use: increased risk of gastric irritation and GI ulceration.

5. Docetaxel (Taxotere)

Adverse reactions

CNS: asthenia, paresthesia, peripheral neuropathy

CV: fluid retention, peripheral edema, hypotension, flushing, chest tightness.
GI: stomatitis, nausea, vomiting, diarrhea.
Hematologic: anemia, neutropenia
Musculoskeletal: myalgia, arthralgia, back pain.
Respiratory: dyspnea, pulmonary edema.
Skin: alopecia, skin eruptions, desquamation, nail pigmentation, nail pain,
rash.

Interactions

Drug-drug:
 Compounds that induce, inhibit, or are metabolized by cytochrome p-450
3A4, such s cyclosporine, erythromycin, ketoconazole, troleandomycin.

9. Discuss common sites of breast cancer recurrence and metastasis

Breast cancer often metastasizes to sites such as:

 Lung
 Bone
 Liver
 Brain.

But breast cancer can show up in a number of different places. The most
common place for breast cancer to spread to is the bone, but it's by no means
the only place. Of all of the places that breast cancer spreads to, the one
place that is very uncommon as a first site is the brain. When a woman's had
breast cancer—because breast cancer can potentially spread to a number of
 different places—if she has a new or unexplained symptom and it persists for
a few weeks or longer, that's something to talk to her doctor about.

10. Discuss client education for breast cancer.

For client’s who are high risk for breast cancer it is important to teach them
self berast examination.

 Self breast examination – is a method of finding abnormalities of the

breast, for early detection of breast cancer. The method involves the
woman herself looking at and feeling each breast for possible lumps,
distortions or swelling.
1. The self-exam is performed by standing in front of a mirror with the torso
exposed to view.
2. The woman looks in the mirror for visual signs of dimpling, swelling, or
redness on or near the breasts. This is usually repeated in several
positions, such as while having hands on the hips, and then again with
arms held overhead.
3. The woman then palpates her breasts with the pads of her fingers to feel
for lumps (either superficial or deeper in tissue) or soreness. To be
effective, this process needs to cover the entire breast, including the
“axillary tail” of each breast that extends toward the axilla (armpit). This is
usually done once while standing in front of the mirror and again while
lying down.
4. Some guidelines suggest mentally dividing the breast into four quadrants
and checking each quadrant separately. Finally, women that are not
breastfeeding gently squeeze each nipple to check for any discharge.

The 7 P’s of Breast Self Examination (BSE)

1. Position: Inspect breasts visually and palpate in the mirror with arms at
various positions. Then perform the examination lying down, first with a
pillow under one shoulder, then with a pillow under the other shoulder, and
finally lying flat.
2. Perimeter: Examine the entire breast, including the nipple, the axillary tail
that extends into the armpit, and nearby lymph nodes.
3. Palpation: Palpate with the pads of the fingers, without lifting the fingers
as they move across the breast.
4. Pressure: First palpate with light pressure, then palpate with moderate
pressure, and finally palpate with firm pressure.
5. Pattern: There are several examination patterns, and each woman should
use the one which is most comfortable for her. The vertical strip pattern
involves moving the fingers up and down over the breast. The pie-wedge
pattern starts at the nipple and moves outward. The circular pattern
involves moving the fingers in concentric circles from the nipple outward.
Don’t forget to palpate into the axilla.
6. Practice: Practice the breast self-exam and become familiar with the feel
of the breast tissue, so you can recognize changes. A health care
practitioner can provide feedback on your method.
7. Plan: Know what to do if you suspect a change in your breast tissue.
Know your family history of breast cancer. Have mammography done as
often as your health care provider recommends.

For premenopausal women, BSE is best done at the same stage of their
period every month to minimize changes due to the menstrual cycle. The
recommended time is just after the end of the last period when the breasts
are least likely to be swollen and tender. Older, menopausal women
should do BSE once a month, perhaps on the first or last day of every
month.

For clients after surgery and radiation therapy, the client and the doctor
will work together to develop a plan for your follow-up care. If the client
had a mastectomy and are undergoing breast reconstruction, he/she have
a series of office visits to check on the healing process. If the client is
taking tamoxifen or another form of hormonal therapy, this usually
continues for a period of about 5 years, so the doctor will want to monitor
the client throughout that time.

Although follow-up care plans can vary from person to person, your plan is at
least likely to include:

 a checkup and physical exam by the doctor every 6 to 12 months for 5

years and then once a year after that
 a mammogram every 12 months and possibly other screening methods
depending on the doctor’s recommendations

In addition to the treatments, rehabilitation is often important to the client’s

quality of life. Self-care must be promoted through:

Teaching arm exercises

1. encourage client to focus on the elbow, wrist, and hand of the affected
side in the early postoperative period (days 1 and 2)
2. Allow client to perform active elbow flexion and extension, gentle
squeezing of a soft rubber ball, and doing deep breathing to facilitate
lymph flow.
3. Shoulder shrugs and active range of motion, including flexion and
abduction, can be added on the second postoperative day.
4. Encourage self care activities (e.g. feeding, combing hair, washing face)
and other activities that use the arm, with care taken not to abduct the arm
or to raise the arm or elbow above shoulder height until the drains are
removed.
5. Approximately 10 days after surgery, the client can begin active assisted
range of motion exercises.
6. Inform to do exercises at least twice a day as tolerated.
7. Provide pain medication 30 minutes before the exercise.

Refer to Reach For Recovery

The Reach for Recovery program of the American Cancer Society is a

rehabilitation program for breast cancer survivors, specifically those who have
had breast surgery. This programs designed to help women meet common
psychosocial, physical and the client’s permission, volunteers from this
program visit the hospital or the home and give the woman information and
help, including:

1. Discussion of brassiere comfort, various breast prosthesis, clothing

adjustments, and personal problems as appropriate.
2. Instruction sheet for demonstration of postoperative axillary nod dissection

Provide support group

1. Refer to cancer programs available in the Philippines for diagnostic

assistance, medications assistance, and recovery assistance and so
forth. Cancer programs and other related programs or organization that
are available are the such:
 Philippine Cancer Control Program (PCCP)
 Breast Cancer Control Program (BCCP)
 Philippine Breast Cancer Network (PBCN)
 Community-based Cancer Care/Control Network (CCCN)
 Local Cancer Control/Care Networks (LCCN)

Provide breast prosthesis

Women who have had a mastectomy may wear a temporary lightweight

prosthesis, immediately after the sutures and drains are removed. This may
facilitate adjustment to the loss of the breast. A cotton padding inserted into a
pocket sewn into a lightweight brassiere as good temporary substitute may be
use. A permanent prosthesis should not be purchased until the wound has
healed completely because the contours of the incision site may change.

Cocoa butter may be rubbed into the incision once healing has occurred to
help soften the scar and prevent scar contracture.