BREAST CANCER

Mr. Jils Suresh MSc (N)

Breast cancer is a malignant tumor that starts in the cells of the breast. A malignant tumor is a
group of cancer cells that can grow into (invade) surrounding tissues or spread (metastasize) to
distant areas of the body. The disease occurs almost entirely in women, but men can get it, too.
 CAUSES/RISK FACTORS
• Breast cancer is always caused by a genetic abnormality (a “mistake” in the genetic material).
However, only 5-10% of cancers are due to an abnormality inherited from your mother or
father. About 90% of breast cancers are due to genetic abnormalities that happen as a result of
the aging process and the “wear and tear” of life in general.

Risk Factors for Breast Cancer

 Gender: female (1% males)

 Race: more common in whites
 Age: increases as a woman gets older.
 Relative : (mother or sister)
 CAUSES/RISK FACTORS
 Menstrual history :early onset, late menopause
 Childbirth: first child After the age of 30 or having no children at all
 Obesity
 Diet: Fat Alcohol
 Lack of Physical Activity ; Stress
 Radiation Exposure
 History of cancer: breast, uterus, cervix, ovary
 Hormones: estrogens in Hormone replacement therapy & Birth control pills
 Genetics : certain conditions that are inherited
 TYPES
The normal breast
The female breast is made up mainly of
lobules (milk-producing glands), ducts (tiny
tubes that carry the milk from the lobules to the
nipple), and stroma (fatty tissue and connective
tissue surrounding the ducts and lobules, blood
vessels, and lymphatic vessels).
 TYPES
The normal breast
• Most breast cancers begin in the cells that
line the ducts (ductal cancers). Some begin
in the cells that line the lobules (lobular
cancers), while a small number start in other
tissues.
 TYPES
The lymph (lymphatic) system of the breast

• The lymph system is important to understand because it is

one way breast cancers can spread. This system has several
parts.

• Lymph nodes are small, bean-shaped collections of immune

system cells (cells that are important in fighting infections)
that are connected by lymphatic vessels. Lymphatic vessels
are like small veins, except that they carry a clear fluid
called lymph (instead of blood) away from the breast. Lymph
contains tissue fluid and waste products, as well as immune
system cells. Breast cancer cells can enter lymphatic vessels
and begin to grow in lymph nodes.
 TYPES
• Most lymphatic vessels in the breast connect to lymph nodes
under the arm (axillary nodes). Some lymphatic vessels
connect to lymph nodes inside the chest (internal mammary
nodes) and those either above or below the collarbone
(supraclavicular or infraclavicular nodes).

• If the cancer cells have spread to lymph nodes, there is a

higher chance that the cells could have also gotten into the
bloodstream and spread (metastasized) to other sites in the
body. The more lymph nodes with breast cancer cells, the
more likely it is that the cancer may be found in other organs
as well.
 TYPES
1. Ductal carcinoma in situ (DCIS;
• Ductal carcinoma in situ (DCIS; also known as intraductal carcinoma) is considered non-
invasive. DCIS means that cells that lined the ducts have changed to look like cancer cells.
The difference between DCIS and invasive cancer is that the cells have not spread (invaded)
through the walls of the ducts into the surrounding breast tissue.
2. Lobular carcinoma in situ
• Lobular carcinoma in situ (also called lobular neoplasia) is not a cancer. It means there are
changes in the cells lining the lobes where milk is made in the breast.
• These changes indicate that a woman has a higher risk of developing breast cancer later in
life.
3. Tubular breast cancer
• It’s called tubular breast cancer because the cancer cells look tube-like when examined under
a microscope.
4. “medullary” carcinoma :
• It is called “medullary” carcinoma because the tumor is a soft, fleshy mass that resembles a
part of the brain called the medulla.
 TYPES
5. Invasive (or infiltrating) ductal carcinoma
This is the most common type of breast cancer. Invasive (or infiltrating) ductal carcinoma
(IDC) starts in a milk duct of the breast, breaks through the wall of the duct, and grows into
the fatty tissue of the breast. At this point, it may be able to spread (metastasize) to other parts
of the body through the lymphatic system and bloodstream. About 8 of 10 invasive breast
cancers are infiltrating ductal carcinomas.
6. Invasive (or infiltrating) lobular carcinoma
Invasive lobular carcinoma (ILC) starts in the milk-producing glands (lobules). Like IDC, it
can spread (metastasize) to other parts of the body. About 1 invasive breast cancer in 10 is an
ILC. Invasive lobular carcinoma may be harder to detect by a mammogram than invasive
ductal carcinoma.
TNM CLASSIFICATION
 PATHOPHYSIOLOGY
• Breast cancer is a malignant tumor that starts in the cells of the breast.
• Like other cancers, there are several factors that can raise the risk of getting breast cancer.
• Damage to the DNA and genetic mutations can lead to breast cancer.
• Breast cancers have been experimentally linked to estrogen exposure.
• Some individuals inherit defects in the DNA and genes like the BRCA1, BRCA2 and P53 among
others.
• Those with a family history of ovarian or breast cancer thus are at an increased risk of breast cancer.
• The immune system normally seeks out cancer cells and cells with damaged DNA and destroys
them.
• Breast cancer may be a result of failure of such an effective immune defence and surveillance.
 CLINICAL MANIFESTATIONS

 Breast cancers occur anywhere in the breast, but most are found in the upper outer quadrant,
where most breast tissue is located.
 Generally, the lesions are nontender rather than painful, fixed rather than mobile, and hard with
irregular borders rather than encapsulated and smooth.
 Complaints of diffuse breast pain and tenderness with menstruation
 Marked pain at presentation, Associated with breast cancer in the later stages.
 Dimpling or orange-peel appearance of the skin (a condition caused by swelling that results
from obstructed lymphatic circulation in the dermal layer).
 Nipple retraction and lesions fixed to the chest wall may also be evident.
 Involvement of the skin is manifested by ulcerating and fungating lesions.
 ASSESSMENT AND DIAGNOSTIC FINDINGS

 Imaging tests
 Breast exam. : feeling for any lumps or other abnormalities.
 Mammogram: A mammogram is an X-ray of the breast. Mammograms are commonly used to screen
for breast cancer.
 Ultrasound. An ultrasound uses high-frequency sound waves to create an image of the breast tissue. An
ultrasound can distinguish between a solid mass, which may be cancer, and a fluid-filled cyst, which is
usually not cancer. Ultrasounds are not used for screening.
 MRI. An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast
medium (a special dye) is injected into a patient’s vein to create a clearer picture of the breast. A breast
MRI may be used once a woman has been diagnosed with cancer to check the other breast for cancer or
to find out how much the disease has grown throughout the breast. It may also be used for screening,
particularly along with mammography for some women with a high risk of breast cancer.
 ASSESSMENT AND DIAGNOSTIC FINDINGS

Surgical tests

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope.
Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis.
The sample removed during the biopsy is analyzed by a pathologist. There are different types of
biopsies, classified by the technique and/or size of needle used to collect the tissue sample.

 A fine needle aspiration biopsy uses a thin needle to remove a small sample of cells.

 A core needle biopsy uses a thicker needle to remove a larger sample of tissue. This is usually
the preferred biopsy technique for finding out whether an abnormality on a physical
examination or an imaging test is cancer. A vacuum-assisted biopsy removes several large
cores of tissue. Local anesthesia (medication to block the awareness of pain) is used to lessen a
patient’s discomfort.
 ASSESSMENT AND DIAGNOSTIC FINDINGS

 Image-guided biopsy : During this procedure, a needle is guided to the location with the help
of an imaging technique, such as mammography, ultrasound, or MRI. A stereotactic biopsy is
done using mammography to help guide the needle. A small metal clip may be put into the
breast to mark where the biopsy sample was taken, in case the tissue is cancerous and more
surgery is needed.

 A surgical biopsy removes the largest amount of tissue. This biopsy may be incisional (removal
of part of the lump) or excisional (removal of the entire lump). Because definitive surgery is
best done after a cancer diagnosis has been made, a surgical biopsy is usually not the
recommended way to diagnose breast cancer.
There are different types of treatment for patients with breast cancer.
Six types of standard treatment are used:
I. Surgery
• Most patients with breast cancer have surgery to remove the cancer from the breast.
• Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:
a) Lumpectomy: Surgery to remove a tumor (lump) and a small amount of normal tissue around it.
b) Other types of surgery include the following:
• Chemotherapy may be given before surgery to remove the tumor. When given before surgery,
chemotherapy will shrink the tumor and reduce the amount of tissue that needs to be removed during
surgery. Treatment given before surgery is called neoadjuvant therapy.
• Breast reconstruction may be considered. Breast reconstruction may be done at the time of the
mastectomy or at a future time. The reconstructed breast may be made with the patient’s own
(nonbreast) tissue or by using implants filled with saline or silicone gel.

• Sentinel lymph node biopsy followed by surgery

• Sentinel lymph node biopsy is the removal of the sentinel lymph node during surgery. The sentinel
lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph
node the cancer is likely to spread to from the tumor. A radioactive substance and/or blue dye is
injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The
first lymph node to receive the substance or dye is removed.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill
cancer cells or keep them from growing. There are two types of radiation therapy.
 External radiation therapy uses a machine outside the body to send radiation toward the cancer.
 Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters
that are placed directly into or near the cancer.
Chemotherapy
 Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by
killing the cells or by stopping them from dividing.
 When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the
bloodstream and can reach cancer cells throughout the body (systemic chemotherapy).
 When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as
the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy
 Eg: (Methotrexate) (Fluorouracil) Cyclophosphamide,Doxorubicin Hydrochloride
Hormone therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops
cancer cells from growing. Some hormones can cause certain cancers to grow. If tests show that
the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation
therapy is used to reduce the production of hormones or block them from working. The
hormone estrogen, which makes some breast cancers grow, is made mainly by the ovaries.
Treatment to stop the ovaries from making estrogen is called ovarian ablation.

Hormone therapy with tamoxifen is often given to patients with early stages of breast cancer
and those with metastatic breast cancer (cancer that has spread to other parts of the body).
Targeted therapy

• Targeted therapy is a type of treatment that uses drugs to identify and attack specific cancer
cells without harming normal cells.

• Monoclonal antibodies and tyrosine kinase inhibitors are two types of targeted therapies used
in the treatment of breast cancer.
• Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the
laboratory. These antibodies can identify substances on cancer cells or normal substances that
may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells,
block their growth, or keep them from spreading. Monoclonal antibodies are given by
infusion.
• Trastuzumab, Pertuzumab ,Ado-trastuzumab emtansine
BONE MARROW TRANSPLANTATION

Bone marrow transplantation (BMT) involves removing bone marrow from the patient and then
administering high-dose chemotherapy. The patient’s bone marrow, spared from the effects of
chemotherapy, is then reinfused intravenously.
 NURSING MANAGEMENT
ASSESSMENT

The health history includes an assessment of the patient’s reaction to the diagnosis and her ability to cope with it.
Pertinent questions include the following:

• How is the patient responding to the diagnosis?

• What coping mechanisms does she find most helpful?

• What psychological or emotional supports does she have and use?

• Is there a partner, family member, or friend available to assist her in making treatment choices?

• What are the most important areas of information she needs?

• Is the patient experiencing any discomfort?

 NURSING MANAGEMENT

1. Acute pain r/t postoperative incision.

• Establish rapport
• Monitor vital signs
• Assess verbal/non-verbal reports of pain, noting location, intensity (0-10 scale), and duration
• Place in Semi-Fowler’s position and support head/neck in neutral position with sandbags or small pillows as
required in immediate postoperative phase
• Instruct client to use hands to support neck during movement and to avoid hyperextension of neck
• Keep call light and frequently needed items within easy reach
• Give cool liquids or soft foods such as ice cream or popsicles.
• Encourage client to use relaxation techniques e.g., guided imagery, soft music, progressive relaxation
• Administer analgesics and throat sprays/lozenges as necessary
• Provide ice if indicated
 NURSING MANAGEMENT
2. Impaired skin integrity secondary to surgery

• monitor and record vital sign

• assess incision site taking note of size, color, location, temperature, texture, consistency of
wound/ lesion if possible
• inspect surrounding skin for erythema, induration, maceration
• assess for odors and drains coming out from the skin/ area of injury
• inspect skin on a daily basis, describing lesions and changes observed
• keep the area clean/dry, carefully dress wounds, support incision, and prevent infection
• use appropriate wound coverings
• encourage an increase in protein and calorie intake
• encourage adequate rest and sleep
• encourage early ambulation and mobilization
• provide position changes
• practice aseptic technique in cleansing/dressing and medicating lesions instruct proper
disposal of soiled dressing
 NURSING MANAGEMENT
3.Activity intolerance related to generalized weakness

• Establish patient’s rapport

• Monitor and record vital signs
• Assess patient’s condition
• Assess patient’s level of mobility
• Assess nutritional status
• Ascertain ability to stand and move about and degree of assistance necessary/ use of equipment
• Provide a quite environment and encourage use of stress management
• Encourage adequate rest periods
• Promote comfort measures and provide for relief of pain
• Plan care with rest periods between activities
• Instruct SO in monitoring response to activity and in recognizing signs and symptoms
• Assist client in learning and demonstrating appropriate safety measures
• Encourage client to maintain positive attitudes; suggest use of relaxation techniques, such as
visualization/guided imagery as appropriate
 NURSING MANAGEMENT
4. Risk for ineffective breathing pattern related to chemically induce muscular relaxation
• Establish patient’s rapport
• Monitor and record vital signs
• Use pulse oximetry to monitor oxygen saturation and pulse rate
• Monitor vital capacity in patients with neuromuscular weakness and observe trends
• Instruct client to deep breathe during walking hours or use an incentive spirometer
• Splint incision to reduce discomfort
• Administer oxygen as prescribed
• Instruct client to self-administer analgesia before deep breathing and coughing if a patient-
controlled analgesia pump is available