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Breast Cancer. By Candace Hunt Misti Smith Quinan McAnlly Nicki Haffner Stefani Delony. Incidence. Incidence. Breast cancer is the most common malignancy in American women except for skin cancer – it is second only to lung cancer as the leading cause of death from cancer in women
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Breast Cancer By Candace Hunt Misti Smith QuinanMcAnlly NickiHaffner Stefani Delony
Incidence Breast cancer is the most common malignancy in American women except for skin cancer – it is second only to lung cancer as the leading cause of death from cancer in women Over 211,000 new cases of breast cancer are diagnosed in women in the US each year and about 1700 new cases are diagnosed in men Each year in the US, approximately 40,870 deaths (40,410 women and 460 men) occur related to breast cancer The incidence rate is slowly decreasing, with a slight decline in the number of deaths related to breast cancer, with the majority of decreases being noted in younger women, including both African American and Caucasian women Patients diagnosed with localized breast cancer with no axillary node involvement have a 5 year survival rate of 98%, however, only 6% of patients diagnosed with advanced stage breast cancer with metastases to distant sites will survive 5 years or more
Gender Incidence Incidence Women account for 99% of breast cancer cases Excluding cancers of the skin, breast cancer is the most common cancer among women, accounting for more than 1 in 4 cancers diagnosed in US women Men are generally at low risk for developing breast cancer; however, they should report any change in their breasts to a physician
Age Incidence Incidence Incidence in women under the age of 25 is very low and increases gradually until age 60, after age 60 the incidence of breast cancer increases dramatically Breast cancer incidence and death rates generally increase with age, during 2000-2004, 95% of new cases and 97% of breast cancer deaths occurred in women aged 40 and older During 2000-2004, women aged 20-24 years had the lowest breast cancer incidence rate, 1.4 cases per 100,000 women, and women aged 75-79 years had the highest incidence rate, 464.8 cases per 100,000.3 - the decrease in age-specific incidence rates that occurs in women aged 80 years and older may reflect lower rates of screening, the detection of cancers by mammography before age 80, and incomplete detection During 2000-2004, the median age at the time of breast cancer diagnosis was 61 years - this means that 50% of Women who developed breast cancer were aged 61 or younger and 50% were older than age 61 when diagnosed
Ethnicity Incidence Incidence Caucasian women have a higher incidence of breast cancer than African American women after age 40, however, African American women have a higher incidence rate before age 40 and are more likely to die from breast cancer at every age Incidence and death rates from breast cancer are lower among women of other racial and ethnic groups than among white and African American women
Risk Factors Risk factors for breast cancer include: Female gender Smoking/ETOH Family history of cancer – a first degree relative with history of breast cancer increases risk 1.5-3 times, depending on age Personal history of other forms of cancer significantly increases risk Aging – 50+ postmenopausal women at greatest risk Early menarche – before age 12/Late menopause – after age 55 Never having children/First full-term pregnancy after age 30 Certain types of hormone therapy – estrogen and progesterone Use of oral contraceptives may increase risk for women under 35 Caucasian Receiving radiation therapy, especially at a younger age Dense or fatty breast tissue Weight gain during adulthood/Obesity/Dietary fat intake Weight gain and obesity after menopause Lack of physical activity
Clinical Manifestations Many breast cancers have no obvious symptoms at all Often detected as a lump that feels different than the surrounding breast tissue or an mammographic abnormality in the breast – occurs most often in upper, outer quadrant of breast because this is the location of most of the glandular tissue Lumps found in lymph nodes located in the armpits/ collarbone may indicate breast cancer Palpable lumps are characteristically hard, and may be irregularly shaped, poorly delineated, non-mobile, and non-tender Change in breast size or shape, skin dimpling, nipple inversion, nipple retraction may occur A small percentage of breast cancers cause nipple discharge, it is usually unilateral and may be clear or bloody Orange peel texture to the skin referred to as “peaud'orange” may be noted due to the plugging of the dermal lymphatics In large cancers, infiltration, induration, and dimpling (pulling in) of the overlying skin may be noted Pain is an unreliable tool in determining the presence of breast cancer
Diagnosing Mammogram MRI Ultrasound MRI Image
Diagnosing There's a whole world of testing that goes along with taking care of your breasts: No matter where you are on the line between healthy breasts and breast cancer, tests can be nerve-wracking They're an indispensable part of: Finding breast cancer early, when it's most treatable Helping your treatment team design the treatment that's right for you Determining the effectiveness of your continuing care There are two different stages of testing: Screening tests (such as an annual mammogram) - these look for signs of disease in women without symptoms; they should be part of every healthy woman's routine Diagnostic tests (such as MRI’s, PET Scans, ultrasounds, blood tests, or bone scans) - these tests become part of the picture when breast cancer is suspected or has been diagnosed
Diagnosing Mammograms Mammograms are probably the most important tool doctors have to help them diagnose, evaluate, and follow women who've had breast cancer Safe and highly accurate, a mammogram is an X-ray photograph of the breast The technique has been in use for about thirty years Mammograms don't prevent breast cancer, but they can save lives by finding breast cancer as early as possible Mammograms have been shown to lower the risk of dying from breast cancer by 35% in women over the age of 50; studies suggest for women between 40 and 50 they may lower the risk of dying from breast cancer by 25–35% Finding breast cancers early with mammography has also meant that many more women being treated for breast cancer are able to keep their breasts When caught early, localized cancers can be removed without resorting to breast removal The recommendation is that women get a mammogram once a year, beginning at age 40 – if you're at high risk for breast cancer, with a strong family history of breast or ovarian cancer, or have had radiation treatment to the chest in the past, it's recommended that you start having annual mammograms at a younger age (often beginning around age 30) - this, however, is something that you should discuss with your healthcare provider
Diagnosing PET Scans PET scans, short for Positron Emission Tomography, are still in the experimental phase, and are one of the newest breast cancer diagnostic techniques around You'll be injected with a small amount of radioactive material - active cells, which often indicate rapid cancer growth, take up the radioactive material - 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 Early results of PET scanning in women with breast cancer show important possibilities, including its ability to assess: whether a tumor still exists after radiation or chemotherapy whether a cancer has spread to the lymph nodes Drawbacks: PET scans have only a limited ability to detect small tumors, are available in only a few centers, are very expensive and sophisticated tests requiring exceptional expertise PET (Positron Emission Tomography) scanning can be useful in defining the extent of disease in a woman with metastatic breast cancer It can also be used to assess response to treatment PET is particularly useful in evaluating lymph nodes
Diagnosing MRI’s The value of MRI for breast cancer detection remains uncertain - some doctors believe MRI can distinguish a breast cancer from normal breast gland tissue better than other techniques - but MRI is expensive and requires highly specialized equipment and highly trained experts - relatively few MRI centers exist, especially outside of major cities - even at its best, MRI produces many uncertain findings It is unlikely that MRI will be used as a general screening tool for breast cancer - it may, however, prove useful in: evaluating a woman who has a palpable mass that isn't visible with ultrasound or mammography assessing a lesion in the densely glandular breast of a young woman screening a young woman who is at high risk for cancer because of a significant family history of breast cancer or an abnormal breast cancer gene
Diagnosing MRI’s Additional advantages of MRI: MRI is sometimes used successfully in women who have breast cancer cells in an underarm lymph node, but have no breast mass that doctors are able to feel or see on a mammogram - in these cases, where mastectomy is typically recommended, MRI can help find the precise site of the cancer's origin within the breast - finding the cancer's precise origin can expand a woman's treatment options from only mastectomy to include lumpectomy plus radiation MRI can help determine if a cancer is limited to one area of the breast, or if it is "multicentric" and involves more than one area - knowing this affects treatment choices, since mastectomy is necessary for multicentric disease - this is particularly useful for women with invasive lobular cancer, which has a tendency to be diffuse or multicentric MRI is good for looking at scar tissue - it can evaluate a significant change in the lumpectomy site In the case of metastatic breast cancer, MRI can evaluate other parts of the body - a woman who has progressive back pain, or who develops new weakness or numbness in the arms or legs (not just hands or feet), can have an MRI scan of her back - the scan can help identify serious conditions such as the possible presence of a spinal tumor or brain metastasis
Diagnosing Ultrasounds Ultrasound sends high-frequency sound waves through your breast and converts them into images on a viewing screen Ultrasound complements other tests - if an abnormality is seen on mammography or felt by physical exam, ultrasound is the best way to find out if the abnormality is solid (such as a benign fibroadenoma, or cancer) or fluid-filled (such as a benign cyst) - it cannot determine whether a solid lump is cancerous, nor can it detect calcifications If you're under age 30, your doctor may recommend ultrasound before mammography to evaluate a palpable breast lump - mammograms can be difficult to interpret in young women because their breasts tend to be dense and full of milk glands (older women's breasts tend to be more fatty and are easier to evaluate) - in mammograms, this glandular tissue looks dense and white - much like a cancerous tumor - some doctors say that locating an abnormality in the midst of dense gland tissue can be like finding a polar bear in a snowstorm - most breast lumps in young women are benign cysts, or clumps of normal glandular tissue Doctors also use ultrasound to guide biopsy needles precisely to suspicious spots in the breast, without radiation exposure Ultrasound is not a substitute for a screening mammogram Its value as a general screening test for breast cancer is unproven
MedicalTreatment Surgery Chemotherapy Radiation
MedicalTreatment Today there's an overwhelming menu of treatment choices that fight the complex mix of cells in each individual cancer : Surgery is usually the first line of attack against breast cancer Lumpectomy - Removal of only the tumor and a small amount of surrounding tissue Mastectomy - Is the removal of all of the breast tissue Lymph Node Removal - Or axillary lymph node dissection Prophylactic Mastectomy - Preventive removal of the breast to lower the risk of breast cancer in high-risk people Prophylactic Ovary Removal - Preventive surgery that lowers the amount of estrogen in the body, making it harder for estrogen to stimulate the development of breast cancer
MedicalTreatment Additional medical treatments for breast cancer include: Chemotherapy systemic therapy - Affects the whole body by going through the bloodstream Radiation therapy - Highly targeted, highly effective way to destroy cancer cells in the breast that may stick around after surgery Hormonal Therapy - Blocks the ability of the hormone estrogen to turn on and stimulate the growth of breast cancer cells Targeted Therapies - Target specific characteristics of cancer cells, such as a protein that allows the cancer cells to grow in a rapid or abnormal - less likely than chemotherapy to harm normal, healthy cells Herceptin - Blocking the ability of the cancer cells to receive chemical signals that tell the cells to grow Tykerb - Unlocking certain proteins that can cause uncontrolled cell growth Avastin - Blocking the growth of new blood vessels that cancer cells depend on to grow and function Complementary & Holistic Medicine - Acupuncture ,yoga, prayer, music therapy, and massage
NM: Assessment Subjective data to assess would include: Any recent changes in breasts such as size Breast and general pain that could signify metastasis Past health history Family health history Medications, especially hormones used Surgery or treatments, especially ones that used radiation Nutritional status
NM: Assessment Objective data to assess would include: Size and location of lump or lumps in breast tissue Presence of nipple discharge Presence and characteristics of breast lesions Breast asymmetry Nipple inversion Ultrasonography and biopsy results Respiratory, integumentary, and GI system to indicate metastasis
NM:Diagnoses Nursing diagnoses related to the care of a patient diagnosed with breast cancer vary - following a diagnosis of breast cancer and before a treatment plan has been selected, the following diagnoses would apply: Decisional conflict related to lack of knowledge about treatment options and their effects Fear related to diagnosis of breast cancer Disturbed body image related to anticipated physical and emotional effects of treatment modalities If a mastectomy or lumpectomy is planned, the nursing diagnoses could include: Acute pain related to surgical procedure as evidenced by verbalization of pain at operative area Anxiety related to a situational crisis and unpredictable outcome secondary to diagnosis of cancer Disturbed body image related to perceived effects of mastectomy See Lewis pg. 1357 and Nursing Diagnosis Handbook for a more thorough examination of these diagnoses
NM: Planning Desired outcomes that could be evaluated would include: Goals specific to each nursing diagnoses will be met or re-evaluated The patient will actively participate in the decision-making process related to treatment options The patient will fully comply with the therapeutic plan The side effects of adjuvant therapy will be managed The patient will be satisfied with the support provided by significant others and health care providers
NM: Implementation • Nursing interventions appropriate after a diagnoses of breast cancer would include: • Educate and assist in accurately evaluating options and support decisions made regarding treatment • Assess for anxiety and intervene appropriately • Educate regarding procedures, treatments and side effects, medications, anesthesia, surgery, post-operative care • Educate client regarding pain management, assess for pain appropriately and intervene effectively • Provide support to client and family by assisting them to develop a positive but realistic attitude • Encouraging them to attend support groups • Encouraging them to verbalize anger and fears • Educate and appropriately intervene to restore arm function on the affected side after surgery • Educate and take measures to prevent/reduce lymphedema • Educate regarding follow-up care • Educate regarding the importance of wearing a well-fitting prosthesis • Perform a post-operative sexual assessment to help patient/family deal with the change in body image • Assess for depression, anxiety, stress, and lowered self-esteem and intervene appropriately • See Lewis pg. 1359 for a more thorough examination of these interventions
Breast Self-Exam • Examining your breasts every month is an important way to find a breast cancer early, when it's most likely to be cured • Not every cancer can be found this way, but it is a critical step you can and should take for yourself • No woman wants to do a breast self-exam (or "BSE"), and for many the experience is frustrating—you may feel things but not know what they mean • However, the more you examine your breasts, the more you will learn about them and the easier it will become for you to tell if something unusual has occurred • BSE is an essential part of taking care of yourself and reducing your risk of breast cancer • Studies show that regular breast self-exams, combined with an annual exam by a doctor, improves the chances of detecting cancer early • Try to get in the habit of doing a breast self-examination once a month to familiarize yourself with how your breasts normally look and feel • Examine yourself several days after your period ends, when your breasts are least likely to be swollen and tender • If you are no longer having periods, choose a day that's easy to remember, such as the first or last day of the month • Don't panic if you think you feel a lump - most women have some lumps or lumpy areas in their breasts all the time - eight out of ten breast lumps that are removed are benign, non-cancerous
Breast Self-Exam • Breasts tend to have different "neighborhoods" - the upper, outer area (near your armpit) tends to have the most prominent lumps and bumps - the lower half of your breast can feel like a sandy or pebbly beach - the area under the nipple can feel like a collection of large grains - another part might feel like a lumpy bowl of oatmeal • What's important is that you get to know the look and feel of YOUR breasts' various neighborhoods - does something stand out as different from the rest (like a rock on a sandy beach)? or has anything changed? • Bring to the attention of your doctor any changes in your breasts that last over a full month's cycle and/or seem to get worse or more obvious over time • Knowing how your breasts usually look and feel may also help you avoid needless • Some women find it helpful to keep a record of their breast self-exam in a journal with notes about where they feel lumps or irregularities, especially in the beginning, this may help you remember, from month to month, what is "normal" for your breasts • It is not unusual for lumps to appear at certain times of the month, but then disappear, as your body changes with the menstrual cycle - only changes that last beyond one full cycle, or seem to get bigger or more prominent in some way, need your doctor's attention
Breast Self-Exam Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips Here's what you should look for: -Breasts that are their usual size, shape, and color -Breasts that are evenly shaped without visible distortion or swelling If you see any of the following changes, bring them to your doctor's attention: -Dimpling, puckering, or bulging of the skin -A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out) -Redness, soreness, rash, or swelling -Drainage coming from nipples
Breast Self-Exam Step 2 & 3: Raise your arms and look for the same changes -Are your breasts their usual size, shape, and color ? -Are your breasts evenly shaped without visible distortion or swelling? -Do you see dimpling, puckering, or bulging of the skin? -Do you see a nipple that has changed position or an inverted nipple (pushed inward instead of sticking out)? -Do you see any redness, soreness, rash, or swelling? -Do you see any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood)?
Breast Self-Exam Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a quarter. Cover the entire breast from top to bottom, side to side — from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. This up-and-down approach seems to work best for most women. Be sure to feel all the tissue from the front to the back of your breasts: for the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use firm pressure for the deep tissue in the back. When you've reached the deep tissue, you should be able to feel down to your ribcage.
Breast Self-Exam Step 5: Finally, feel your breasts while you are standing or sitting -Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower -Cover your entire breast, using the same hand movements described in Step 4
References/Credits Information & photos courtesy of : Breastcancer.org Cancer.org Carol Sutton’s Pink Ribbon Campaign - carolsutton.net Domai.com Lewis’ Medical-Surgical Nursing 7th Edition Nursing Diagnostic Handbook 8th Edition
