Nursing Care of the Woman with a Disorder of the Breast

1. Nursing Care of the Woman with a Disorder of the Breast

2. Benign Breast Disorders

3. Fibrocystic Breast Disease Related to Relatively High estrogen and Low progesterone

4. Normal Breast

5. Fibrocystic Changes • Development of excess fibrous tissue • Hyperplasia of the epithelial lining of the mammary ducts • Proliferation of mammary ducts • Cyst formation

6. Signs and Symptoms • Palpable lumps that are round, well-delineated and freely movable • Lumps increase in size premenstrual • Tenderness • Pain • Nipple discharge

7. Diagnosis • Ultrasound • Biopsy • Aspiration • Excisional

8. Nursing Care • Patient Teaching • Wear good support bra • Diet Therapy • Low salt • No chocolate or caffeine

9. Nursing Care • Medications • Vitamin E • Antiestrogen - Danazol • Diuretics • Analgesics • Remind Patient to have a Yearly follow-up • Continue to perform monthly BSE

10. Review • In teaching the patient with painful fibrocystic breast changes about the condition, the nurse explains that • All breast lumps must be biopsied to rule out malignant changes • The symptoms will probably subside after menopause unless you use HRT • Restrictions of coffee and chocolate and supplements of vitamin E may relieve the discomforts • The lumps will become progressively larger and more painful, eventually necessitating surgical removal

11. Fibroadenoma Benign lump in breast

12. Fibroadenoma • Not affected by menstrual cycle • Small, painless, well-delineated, very mobile __________________________ Diagnosed via mammogram or biopsy Treatment – surgical excision

13. Breast Cancer

14. Significant health concern for women • 1 in 7 chance of being diagnosed • with Breast Cancer • Intense feelings of shock, fear, denial • One of the most common • malignancies in American women

15. Risk Factors • Female gender; ≥50 years of age • Personal History • Family history • Personal history of cancer (breast, colon, endometrial, ovarian) • Hormonal factors • Early menarche or late menopause • No pregnancies • First child after 30 years of age • Weight gain and obesity after menopause • High fat diet, alcohol intake • Exposure to ionizing radiation

16. Risk Factors BRCA genebreast cancer susceptibility gene 1 and 2 • In normal cells, BRCA1 and BRCA2 help ensure the stability of the cell’s genetic material (DNA) and help prevent uncontrolled cell growth. • A woman’s lifetime risk of developing breast and/or ovarian cancer is greatly increased if she inherits a harmful mutation in BRCA1 or BRCA2. Another risk – a woman who has been on combined estrogen and progesterone therapy

17. Pathophysiology • Breast Cancer arises from: • Epithelial lining of ducts • Epithelium of lobules Most Breast Cancers arise from ducts and are invasive

18. Prognosis • Factors that affect cancer prognosis • Size • Axillary node involvement • Tumor differentiation • Human epidermal growth factor receptor 2 (HER-2) status

19. HER-3 Receptors HER-2 receptors are found on the inside and outside of the Cancer cell. Receptors join together to send messages telling cancer cells to grow and divide

20. Signs and Symptoms • Detected as a lump • Abnormality on mammography • If palpable, irregular shaped, poorly delineated, nonmobile (usually attached to chest wall), and nontender • May have nipple discharge – bloody • Nipple retraction • Dimpling

21. Distribution of Breast Cancer Most commonly found in the upper outer quadrant

22. Diagnostic Testing

23. Breast Self Examination • Helps women to become self-aware of how their breasts normally look and feel and to detect when something changes. • Should be done monthly when the breasts are non tender, right after the end of menses • If no longer have menses – use the first day of each month

24. Breast Self Examination • 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

25. Breast Self Examination • 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. Go around breast, up and down over breast • and in outward from nipple. • Look at breasts with arms at side and arms raised and on hips • Next, lie down and do same procedure in palpating breasts.

26. Diagnosis • DNA testing for BRCA – 1 and BRCA-2 • Mammogram / ultrasound Mammogram showing Bilateral Invasive Ductal Carcinoma • Biopsy

27. Diagnostic Studies • Lymphatic mapping and sentinel lymph node dissection (SLND) • Helps surgeon identify lymph nodes that drain first from tumor site • Radioisotope and/or blue dye is injected into tumor site • Lymph nodes dissected and sent to lab for analysis

28. Review • While discussing risk factors for breast cancer, the nurse stresses that the greatest known risk factor for breast cancer is • Being a woman over 60 years of age • Experiencing menstruation for 40 years or more • Using estrogen replacement therapy during menopause • Having a paternal grandmother with postmenopausal breast cancer

29. Treatment

30. Treatment Options

31. Surgical Therapy

32. Surgical Therapy • Most common options for resectable Breast Cancer • Breast conservation surgery with radiation therapy • Modified radical mastectomy with or without reconstruction

33. Surgical TherapyAxillary Node Dissection • Sentinel lymph node dissection (SLND) has replaced ALND for patients who do not have malignant cells • ALND performed when one or more sentinel lymph nodes contain malignant cells • Examination of lymph nodes provides prognosis and treatment information

34. Surgical TherapyBreast Conservation Therapy • Involves removal of entire tumor with a margin of normal tissue • Radiation therapy is delivered to entire breast, ending with a boost to tumor bed • Evidence of systemic disease may warrant chemotherapy before radiation

35. Surgical Therapy • Modified radical mastectomy • Removal of breast and axillary lymph nodes with preservation of the pectoralis major muscle • Patient has the option of breast reconstruction

36. Radiation Therapy

37. Radiation Therapy • Primary radiation therapy • Usually performed after local excision of breast mass • Breast is radiated daily over ~5 to 6 weeks • “Boost” treatment may be given to full breast following primary dose • Intraoperative Radiation Therapy • Single intense dose delivered to surgery site in the operating room

38. Radiation Therapy • High-dose brachytherapy • Internal radiation delivered via radioactice seeds into a balloon catheter • Balloon catheter is placed within the lumpectomy site • Treatment is over 4-5 days

39. Radiation Therapy • Palliative radiation therapy • Used to stabilize symptomatic metastatic lesions in such sites as • Bone • Soft tissue organs • Brain • Chest • Relieves pain • Successful in controlling recurrent or metastatic disease for long periods

40. Radiation Therapy • Radiation therapy side effects • Fatigue • Skin changes • Breast edema

41. Hormonal Therapy

42. Hormonal Therapy • Removes or blocks source of estrogen, promoting tumor regression • Estrogen can increase growth of BC cells if cells are estrogen receptor positive • Most common drug used in estrogen-receptor positive women is: • Tamoxifen (Nolvadex) – antiestrogen • Side effects – decreased visual acuity, and vascular changes • Fulvestrant (Faslodex) - antiestrogen

43. Hormonal Therapy • Hormonal therapy (cont'd) • 2 advances have increased use in BC • Hormone receptor assays developed to identify those likely to respond to treatment • Drugs have been developed that can inactivate hormone-secreting glands as effectively as surgery or radiation

44. Biologic and Targeted Therapies

45. Biologic and Targeted Therapies • Trastuzumab (Herceptin) is a monoclonal antibody to HER-2 • Once the antibody attaches to antigen, it is taken to cells and eventually kills them • It can be used alone or in combination with other chemotherapies • Side-effect – monitor for signs of ventricular dysfunction and congestive heart failure.

46. Chemotherapy

47. Chemotherapy • Use of cytotoxic drugs to destroy cancer cells • BC is one of the solid tumors that is most responsive to chemotherapy • Given preoperatively in some patients to decrease size of primary tumor

48. Chemotherapy • Variety of side effects since healthy cells are also affected • Influenced by specific drug combinations, drug schedule, and dose of drug(s) • Most common side effects involve • Gastrointestinal tract • Bone marrow • Hair follicles

49. Nursing Care

50. Goals The patient will: • Actively participate in decision-making process related to treatment options • Fully comply with therapeutic plan • Manage side effects of therapy • Be satisfied with support provided by significant others and health care providers