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

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

6. Ask Yourself? Does having a fibrocystic breast condition increase a woman’s risk for development of breast cancer ?

7. Diagnosis • Ultrasound • Biopsy • Fine needle Aspiration • Excisional Why is a fine needle aspiration biopsy preferred over an excisional biopsy?

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. Breast Cancer

12. 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

13. 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

14. Risk Factors BRCA genebreast cancer susceptibility gene 1 and 2 • BRCA1 and BRCA2 are human genes that belong to a class of genes known as tumor suppressors. • In normal cells, BRCA1 and BRCA2 help ensure the stability of the cell’s genetic material (DNA) and help prevent uncontrolled cell growth. • Mutation of these genes has been linked to the development of hereditary breast and ovarian cancer. • 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.

15. How does assessing for HER-2 Receptors help in determining the prognosis? 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

16. Signs and Symptoms of breast cancer • 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

17. Diagnostic Testing

18. Breast Self Examination • One of the best ways for a woman 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

19. 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

20. 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.

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

22. 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

23. 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

24. Treatment

25. Treatment Options

26. Surgical Therapy

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

28. 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

29. 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

30. 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

31. Radiation Therapy

32. 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

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

34. 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

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

36. Hormonal Therapy

37. 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

38. 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

39. Biologic and Targeted Therapies How are these used in treatment?

40. 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 to alone or in combination with other chemotherapies • Side-effect – monitor for signs of ventricular dysfunction and congestive heart failure.

41. Chemotherapy

42. 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

43. Nursing Care

44. 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

45. Nursing Intervention • Complications; • Heaviness • Pain • Impaired motor function in arm • Numbness • Paresthesia of the fingers • Cellulitis and progressive fibrosis can result http://www.youtube.com/watch?v=Di5E_KXbAnU&feature=related

46. Measures to decrease Lymphedema • Positioning • Place in a semi-Fowler’s position with arm on affected side elevated on a pillow, never dependent • Exercise • Flexing and extending fingers should begin in recovery room and progressive increase in activity • Exercises are designed to prevent contractures and muscle shortening, maintain muscle tone, and improve lymph and blood circulation • Postoperative arm and shoulder exercises are instituted gradually at surgeon’s direction

47. Measure to decrease Lymphedema • Avoid constriction • Do not take Blood pressure readings on that arm • Avoid constrictive clothing • Compression • Wrap arm with bandages going from distal to proximal • Use intermittent pneumatic compression sleeve or a fitted elastic pressure gradient sleeve • Massage Therapy

48. Protection of the Arm with Lymphedema • Venipunctures, and injections should not be done on affected arm • Apply insect repellant • Wear gloves when gardening • Use cooking mitt • Use electric razor for shaving axilla • Avoid cutting cuticles – push back cuticle • No heavy lifting • Keep clean and dry

49. Postoperative Exercises

50. Nursing Interventions • Relieve postmastectomy pain syndrome: • Chest and upper arm pain, tingling down arm • Numbness, shooting or prickling pain • Unbearable itching persisting beyond 3-month healing time • Treatment includes • Nonsteroidalantiinflammatory drugs • Antidepressants • Topical lidocaine patches or EMLA