Breast Cancer

Question 1

What is the pathophysiology of breast cancer?

Answer 1

Cancer of the breast begins as a single transformed cell that grows and multiplies in the epithelial cells lining one or more of the mammary ducts or lobules. It is a heterogeneous disease, having many forms with different clinical signs and symptoms, and varying responses to therapy. Some breast cancers present as a palpable lump in the breast, whereas others show up only on a mammogram.
- There are two broad categories of breast cancer: noninvasive and invasive. As long as the cancer remains within the mammary duct, it is referred to as noninvasive. The more common type of breast cancer is classified as invasive; this type grows into surrounding breast tissue.

Question 2

What are the common sites of breast cancer metastasis?

Answer 2

The most common sites of metastasis are brain, bones, liver, and lung, but breast cancer can spread to any organ.

Question 3

What are the types of noninvasive (in situ) breast cancers?

Answer 3

• Ductal carcinoma in situ (DCIS) is an early noninvasive form of breast cancer. In DCIS, cancer cells are located within the duct and have not invaded the surrounding fatty breast tissue. Because of more precise mammography screening and earlier detection, the number of women diagnosed with DCIS has increased. Currently there is no way to determine which DCIS lesions will progress to invasive cancer and which ones will remain unchanged; however, evidence does confirm that DCIS can be a precursor to invasive cancer.
• Lobular carcinoma in situ (LCIS) the cells look like cancer cells and are contained within the lobules (milk-producing glands) of the breast. LCIS is not considered cancer but does increase the patient’s risk for developing invasive breast cancer. It is usually diagnosed before menopause in women 40 to 50 years of age. Traditionally LCIS is treated with close observation only, but surgical excision is an option.

Question 4

What are invasive types of breast cancer?

Answer 4

• Invasive ductal carcinoma. As the name implies, the disease originates in the mammary ducts and breaks through the walls of the ducts into the surrounding breast tissue. Once invasive, the cancer grows into the tissue around it in an irregular pattern. If a lump is present, it is felt as an irregular, poorly defined mass. As the tumor continues to grow, fibrosis (replacement of normal cells with connective tissue and collagen) develops around the cancer. This fibrosis may cause shortening of the Cooper ligaments and the resulting typical skin dimpling that is seen with more advanced disease. Another sign, sometimes indicating late-stage breast cancer, is an edematous thickening and pitting of breast skin called peau d’orange (orange peel skin).
• Inflammatory breast cancer (IBC). It is characterized by diffuse erythema and edema (peau d’orange). Patients typically report breast pain or a rapidly growing breast lump. Other common symptoms include a tender, firm, enlarged breast and breast itching. Because of its aggressive nature, IBC is usually diagnosed at a later stage than other types of breast cancer and is often harder to treat successfully.

Question 5

What are other types of breast cancer?

Answer 5

Paget Disease
- Paget disease of the nipple is a rare breast cancer that occurs in or around the nipple. Although more common in women, it can also occur in men. It usually affects the nipple ducts, followed by the nipple surface, and then the areola, leaving the area scaly, red, and irritated. It is critical to teach patients to see their health care provider if they have these symptoms, as people with Paget disease often have other types of breast cancer.

Triple-Negative Breast Cancer
- Triple-negative breast cancer (TNBC) lacks expression of the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). This type of breast cancer grows rapidly and is often found in women with BRCA mutation who are premenopausal. African-American women are at higher risk for TNBC than women of other races.

Question 6

What risk factors are associated with breast cancer?

Answer 6

• Female gender
• Age >65 years old
• Genetic factors: Inherited BRCA1 and/or BRCA2 increases risk
• History of a previous breast cancer
• Breast density: Dense breasts contain more glandular and connective tissue, which increases the risk for developing breast cancer.
• Atypical hyperplasia
• Family history
• Exposure to ionizing radiation
• High postmenopausal bone density: High estrogen levels over time both strengthen bone and increase breast cancer risk.
• Childless women have an increased risk, as do women who bear their first child at or after age 30.
• Menstrual history
  Early menstruation (younger than 11 years) or Late menopause (at or older than 55 years) or Both
• Recent oral contraceptive use
• Recent hormone replacement therapy (HRT)
• Obesity
• Alcohol consumption
• High socioeconomic status: Breast cancer incidence is greater in women of higher education and socioeconomic background. This relationship is possibly related to lifestyle differences, such as later age at first birth.
• Jewish heritage: Women of Ashkenazi Jewish heritage have higher incidences of BRCA1 and BRCA2 genetic mutations.

Question 7

What are some health promotion and maintenance tips the nurse notify the patient about?

Answer 7

Mammography
* Women at average risk of breast cancer begin annual screening mammography at age 45 up to age 54. Women ages 40 to 44 should have the choice to start annual mammograms after the risks and potential benefits have been explained. Women age 55 and older may switch to mammograms every 2 years, or continue annual screening mammograms if they choose to do so. Mammography should continue as long as a woman is in good health and has a life expectancy of at least 10 years

Breast Self-Awareness/Self-Examination
- Data demonstrate that breast self-examination is not a meaningful screening tool for breast cancer (Komen, 2020). However, it is recommended that women increase breast self-awareness by becoming familiar with how their breasts look and feel so that they can report differences or abnormalities.
- Teach a woman that lumps are not necessarily abnormal. For premenopausal women, lumps can come and go with the menstrual cycle. Most lumps that are detected and tested are not malignant.
- Some women may want to practice regular breast self-examination (BSE) as a method for breast self-awareness. BSE should be presented as an option to women beginning in their early 20s. In addition to breast self-awareness, place emphasis on clinical breast examination (CBE) and mammogram for early detection of breast cancer. The combined approach is better than any single test. A woman who chooses to perform BSE should be taught the correct technique and have it reviewed by a health care provider during her CBE.
- Use teaching models of normal and abnormal breasts when teaching BSE. Discuss the proper timing for BSE. Instruct premenopausal women to examine their breasts 1 week after the menstrual period. At this time, hormonal influence on breast tissue is decreased, so fluid retention and tenderness are reduced. Teach women whose breast tissue is no longer influenced by hormonal fluctuations, such as after a total hysterectomy or menopause, to pick a day each month to do BSE, such as the first day of the month. The BSE technique is similar for women and men. The Best Practice for Patient Safety & Quality Care: Performing Breast Self-Examination box describes the procedure for breast self-examination and may be used as a patient resource.

Question 8

What are some other options for high-risk women?

Answer 8

• Those with a personal history of breast cancer are at risk for developing a recurrence or a new breast cancer. Women with known BRCA1 and/or BRCA2 genetic mutation have a lifetime risk of developing breast cancer by age 70 of about 55% to 60% and 45%, respectively. Women in this category usually practice close surveillance as a prevention option. It is a method of secondary prevention and is used to detect cancer early in the initial stages. In addition to annual mammography and clinical breast examination, high-risk women are recommended to have an annual breast MRI screening. Close surveillance may begin as early as age 30 years, but evidence is limited regarding the best age at which to start screening. For women with a high risk for breast cancer development due to family history such as cancer in a mother or sister, it is recommended that cancer screening begin at the age that is 10 years younger than the age at which the affected cancer patient was initially diagnosed. Encourage high-risk women to discuss their personal preferences for close surveillance with their primary health care providers.
• Other options currently available for reducing a woman’s breast cancer risk are prophylactic mastectomy (preventive surgical removal of one or both breasts), prophylactic ophorectomy (removal of the ovaries), and chemopreventive drugs. Although each option significantly reduces the risk for breast cancer, no option completely eliminates it. Each option has its own risks and potentially serious complications.
• Even though a woman may decide to have a prophylactic mastectomy, there is a small risk that breast cancer will develop in residual breast glandular tissue because no mastectomy reliably removes all mammary tissue. Women must also understand that breast reconstruction after a prophylactic mastectomy is very different from breast augmentation. It is a more complex surgical procedure with a greater potential for complications. The decision to have this type of surgery can be a very difficult one to make. Women may find it helpful to reach out to a breast cancer support organization and talk to someone who has been through a prophylactic mastectomy.
• Women undergoing prophylactic oophorectomy will likely experience menopausal symptoms, although some estrogen remains in body fat tissue. Chemoprevention drugs, such as tamoxifen, reduce breast cancer recurrence but carry other risks such as blood clots and endometrial cancer. Encourage women to carefully consider the benefits and risks of breast cancer risk–reducing options and discuss them with their health care provider.

Question 9

What questions should the nurse ask the patient regarding their history?

Answer 9

Ask specific information about personal and family histories of breast cancer. In addition to increasing the woman’s own risk, these factors also affect any sisters’ or daughters’ risk and should be part of later counseling.

Ask about the woman’s gynecologic and obstetric (if any) history, including:
- Age at menarche
- Age at menopause
- Symptoms of menopause
- Age at first child’s birth (or nulliparity—having no children)
- Number of children and pregnancies, including miscarriages or terminations

Question 10

What is included in the physical assessment/signs and symptoms?

Answer 10

• Document any abnormal findings from the clinical breast examination.
• Describe specific information about a breast mass (as described in the Best Practice for Patient Safety & Quality Care: Assessing a Breast Mass box), such as location, using the “face of the clock” method; shape; size; consistency; and whether the mass is mobile or fixed to the surrounding tissue.
• Note any skin change, such as peau d’orange, redness and warmth, nipple retraction, or ulceration, which can indicate advanced disease. - Document the location of any enlargements of axillary and supraclavicular lymph nodes.
• Evaluate for the presence of pain or tenderness in the affected breast.

Question 11

What is a part of the psychosocial assessment?

Answer 11

• A breast cancer diagnosis is usually an unanticipated event in the life of a woman who feels physically well. It initiates a sudden and distressing transition into a potentially life-threatening illness.
• Feelings of fear, shock, and disbelief are predominant as a woman learns about the disease and faces numerous treatment decisions. Psychological distress is common at cancer diagnosis and at the various transitions of treatment.
• A previous history of mental illness, age, and life circumstances can contribute to increased psychological distress. Encourage expression of feelings, focusing on the human component of care and determine if a referral to a counselor would be helpful.
• There are also multiple community resources available for the person diagnosed with breast cancer. Talking with someone who has been through the experience is particularly helpful in dealing with the emotional aspects of the disease.
• Assess the patient for concerns related to sexuality. Sexual dysfunction affects most breast cancer survivors in some way. Sometimes it is related to the loss of a breast and the threat to one’s femininity, her image of herself, or how she perceives her partner’s response. Lack of libido (sexual desire) related to hormonal changes, psychological distress, and anxiety are commonly experienced by women with breast cancer.
• If the patient does not discuss sexual concerns voluntarily, open the conversation in a nonthreatening, nonjudgmental way. Use resources that provide education about alternative expressions of intimacy and a focus on pleasure rather than performance. Refer the patient and her partner to counseling if appropriate.

Question 12

What laboratory assessments are involved?

Answer 12

• The diagnosis of breast cancer relies on pathologic examination of tissue from the breast mass. After the diagnosis of cancer is established, laboratory tests, including pathologic study of the lymph nodes, help detect possible metastases.
• Elevated liver enzyme levels indicate possible liver metastases, and increased serum calcium and alkaline phosphatase levels could suggest bone metastases.

Question 13

What diagnostics/imaging is done?

Answer 13

• Mammography is a sensitive screening tool for breast cancer. The uniqueness of this test results from its ability to reveal preclinical lesions (masses too small to be palpated manually). Most breast centers now use digital mammography, a system that is able to read, file, and transmit mammograms electronically.
• Some women may voice concern about radiation exposure with mammograms. Reassure them that the dose is very small and the risk for harm from radiation is minimal.
• Digital breast tomosynthesis is technology that is similar to mammography but uses three-dimensional images. It is useful in evaluating dense breasts and is more accurate in women younger than 50. In the United States, currently it is covered by Medicare and most other major health insurances. This advanced technology is also available in Canada.
• Ultrasonography of the breast is an additional diagnostic tool used to clarify findings on mammography. If the mammogram reveals a lesion, ultrasonography is helpful in differentiating a fluid-filled cyst from a solid mass. Mammography screening combined with ultrasound may be effective for detecting cancers in women with dense breasts, but currently it is not recommended for routine breast cancer screening as a stand-alone imaging tool.
• MRI is used for screening high-risk women and better examination of suspicious areas found on a mammogram. It is more expensive than mammography. Most insurance companies will cover a portion of the cost if the woman is shown to be at high risk. Although higher-quality images are produced, there is concern about high costs and access to quality breast MRI services for high-risk women. Most major insurances will cover a portion of MRI costs for women shown to be at higher risk
• If the patient has an invasive breast cancer, other imaging tests may be done to rule out metastases. Positron emission tomography (PET) scan, brain MRI, and CT scans of the chest, abdomen, and pelvis can reveal distant metastases.

Question 14

What are other diagnostics that can be done?

Answer 14

• Although imaging techniques serve as tools for screening and more precise visualization of potential breast cancers, breast biopsy (pathologic examination of the breast tissue) is the only definitive way to diagnose breast cancer. - Tissue samples are analyzed by a pathologist to determine the presence of breast cancer. If breast cancer is identified, it is classified according to the size and type of breast cancer, the histologic grade, and the type of receptors on the cells. These characteristics are used to guide treatment. For example, a small, noninvasive breast cancer may only be treated with lumpectomy and radiation, whereas a larger, aggressive tumor (one with a high histologic grade) may be treated with a mastectomy and chemotherapy, followed by radiation.
• Cancer cells that contain estrogen receptors (ER positive) or progesterone receptors (PR positive) have a better prognosis and usually respond to hormonal therapy. If the type of breast cancer is HER2 positive, or one in which the neu gene is overexpressed, it may be treated successfully with trastuzumab, which is a HER2-positive breast cancer–specific targeted therapy.
• Most women, even those with very small tumors, receive some sort of treatment in addition to surgery for breast cancer. Research has focused on ways to predict clinical outcomes so that low-risk women may avoid unnecessary treatments. Genomic tests, such as Oncotype DX and MammaPrint, have been developed to help predict clinical outcomes by analyzing genes in breast cancer tissue. Some health care providers use this information in addition to the pathologic analysis for guiding treatment decisions. These multigene tests have been shown to be accurate predictors of patient prognosis and response to therapy in breast cancer

Question 15

What are the collaborative problems for a patient with breast cancer?

Answer 15

1. Potential for cancer metastasis due to lack of, or inadequate, treatment
2. Potential for impaired coping due to breast cancer diagnosis and treatment

Question 16

What nonsurgical interventions are associated with breast cancer?

Answer 16

Complementary and integrative health
- Women with breast cancer often cope with distressing symptoms related to the disease itself or the side effects of treatment.
- Common symptoms associated with these treatments include pain, nausea/vomiting, hot flashes, anxiety, depression, and fatigue. Physical and emotional symptoms associated with breast cancer may be eased with the use of complementary and integrative therapy. Prayer is also widely used.
- Other types of therapies include guided imagery and massage. The most frequently used strategies are biologically based therapies such as vitamins, special cancer diets, and herbal therapy.
- Teach the patient that all ingested complementary agents potentially risk interaction with conventional drugs.
- Encourage women to seek a practitioner with a certification or license for the specific type of integrative therapy intervention. In some states, a certification or license is required for acupuncture, chiropractic therapy, massage, and shiatsu.
- Some types of complementary and integrative therapy can be self-taught or done alone after a few sessions of instruction.
- Although the use of complementary and integrative therapy can improve quality of life, its use does not alter the outcome of breast cancer, and it should not be used in place of standard treatment. Encourage patients who are interested in trying these therapies to check with their health care provider before using them.
- Cost may be a factor in decision making because not all insurances provide coverage for complementary and integrative therapies. Remind the patient that it is important to disclose to the health care provider all treatments undertaken.
- For patients with breast cancer at a stage for which surgery is the main treatment, follow-up with adjuvant (in addition to surgery) radiation, chemotherapy, hormone therapy, or targeted therapy is commonly prescribed. For those who cannot have surgery or whose cancer is too advanced, these therapies may be used to promote comfort (palliation).

Question 17

What surgical interventions are associated with breast cancer?

Answer 17

• The patient with breast cancer may appear to have difficulty coping and experience anxiety related to the disease or treatment. The fear and uncertainty for the patient with breast cancer begin the moment a lump is discovered or when a mammogram reveals an abnormality. These feelings may be related to past experiences and personal associations with the disease. Assess the patient’s situational perceptions. Allow the expression of feelings even if a diagnosis has not been established.
• Assess the patient’s need for knowledge. Some may want to read and discuss any available information. Provide accurate information and clarify any misinformation the patient may have received through the media, on the Internet, or from family and friends. If the mass has been diagnosed as cancer, many people feel a partial sense of relief to be dealing with a known entity. A feeling of shock or disbelief usually occurs. It is difficult to accept a diagnosis of cancer when one feels basically well. Patients and their families or significant others deal in individual ways with the mix of feelings. Adjust your approach to care as the patient’s emotional state changes. The goal is to have the patient participate as an active partner in management of the disease.
  An integral part of the plan to meet these emotional needs is the use of outside resources. For example, the patient who is worried in particular about the side effects of radiation therapy may benefit more from talking to someone who has undergone radiation than from talking to the nurse or primary health care provider. The American Cancer Society’s “Reach to Recovery” program is just one community resource that connects breast cancer patients to a peer who has lived through the treatment the patient is facing. Be sure to assess her preference and place appropriate referrals.
• Another helpful resource for patients who desire to receive care at one location is a full-service cancer center. Some agencies have all cancer services offered comprehensively in one location, including surgeon and provider services, counseling, nursing care, social services, nutrition services, rehabilitation, various therapies (including chemotherapy), and spiritual ministry. Obtaining all services in one familiar location can decrease the stress that the patient feels.

Question 18

What is included in the preoperative care for surgical management?

Answer 18

Care of the patient facing surgery for breast cancer focuses on psychological preparation and preoperative teaching. Priority nursing interventions are directed toward relieving anxiety and providing information to increase patient knowledge. Include the spouse, partner, or other family member or significant other, who may be experiencing similar stress and confusion, in the health teaching unless the patient does not desire this or the patient’s culture does not permit this approach.

Review the type of procedure planned. Use open-ended questions (e.g., “What type of surgery are you having? Can you explain what will happen?”) to assess the patient’s current level of knowledge. Provide postoperative information, including:
- The need for a drainage tube
- The location of the incision
- Mobility restrictions
- The length of the hospital stay (if any)
- General preoperative and postoperative information needed by any surgical patient

Supplement teaching with written or digital materials for the patient and family. This information should include whom to call in case there are any complications or questions.

Address body image issues and expectations before surgery to avoid misconceptions about appearance after surgery.

If available, suggest that patients and their caregivers attend classes before surgery in an ambulatory care setting, such as a breast cancer center, to promote successful early discharge from the hospital.

Programs that provide emotional support, information, and opportunities for discussion related to sexuality, body image, and preoperative and postoperative care enhance the recovery of the short-stay mastectomy patient.

Question 19

What are the different types of breast surgery that a patient can have?

Answer 19

Lumpectomy
- Removal of the lump (tumor).

Partial Mastectomy
- Removal of the lump (tumor) as well as the removal of some of the lymph nodes.

Total (simple) Mastectomy
- The entire breast is removed as well as some of the lymph nodes under the arm may be removed.

Modified Radical (total) Mastectomy
- The entire breast and some of the lymph nodes are removed. Part of the chest wall muscle may also be removed.

Question 20

What are indications for mastectomy?

Answer 20

• Multicentric disease (tumor is present in different quadrants of the breast)
• Inability to have radiation therapy
• Presence of a large tumor in a small breast
• Genetic testing results
• Patient preference

Question 21

What is a part of the postoperative care?

Answer 21

• The hospital stay after breast surgery is short, often same day or just overnight, and recovery is usually not complicated.
• After surgery, avoid using the affected arm for measuring blood pressure, giving injections, or drawing blood.
• If lymph nodes are removed, it is critical to prevent trauma to the affected arm. The patient returns from the postanesthesia care unit (PACU) as soon as vital signs return to baseline levels and if no complications have occurred.
• Assess vital signs on a schedule of decreasing frequency, such as every 30 minutes for two times, every hour for two times, and then every 4 hours. During these checks, assess the dressing for bleeding.
• Assess the patient’s position to ensure that the drainage tubes or collection device is not pulled or kinked. The patient should have the head of the bed elevated at least 30 degrees, with the affected arm elevated on a pillow while awake. Keeping the affected arm elevated promotes lymphatic fluid return after removal of lymph nodes and channels.
• Provide other basic comfort measures, such as repositioning and analgesics as prescribed, on a regular basis until pain ceases. Patient-controlled analgesia may be used for some patients for a short time, depending on the type of surgery that was performed.
• Ambulation and a regular diet are resumed by the day after surgery. While the patient is walking, the arm on the affected side may need to be supported at first. Gradually the arm should be allowed to hang straight by the side. Encourage the patient to use good posture to prevent mobility issues.
• Beginning exercises that do not stress the incision can usually be started on the first day after surgery. These exercises include squeezing the affected hand around a soft, round object (a ball or rolled washcloth) and flexion/extension of the elbow.
• The progression to more strenuous exercises depends on the subsequent procedures planned (e.g., reconstruction) and the surgeon’s directions. The patient can be discharged to home after safely ambulating and when surgical pain is under control.

Question 22

What are some post mastectomy exercises?

Answer 22

Hand Wall Climbing
* Face the wall and put the palms of your hands flat against the wall at shoulder level.
* Flex your fingers so your hands slowly “walk” up the wall.
* Stop when your arms are fully extended.
* Slowly “walk” your hands back down the wall until they return to shoulder level.

Rope Turning
* Tie a rope to the knob of a closed door.
* Hold the other end of the rope and step back from the door until your arm is almost straight out in front of you.
* Swing the rope in a circle. Start with small circles and gradually increase to larger circles as you become more flexible.

Side Bends
* Sit in a chair.
* Clasp your hands together.
* Slowly raise your arms over your head and then gently bend to each side.

Shoulder Blade Squeeze
* Sit in chair. Do not rest your back against the chair.
* Place arms at side, elbows bent.
* Squeeze your shoulder blades together behind you. Do not lift your shoulders up toward your ears.

Question 23

What should be assessed when it comes to breast reconstruction?

Answer 23

Assess her attitude by asking about future plans for restoring appearance. Although reconstruction is not appropriate for some women and others may not be interested in it, the surgeon should discuss the indications and contraindications, advantages and disadvantages, and typical recovery. If immediate reconstruction is chosen, the breast surgeon should be aware of this before surgery so plans can be coordinated with those of the plastic surgeon.

Question 24

What are the common types of breast reconstruction?

Answer 24

• Breast expanders are the most common method of breast reconstruction used in the United States. A tissue expander is a balloon-like device with a resealable metal port that is placed under the pectoralis muscle. A small amount of normal saline is injected intraoperatively into the expander to partially inflate it. The patient then receives additional weekly saline injections for about 6 to 8 weeks until the expander is fully inflated. When full expansion is achieved, the tissue expander is then exchanged for a permanent implant during surgery in an ambulatory care center. The permanent implant is filled with either saline or silicone.
• Autologous reconstruction using the patient’s own skin, fat, and muscle is advantageous because the donor site tissue is similar in consistency to that of the natural breast. Therefore the results more closely resemble a real breast compared with implant reconstruction. Flap donor sites include the latissimus dorsi flap (back muscle); transverse rectus abdominis myocutaneous flap, known as the TRAM flap (abdominal muscle); and the gluteal flap (buttock muscle). Reconstruction of the nipple-areola complex is the last stage in the reconstruction of the breast.

Question 25

What is a part of the postoperative care of the patient after breast reconstruction.

Answer 25

• Assess the incision and flap for signs of infection (excessive redness, drainage, odor) during dressing changes.
• Assess the incision and flap for signs of poor tissue perfusion (duskiness, decreased capillary refill) during dressing changes.
• Avoid pressure on the flap and suture lines by positioning the patient on her nonoperative side and avoiding tight clothing.
• Monitor and measure drainage in collection devices, such as for Jackson-Pratt (JP) drains.
• Teach the patient to return to her usual activity level gradually and to avoid heavy lifting.
• Remind the patient to avoid sleeping in the prone position.
• Teach the patient to avoid participation in contact sports or other activities that could cause trauma to the chest.
• Teach the patient to minimize pressure on the breast during sexual activity.
• Remind the patient to refrain from driving until advised by the surgeon.
• Remind the patient to ask at the 6-week postoperative visit when full activity can be resumed.
• Reassure the patient that optimal appearance may not occur for 3 to 6 months after surgery.
• If implants have been inserted, teach the proper method of breast massage to enhance expansion and prevent capsule formation (consult with the health care provider).
• Emphasize breast self-awareness; if the patient performs breast self-examination (BSE), review her technique.
• Remind the patient of the importance of clinical breast examination and follow-up surveillance by her health care provider

Question 26

What should women have done for close surveillance?

Answer 26

Women who have had a mastectomy and breast reconstruction in one breast should have close-surveillance breast cancer screening in the contralateral (opposite) breast, including imaging with mammography or mammography and MRI. Mammography and MRI are not recommended to be done routinely in reconstructed breasts because most local recurrences of breast cancer in the residual tissue are palpable during clinical breast examination.

Question 27

What is it called when a woman decides to follow the original surgical procedure with additional treatment to help keep the cancer from recurring is known as what?

Answer 27

Adjuvant therapy

Question 28

The decision to have adjuvant therapy is based on what factors?

Answer 28

• Stage of the disease
• Patient’s age and menopausal and functional status
• Patient preferences
• Pathologic examination
• Hormone receptor (ER/PR) status
• HER2/neu status
• Presence of a known genetic predisposition

Question 29

What does adjuvant therapy for breast cancer consist of?

Answer 29

Adjuvant therapy for breast cancer consists of systemic chemotherapy, radiation therapy, or a combination of both. The purpose of radiation therapy is to reduce the risk for local recurrence of breast cancer. The goal of systemic therapy (with chemotherapy, hormone therapy, and targeted therapy) is to reduce the risk of recurrence (locally or at distant sites) and prevent cancer-related death. These drugs destroy breast cancer cells that may be present anywhere in the body. They are typically delivered after surgery for breast cancer, although neoadjuvant chemotherapy may be given to reduce the size of a tumor before surgery. Endocrine therapy may also be used as a chemoprevention option for high-risk women with a personal history of breast cancer.

Question 30

When is radiation therapy administered?

Answer 30

Radiation therapy is administered after breast-conserving surgery to kill breast cancer cells that may remain near the site of the original tumor. This therapy can be delivered to the whole breast or to only part of the breast. Whole-breast irradiation is delivered by external beam radiation over a period of 5 to 6 weeks.

Question 31

What is partial breast irradiation (PBI)?

Answer 31

Partial breast irradiation (PBI) is an option for women with early-stage breast cancer. PBI is a convenient alternative to whole-breast radiation. Less time is needed for completion, and outcomes are comparable to those of whole-breast radiation. The advantage of this type of radiation is that it is delivered over a much shorter time interval, eliminating the need for weeks of treatment.

Question 32

What are the different types of methods available for delivering PBI?

Answer 32

• Brachytherapy is a form of treatment in which an external catheter is inserted at the lumpectomy cavity and surrounding margin, and radioactive seeds are inserted into a multicatheter or balloon catheter device. Radiation is given over a period of 5 days. Ten treatments are given in total, with at least 6 hours between treatments.
• Intraoperative radiation therapy is the most accelerated form of PBI. It uses a high single dose of radiation delivered during the lumpectomy surgery

Question 33

What nursing care is provided for the patient undergoing radiation therapy?

Answer 33

Nursing care for the patient undergoing radiation therapy includes patient education and side effect management. Skin changes are a major side effect during this therapy. If brachytherapy is planned, instruct patients about the procedure. Assure them that they will be radioactive only while the radiation source is dwelling inside the breast tissue.

Question 34

When is chemotherapy recommended?

Answer 34

Chemotherapy is recommended for treatment of invasive breast cancer after surgery (adjuvant chemotherapy). It may also be given before surgery to reduce the size of the tumor (neoadjuvant chemotherapy) and is most effective when combinations of more than one drug are used. Sometimes a patient needs to have a surgically implanted IV catheter before chemotherapy administration. Chemotherapy drugs are usually delivered in four to six cycles, with each period of treatment followed by a rest period to give the body time to recover from the adverse effects of the drugs. Each cycle is 2 to 3 weeks long. The total treatment time is 3 to 6 months, although treatment may be longer for advanced or HER2-positive breast cancer.

Question 35

What is a common chemotherapy regimen?

Answer 35

A common chemotherapy regimen for breast cancer treatment is doxorubicin, cyclophosphamide, and paclitaxel, which in the United States is also known as AC-T. If the patient is HER2 positive, a trastuzumab-based regimen will be used. In early-stage breast cancer, chemotherapy regimens lower the risk for breast cancer recurrence and death. In metastatic breast cancer, chemotherapy regimens reduce cancer size and slow the progression of disease.

Question 37

What are some home management points that the nurse should relay to the patient?

Answer 37

• In collaboration with the case manager and members of the interprofessional health care team, make the appropriate referrals for care after discharge. Preoperative teaching and arrangements for home care management and referrals can be started before surgery or other treatment.
• The patient who has undergone breast surgery can be discharged to the home setting unless other physical disabilities exist. Some are discharged the day after surgery with drains in place; some are discharged to home on the day of surgery. Older adults should not be sent home without a family member or friend who can stay with them for 1 to 2 days. These patients may need some assistance at home with drain care, dressings, and ADLs because of pain and impaired range of motion of the affected arm.
• Teach patients that activities involving stretching or reaching for heavy objects should be avoided temporarily. This restriction can be discussed with a family member or significant other who can perform these tasks or place the objects within easy reach.

Question 38

What self-management education should the nurse educate the patient about?

Answer 38

The teaching plan for the patient after surgery includes:
* Care of the incision and drainage device
* Exercises to regain full range of motion
* Measures to avoid lymphedema
* Measures to improve body image, coping, and self-esteem
* Information about interpersonal relationships and roles

Question 39

What should be assessed about a patient recovering from breast cancer surgery?

Answer 39

Assess cardiovascular, respiratory, and urinary status:
* Vital signs
* Lung sounds
* Urine output patterns

Assess for pain and effectiveness of analgesics.

Assess dressing and incision site:
* Excess drainage
* Symptoms of infection
* Wound healing
* Intact staples, sutures

Assess drain and site:
* Drainage around site and within drain reservoir
* Color and amount of drainage
* Symptoms of infection

Review patient’s recordings of drainage.

Evaluate patient’s ability to care for and empty drain reservoir.

Assess status of affected extremity:
* Range of motion
* Ability to perform exercise regimen
* Lymphedema

Assess nutritional status:
* Food and fluid intake
* Presence of nausea and vomiting
* Bowel sounds

Assess functional ability:
* ADLs
* Mobility and ambulation
Assess home environment:
* Safety
* Structural barriers

Assess patient’s compliance and knowledge of illness and treatment plan:
* Follow-up appointment with surgeon
* Symptoms to report to health care provider
* Hand and arm care guidelines

Question 40

The teaching that a patient should be given postoperative from a mastectomy?

Answer 40

• Teach incisional care to the patient, family, and/or other caregiver. The patient may wear a light dressing to prevent irritation. Although swelling and redness of the scar itself are normal for the first few weeks, swelling, redness, increased heat, and tenderness of the surrounding area indicate infection and should be reported to the surgeon immediately. If a lymph node dissection was performed, instruct the patient to elevate the affected arm on a pillow and to use interventions to decrease risk of lymphedema. Encourage the patient to dress in comfortable street clothes at home, not pajamas, to further enhance a positive self-image
• Teach the patient to continue performing the exercises that began in the hospital. Active range-of-motion exercises should begin 1 week after surgery and should be continued after sutures and drains are removed. Emphasize that reaching and stretching exercises should continue only to the point of pain or pulling, never beyond that. Some YWCA locations have a free postmastectomy program that supports patients following breast cancer surgery.
• Patients should be screened for mobility and provided education on exercises to perform after surgery. Referral to physical therapy prior to surgery allows for education and assessment to be done in a nonhurried environment. Additionally, if the patient is unable to raise her arm over her head, positioning for radiation therapy will be difficult.
• Lymphedema, an abnormal accumulation of protein fluid in the subcutaneous tissue of the affected limb after a mastectomy, is a commonly overlooked topic in health teaching. Risk factors include injury or infection of the extremity, obesity, presence of extensive axillary disease, and radiation treatment. Once lymphedema develops, it can be very difficult to manage, and lifelong measures must be taken toprevent it. Nurses play a vital role in educating patients about this complication. Teach patients, especially those who have had axillary lymph nodes removed, that measures to prevent lymphedema are lifelong and include avoiding trauma to the arm on the side of the mastectomy. Teach your patient to immediately report symptoms of lymphedema such as sensations of heaviness, aching, fatigue, numbness, tingling, and/or swelling in the affected arm, as well as swelling in the upper chest. Nurses should not assume that women with lymphedema are disabled; they are able to live full lives within this limitation. A referral to a lymphedema specialist may be necessary for the patient to be fitted for a compression sleeve and/or glove, to be taught exercises and manual lymph drainage, and to discuss ways to modify daily activities to avoid worsening the problem. Management is directed toward measures that promote drainage of the affected arm.

Question 41

What to do for psychosocial preparation?

Answer 41

• Concerns about appearance after surgery are common and are often a threat to the patient’s self-concept as a woman. Before breast surgery, the woman and her partner can benefit from an explanation of the expected postoperative appearance. After a modified radical mastectomy, the chest wall is fairly smooth and has a horizontal incision from the axilla to the mid-chest area. After breast-conserving surgery, scars vary according to the amount of breast tissue removed. Emphasize that scars will fade and edema will lessen with time. Scars may be red and raised at first, but these features lessen in the first few months. After surgery, encourage the woman to look at her incision when she is ready. Do not push her to accept this body image change immediately.
• Much of one’s body image is a reflection of how others respond. Therefore the response of the patient’s partner or family members to the surgery impacts the effect on self-esteem. These people may also need the support of the nurse. They may have concerns about their ability to accept the changes and need to discuss these feelings with an objective listener. They may also need help with communicating their feelings, both negative and positive, to their loved one. Involving them in teaching, if the patient desires, may also help reinforce learning and increase retention.
• Discuss sexual concerns before discharge. Most surgeons recommend avoiding sexual intercourse for 4 to 6 weeks. Patients may prefer to lay a pillow over the surgical site or to wear a bra, camisole, or T-shirt to prevent contact with the surgical site during intercourse. He or she may be embarrassed to discuss the topic of sexuality. Be sensitive to possible concerns and approach the subject first.
• For young women, issues related to childbearing may be a concern. Chemotherapy and radiation are considered serious teratogenic (birth defect–causing) agents. Advise sexually active patients receiving chemotherapy or radiotherapy to use birth control during therapy. The method and length of birth control should be discussed with the health care provider. Patients with hormone ER/PR–positive breast cancer need to avoid estrogen, including contraceptives.

Question 42

What hormonal therapy medications can the patient take as a form of nonsurgical management of breast cancer?

Answer 42

• Drugs that alter hormone levels may also be used in breast cancer prevention and treatment. The purpose of endocrine therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth. Premenopausal women whose main estrogen source is the ovaries may benefit from drugs that inhibit estrogen synthesis. These drugs include leuprolide and goserelin, which suppress the hypothalamus from making luteinizing hormone–releasing hormone (LH-RH). When LH-RH is inhibited, the ovaries do not produce estrogen. Although the suppression of ovarian function decreases breast cancer risk, the drastic drop in estrogen causes significant menopausal symptoms. Therefore the decision to use these drugs is not made lightly.
• Selective estrogen receptor modulators (SERMs), on the other hand, do not affect ovarian function. Rather, they block the effect of estrogen in women who have estrogen receptor (ER)–positive breast cancer. SERMs are also used as chemoprevention in women at high risk for breast cancer and in women with advanced breast cancer. For women with hormone receptor–positive breast cancer, tamoxifen reduces the chances of the cancer coming back by about half. Common side effects of SERMs include hot flashes and weight gain. Rare but serious side effects of these drugs include endometrial cancer and thromboembolic events.
• Aromatase inhibitors (AIs), such as letrozole and anastrozole, are used in postmenopausal women whose main source of estrogen is not the ovaries but, rather, body fat. AIs reduce estrogen levels by inhibiting the conversion of androgen to estrogen through the action of the enzyme aromatase. They are beneficial when given to postmenopausal women for up to 5 years. Newer research is recommending up to 10 years of tamoxifen or AI therapy to prevent recurrence. A side effect of AIs, not seen with tamoxifen, is loss of bone density. Women taking AIs are candidates for bone-strengthening drugs and must be closely monitored for osteoporosis. Weight-bearing exercises and supplementation should be implemented into the daily routine.

Question 43

Recovery from breast cancer surgery points?

Answer 43

• There may be a dry gauze dressing over the incision when you leave the hospital. You may change this dressing if it becomes soiled.
• A small, dry dressing will be around the site where a drain is placed. Often there is some leakage of fluid around the drain. Check the gauze dressing for drainage and change it if it becomes soiled. Some leakage is normal, but if the dressing becomes soaked more than once a day, call your health care provider.
• You have been taught how to empty the reservoir from your drain and how to measure the volume of drainage. You should empty the reservoir twice a day and record the measurements.
• Drains are generally removed when drainage is less than 30 mL/day for 3 consecutive days.
• You may take sponge baths or tub baths, making certain that the area of the drain and incision stays dry. You may shower after the stitches, staples, and drains are removed.
• You can begin using your arm for normal activities, such as eating or combing your hair. Exercises involving the wrist, hand, and elbow, such as flexing your fingers, circular wrist motions, and touching your hand to your shoulder, are very good. You can usually resume more strenuous exercises after the drains have been removed.
• You can expect mild pain after surgery; but within 4 to 5 days, most patients have no need for pain medication or require medication only at bedtime.
• Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in almost all patients owing to injury to the nerves. Patients have described sensations of heaviness, pain, tingling, burning, and “pins and needles.” This is neuropathic pain, and short-acting analgesics may be given. These sensations may change over the next several months, becoming less and less noticeable, and may resolve entirely by the end of the first year following surgery.
• Pamphlets on exercises, hand and arm care, and general facts about breast cancer are available from your hospital or from a volunteer visitor of the local or national office on cancer or breast cancer. The American Cancer Society has volunteers who have had surgery similar to yours and are available to visit you