Med-Surg: Chapter 65: Breast Cancer Flashcards
Cancer if the breast
- mostly occurs in women
- second most common cause of caner-related deaths in women
- single greatest risk factor: woman’s age
Risk Factors
- age
- higher number of ovulatory cycles in their lifetime
- early menarche
- late menopause
- lack of pregnancy and live childbirth before the age of 30; only pregnancies resulting in a live birth lower the breast cancer risk
- family hx of a first degree relative
- benign, noncancerous breast disease that is proliferative; those with quickly growing cells such as hyperplasia, have an increased risk
- excessive alcohol use, inactivity, obesity, and the use of hormones
Genetic Testing to Assess Breast Cancer Risk
-genetic testing provides an opportunity for women to learn whether they have a family hx of breast cancer caused by an inherited gene mutation
>two gene mutations: BReast CAncer gene (BRCA) 1 and BRCA 2
-can be done by a simple blood test
>indicated for patients who are at high-risk:
Cancer
condition in which the cells of the body grow and divide abnormally and uncontrollably
-cells can invade nearby tissues and spread to other areas through the bloodstream and lymphatic system
The First Stage: Stage 0
- in-situ lesion of ductal carcinoma in situ (DCIS); ductal lesions occur in and are limited to the lining of the milk ducts
- Lobular carcinoma in situ (LCIS); lobular lesions occurring in the lobules where milk is produced
- DCIS and LCIS place the patient at higher risk for developing invasive breast cancer; invasive lesions are those that spread to other areas or organ systems
Stage I of breast cancer
- tumor 2cm or less
- no lymph node spread
- no distant metastasis
Stage II of Breast Cancer
- tumor may increase in size
- possible spread to nearby lymph nodes
- no distant metastasis
Stage III of Breast Cancer
- tumor may increase in size
- possible spread to lymph nodes, chest wall, or skin
- no distant metastasis
Stage IV of breast cancer
- tumor of any size with direct extension to chest wall or skin
- with distant metastasis
Stages of Breast Cancer
> Stage 0:
- in situ lesions (DCIS)
- no lymph node
- no metastasis
> Stage I:
- tumor 2 cm or less
- no lymph node
- no metastasis
> Stage II:
- tumor may increase in size
- possible spread to nearby lymph nodes
- no metastasis
> Stage III:
- tumor may increase in size
- tumor may spread to chest wall, lymph nodes, or skin
- no metastasis
> Stage IV:
- Tumor of any size
- lymph node spread
- metastasis
Clinical Manifestations
- new mass or lump
- cancerous masses: hard, irregular, and painless; may be soft, rounded, and tender
- changes in shape of the breast or swelling
- changes such as peeling, flaking, pitting, dimpling, or redness
- changes in nipple such as inversion, thickening of the tissue, or drainage
Diagnostic Tests
-mammography
-ultrasonography
-magnetic resonance imaging (MRI)
-if necessary, biopsy
>patients may have breast cancer detected as part of routine screening mammography or mammography with MRI, or may present with a specific complaint that leads to the discovery of the tumor through diagnostic imaging
>once mammography detects a suspicious area, ultrasonography may be used to further define the area; the area will be recommended for biopsy if it is deemed suspicious on imaging
>Biopsy results will be definitive for diagnosis
Results from what will be definitive for diagnosis
biopsy
What may be indicated if the initial diagnostics indicate the tumor may be invasive?
a sentinel node biopsy
-this may help determine the extent or stage of breast cancer
Sentinel Node
the first lymph node to which cancer cells travel if they are to spread
-in breast cancer, generally found in the axilla but may be more center if the cancer is in the center of the chest
-injecting a radioactive substance or blue dye near the tumor and tracking it to the first node determines the sentinel node(s)
>if the sentinel lymph node is found to be free of cancer, it may not be necessary to proceed with removal of further lymph nodes
-if has cancer cells, more complete removal of the lymph nodes for evaluation, and axillary lymph node dissection may be completed
What happens after a diagnosis is made?
-laboratory data that may be obtained: a complete blood count (CBC) with platelets
-liver function tests
-chest x-ray
>CT of the abdomen and a bone scan if stage II or higher
Treatment
surgery, chemotherapy, and radiation
Surgery Alternatives
- breast conservation therapy (lumpectomy)
- total mastectomy
Chemotherapy Options
- Adjuvant chemotherapy, which is administered after surgery to destroy any remaining cancer cells
- Neoadjuvant chemotherapy, administered before/prior to the surgical procedure in an attempt to shrink the tumor
Treatment for In Situ Lesions
- Lobular carcinoma in situ (LCIS) is not considered a precursor for invasive breast cancer and therefore has no directed treatment; directed at risk-reduction strategies b/c these women are at an increased risk of developing invasive breast cancer
- Ductal Carcinoma in situ (DCIS) requires surgical treatment; lesions more than 4 cm require mastectomy
- lesions of intermediate size that can be removed with clear margins can be considered for mastectomy or breast conservation therapy
- small DCIS can be excised if the lesion without radiation therapy
- Tamoxifen (Nolvadex), antiestrogen therapy, reduces risk of local recurrence in women undergoing breast conservation therapy
Treatment for Early-stage Invasive Cancers
- cancers smaller than 1 cm with clinically negative axilla treated with surgical excision
- patients with large tumors that have comorbidities or no spread to axillary nodes may have surgical excision
- mastectomy and breast conservation can be considered
- radiation therapy recommended for patients undergoing breast conservation therapy
- tumors at least 1 cm in size or with axillary node involvement are recommended to have cytotoxic adjuvant chemotherapy
- if hormone receptor positive, endocrine therapy (aromatase inhibitor or tamoxifen) after completion of cytotoxic therapy
Treatment for Immediate or Advanced Stage Cancers (operable)
- preoperative neoadjuvant chemotherapy first line treatment unless has underlying comorbidities that preclude use of chemotherapy
- after chemotherapy, tumor is reassessed to evaluate the potential of breast conservation therapy as a result of tumor response to chemotherapy
- chemotherapy recommended after surgical treatment in all patients; followed by or done concurrently with radiation therapy
- if tumor is hormone receptor-positive, endocrine therapy offered for 5 to 10 years
Treatment for Locally advance and Inoperable Cancers
- undergo neoadjuvant chemotherapy as initial treatment
- if tumor responds to chemotherapy and becomes operable= undergo modified radical mastectomy
- if responds dramatically = can be offered breast conservation therapy
- if tumor does not respond to initial chemotherapy= switched to another chemotherapy regimen before surgery attempted
- all patients should be offered postoperative chemotherapy and radiation to the breast or chest wall; in these cases immediate breast reconstruction is not encouraged
Treatment for Local Recurrence and Systemic Metastases
- if undergone initial breast conservation therapy; complete mastectomy is next step
- if tumor not initially operable, chemotherapy may be considered
- when not previously undergone radiation, surgical excision is done followed by chemotherapy and radiation
Complications of Treatment
- wound infection and dehiscence
- immobility side effects of surgery such as pulmonary embolism and pneumonia
- long-term complaints: shoulder immobility, pain, and lymphedema
Lymphedema
occurs because of the removal of the axillary lymph nodes and subsequent scarring, resulting in disruption of lymph drainage in the arm
-result is swelling of the arm
Once Chemotherapy has begun, the patient may experience a variety of side effects associated with the cytotoxic drugs
- hair loss
- nausea
- vomiting
- mouth pain
- diarrhea or constipation
- peripheral neuropathy
- rash
- nail changes
- decreased WBC count with possible subsequent fever
- may result in premature ovarian failure which may lead to bone loss and loss of fertility
- possible long-term risk of myelodysplastic syndrome (dysfunctional blood cells)
Radiation Side Effects
- redness with patchy desquamation (shedding of the outer skin layers) of the treated skin
- skin may also itch but does not have a “burning” sensation
- breast swelling and discoloration may continue for 6 months after treatment but usually resolves in 12 to 18 months
- pneumonitis, a nonproductive cough with a chest x-ray demonstrating an infiltrate in the radiated area may develop 6 weeks to 6 months after treatment completion
- radiation to the myocardium may lead to latent (15-20 years) cardiac morbidity and mortality
Nursing Management: Assessment and Analysis
- initial clinical manifestations are associated with the presence of a tumor, noting a lump in the breast, skin changes and nipple changes
- later manifestations associated with treatment
- due to the killing of all rapidly dividing cells, chemotherapy may result in hair loss, nausea, vomiting, mouth pain, diarrhea or constipation, peripheral neuropathy, rash, and nail changes
- decreased WBC count
- lymph node removal may result in lymphedema or swelling of the arm on the affected side due to blockages in lymph flow
- radiation causes skin changes: irritation, redness, itchiness, or burning
- breast swelling
- nonproductive cough with lung an infiltrate
Nursing Interventions: Assessments
> Vital Signs
- elevated BP and rapid pulse can be a sign of pain or anxiety
- elevated temperature and pulse indicative of infection
> Pain
-should verbalize their pain on a rating scale to help understand their pain level and to ensure adequate treatment
> Daily weight
- give an idea of the nutritional status
- drastic weight loss indicates a nutritional deficit
> Intake and Output
-allows evaluation for tolerance of oral liquids and foods and an evaluation of vomiting
> Wound evaluation
-good wound evaluation detects the early signs of infection such as redness, warmth, and increased or purulent drainage
> Skin evaluation
-inspect any radiated skin for radiation side effects such as irritation, redness, itchiness, or burning
> Monitor CBC and metabolic profile
-due to its cytotoxic effects, chemotherapy may result in decreased WBC counts, decreased hemoglobin and hematocrit, and elevations in liver enzymes
> Assess mood and nonverbal cues
- at great risk for psychological issues
- patients with depression are often withdrawn or offer other nonverbal cues that indicate pain, depression, and anxiety
Nursing Interventions: Actions
> Give chemotherapeutic drugs as ordered
-indicated for invasive breast cancer
> Give pain medications as ordered
-provides pain relief allowing the patient to more fully participate in activities of daily living
> Give antiemetics as ordered
-help to relieve nausea and vomiting, promoting adequate nutritional intake
> Have the patient cough and deep breathe postoperatively
-prevents atelectasis and pneumonia
> Keep the wound clean and dry
-aids in wound healing and helps prevent infection
> Encourage Verbalization
-important to actively involve patients in their care
Teaching
>explain treatment course >medications and treatment side effects >wound care >nutritional counseling >support groups >breast cancer screening with mammography
Breast Cancer Screening with Mammography
- women ages 40-44 may begin annual screening
- women ages 45-54 should have annual screening
- women ages >55 can maintain yearly or move to biannual; screening should continue as long as the woman is in good health
Evaluating care outcomes
- adequate treatment
- those with advanced-stage cancer are still able to achieve prolongation of their life while balancing quality of life
- patient undergoing treatment will have immediate needs associated with surgery, chemotherapy, and radiation
- the well managed patient should be able to manage any nausea and vomiting in a way that allows her to maintain adequate nutrition and weight
- surgical sites should heal without infection
- scarring and lymphedema should be kept to a minimum through appropriate therapy
- psychosocial support provided throughout tx helps to manage anxiety and depression
Breast Cancer Tx Options
- Breast Conservation Surgery (lumpectomy)
- Modified radical mastectomy
- Axillary lymph node staging
- Chemotherapy
- Radiation Therapy
Breast Cancer Tx Options: Breast conservation surgery (lumpectomy)
removes only the involved breast tissue and a minimal surrounding margin with the best possible cosmetic preservation of the breast
- option in early-stage disease or advanced disease that has been reduced by chemotherapy
- used in conjunction with postoperative radiation and chemotherapy
Breast Cancer Tx Options: Modified Radical Mastectomy
removal of the entire breast tissue
- option in early-stage disease or more advanced disease that has been reduced by chemotherapy
- used in conjunction with chemotherapy and may or may not require postoperative radiation
Breast Cancer Tx Options: Axillary lymph node staging
removal of axillary lymph nodes
- done with invasive breast cancer and some noninvasive
- recent advances allow for removal of only the first lymph node from the tumor (sentinel node)
- other nodes are then removed only if the sentinel node is positive
Breast Cancer Tx Options: Chemotherapy
drugs used to treat cancer
-may be used prior to surgery or after
Breast Cancer Tx Options: Radiation Therapy
radiation directed at the tumor and surrounding tissue to treat cancer
-typically done after surgery for lumpectomy or inflammatory breast disease, for recurrence, or for palliation in advanced disease
Breast Cancer: Risk factors, S/S, and Metastasis
>Risk Factors: endocrine disrupters: -early menses -late menarche -nulliparity and -late first child -genetic propensity (BRCA1, BRCA2) -obesity, high-fat diet
> S/S:
- breast mass
- axillary node enlargement
- asynchrony of breasts
- nipple discharge
> Metastasis
-bone, lung, lymph nodes, liver, brain
