BREAST CANCER

ANATOMY OF BREAST

• The breast is a dome shaped organ and contains a pigmented center called areola.

• The areolar region contains Montgomery’s tubercles, which assists in lubricating the nipple

• During lactation, the alveoli secretes milk

• The milk then flows into a ductal system and is transported to the lactiferous sinuses

• It extends from the second to the sixth ribs

DEFINITION

The term “breast cancer” refers to a malignant tumor that develop from cells in the breast.

RISK FACTORS

NON-MODIFIABLE RISK FACTORS

• Female gender

• Age > 50 years – Post menopausal women

• Family history

• Genetic factors - women carrying BRCA 1 and BRCA 2 genes are at risk

• Early menstruation/late menopause – Before 12 yrs and after 55 years

• Personal history of breast cancer – cancer in one breast, high risk to develop in other breast

MODIFIABLE RISK FACTORS

• Exposure to ionizing radiation- Damages DNA

• Weight gain and obesity after menopause – Fat cells store oestrogen

• Sedentary life style

• Smoking

• Increased Dietary fat intake

• Alcohol

• First full term pregnancy after 30 years – prolonged exposure to oestrogen

CLASSIFICATION OF BREAST CANCER

I. Based on the invasiveness

• Non invasive ( In situ)

• Ductal carcinoma in situ

 • Lobular carcinoma in situ

• Invasive ( Spreading to other locations)

• Invasive ductal carcinoma

• Invasive lobular carcinoima

DUCTAL CARCINOMA IN SITU

• Non-invasive

• Contained within the milk ducts

• May become invasive if untreated

LOBULAR CARCINOMA IN SITU

• Non-invasive

• Contained in the lobules and does not spread to the tissues of the breast

• May become malignant

INVASIVE DUCTAL CARCINOMA

• Most common type

• It starts in the milk ducts and then breaks through the walls of duct, invading the surrounding
tissue

• Subtypes of invasive ductal carcinoma are medullary carcinoma, tubular carcinoma, colloid
(mucinous carcinoma)

INVASIVE LOBULAR CARCINOMA

• It begins in the lobules (milk producing glands) of the breast and then break out of the lobule and
then spread to other areas of the body

II. Based on tissue type

• Ductal carcinoma ( affects milk ducts)

• Medullary

• Tubular

• Colloid (mucinous)

• Lobular carcinoma ( affects milk-producing glands)

III. Based on Hormone receptor and genetic status

 Estrogen and progesterone receptor status

• Estrogen receptor positive

 • Estrogen receptor negative

• Progesterone receptor positive

• Progesterone receptor negative

 HER-2 Genetic status

• HER-2 positive

• HER-2 negative

IV. Other types

• Inflammatory breast cancer

• Paget’s disease

• Phyllodes tumor

INFLAMMATORY BREAST CANCER

• It is an aggressive and fast growing breast cancer

• The inflammatory changes do not improve with antibiotics, as the lymph channels in the skin of
the breast are blocked by cancer cells.

• The breast looks red, feels warm, and has thickened appearance – resembling an orange peel
(peau d’ orange)

• Difficult to identify in mammogram

PAGET’S DISEASE

• It is a rare breast malignancy that starts in the breast ducts and spreads to the nipple and areola

• Itching, burning, bloody nipple discharge with superficial skin erosion and ulceration may be
present

PHYLLODES TUMOR

• It is a rare tumor that develops in the connective tissue (stroma) of the breast

PATHOPHYSIOLOGY

Etiological factors

Damage and failure to repair DNA

Mutation in genome (BRCA1 and BRCA2)

Activation of growth promoting oncogenes, inactivation of tumor suppressor genes, alteration in genes
that regulate apoptosis

Unregulated cell proliferation

 Colonial expansion

Tumor progression

Malignant neoplasm

CLINICAL MANIFESTATIONS

• A lump or thickening in the breast- commonly occurs in the upper, outer quadrant of the breast
(location of most glandular tissue)

• Nipple discharge

• Nipple retraction

• Peau d orange appearance

DIAGNOSTIC TESTS

PREDIAGNOSIS

• Health history including risk factors

• Physical examination including breast and lymph nodes

BREASE SELF EXAMINATION (BSE)

Definition

BSE can be defined as an regular examination of one’s own breasts to detect lumps or other
changes that may need to be further evaluated as part of screening for breast cancer.

Purposes

 To detect breast cancer early.

 Knowing how the breasts feel normally, will allow to notice changes in the future
 To detect changes in breast such as a lump or change in appearance early

Time of performing BSE

• Optimal timing for BSE is 5-7 days after menses and for post menopausal women monthly once.

Instructions before doing BSE

 Mark the reminder in calendar to do BSE on a regular schedule.

 Use the fingertip pads to do the exam
 Use three types of pressure on doing BSE, Light, medium and firm pressure
 Use small circles to feel the breast tissue and armpits.
 Examine the entire breast area using up and down lines.

Palpation patterns

Linear

Starting from the underarm area, slowly move fingers down until, below the breast and then move fingers
back up.
Circular

Begin in outer edge of breast and move fingers slowly around whole breast in a circle.

Wedges

Start at outer edge of breast and move fingers toward nipple and back to edge, covering whole breast.

Steps of BSE

Step 1

• Stand infront of a mirror

• Check both breasts for anything unusual

• Look for discharge from the nipple, dimpling or scaling of the skin

Step 2

• Step 2 and 3 are done to check for any changes in the contour of the breast

• Clasp the hands behind the head and press the hands forward and watch closely in the
mirror

• Note any change in contour

Step 3

• Press the hands firmly on the hips and bow slightly toward the mirror and pull the shoulders and
elbows forward.

• Note for any change in contour

Step 4

• Raise the left arm

• Use 3 or 4 fingers of the right hand to feel the left breast firmly, carefully and thoroughly

• Beginning at the outer edge, press in small circles slowly around the breast

• Gradually move toward the nipple

• Be sure to cover the whole breast

• Special attention to be given to the area between the breast and under the arm

• Feel for any unusual lumps or masses under the skin

• Repeat the examination on the right breast

Step 5

• Lie flat on back with left arm over the head and a pillow or folded towel under the left shoulder
 • Palpate in same circular motion as in step 4

• Repeat in right breast

Mammography

• An X-ray of the breast

• The breast is pressed between 2 plates to flatten and spread the tissue

• The pressure lasts only a few seconds while the picture is taken

• Ultrasound

• Uses sound waves to outline a part of the body

• Breast MRI

• Biopsy

• Breast tissue is removed and cell cytology is studied

POSTDIAGNOSIS

• Lymphnode analysis

• Estrogen and progesterone receptor status

• Cell proliferative indices- measure the rate of tumor cell proliferation

• HER-2 marker

• Genetic assays

Lymph node biopsy

• A sentinel lymph node biopsy (SLNB) helps to identify the lymph node that drain first from the
tumor site

• A radioisotope or dye is injected into the affected breast

• Determine the lymph node in which the radioisotope is located

Estrogen and progesterone receptor status

• Hormone receptors are proteins in cells that can attach to hormones

• Estrogen and progesterone are hormones that fuel breast cancer growth

• Breast cancers are tested for hormone receptors. If the tumor has them, it is often called ER-
positive , PR-negative

HER-2 marker

• About 1 out of 5 breast cancers have too much of a protein

 • Tumors with increased levels of HER2 are called HER2-positive

• These cancers tend to grow and spread faster than other breast cancers

OTHER INVESTIGATIONS

• CBC, platelet count

• Alkaline phosphatase

• Liver function test

• Chest X ray

• Bone scan

• MRI

STAGING OF BREAST CANCER

Stage 0:

Non-invasive breast cancer. Has not spread to breast tissue

Stage I:

≤2cm and has not spread to lymph nodes

Stage II:

Stage II A: - ≤2cm and has spread to lymph nodes

Stage II B :- 2-5 cm and has spread to lymph nodes

Stage III:

Stage IIIA :- ≤5 cm and spread to lymph nodes

Stage IIIB :- Any size and spread to the skin or chest wall.

Stage IIIC :- Any size and spread to lymph nodes, skin and chest wall.

Stage IV:

Metastasized

MANAGEMENT

• Surgery is the primary treatment of breast cancer

• Breast conservation surgery (lumpectomy)

• Mastectomy with or without reconstruction

BREAST-CONSERVING SURGERY

• It is also called lumpectomy

 • It involves removal of the entire tumor along with the margin of normal surrounding tissue.

• Wide excision of tumor, sentinel lymph node excision and or axillary lymph node dissection is
made

• After surgery radiation therapy is delivered to the entire breast

MASTECTOMY

• A total or simple mastectomy removes the entire breast.

• Simple mastectomy

• Removal of breast, preservation of pectoralis muscle with SLNB

• Modified radical mastectomy

• Removal of breast and pectoralis muscle along with axillary lymph node

• RECONSTRUCTIVE OR BREAST IMPLANT SURGERY

• Surgical procedures aimed at recreating a breast so that it looks as much as possible like other
breast.

MAMMOPLASTY

• Mammoplasty is the surgical change in the size or shape of the breast

• It is done electively for cosmetic purposes to either enlarge or reduce the size of the breast.

• It is also done to reconstruct the breast after mastectomy

Augmentation surgery

• Breast augmentation — also known as augmentation mammoplasty — is surgery to increase

breast size. It involves placing breast implants under breast tissue or chest muscles

Reduction surgery

• Breast reduction surgery, also known as reduction mammoplasty, is a procedure used to remove
excess fat, tissue and skin from the breasts.

1. BREAST IMPLANTS AND TISSUE EXPANSION

• Breast implants are placed in a pocket under the pectoralis muscle which protects the implant and
provides a soft tissue protection over the implant

[Link] FLAP PROCEDURE

• If insufficient muscle is left after mastectomy, the person’s own tissue may be used to repair the
soft tissue defects

3. NIPPLE AREOLAR RECONSTRUCTION

• Flaps of tissues are used to reconstruct the areola

RADIATION THERAPY

• It is a form of adjuvant therapy after surgery

• It is done to prevent recurrence

EXTERNAL RADIATION THERAPY

• It is a method of delivering high energy X-rays or electron beams to the patient’s tumor from an
external source or radiation machine

• Done after mastectomy

• Radiation of the axilla and or supraclavicular nodes is indicated when lymph nodes are involved
to decrease the risk of axillary recurrence

• The area is radiated 5 days per week over the course of about 5 to 7 weeks

• It delivers 1.8Gy to 2 Gy daily fractions to a total dose of 45-50Gy.

• Fatigue, skin changes and breast edema are temporary side effects of external radiation therapy

BRACHYTHARAPY (INTERNAL RADIATION)

• It involves placing the radioactive material inside the body and is called internal radiation

• Radiation is delivered directly into the cavity left after a tumor is surgically removed by a
lumpectomy

• It requires only 5 days of treatment

• It is primarily delivered using a multicatheter method or balloon-catheter system

Multicatheter method

• Many very small catheters are placed in the breast at the site of the tumor

• It is inserted through a small incision , and the catheter bundle expands uniformly

• Small radioactive seeds are placed in the catheters .

• The seeds are left in place just long enough to deliver the radiation dose (5-10mts)

• The tiny radioactive seeds are inserted only during treatment and then removed

Balloon catheter system

• The balloon is placed where the tumor is located.

• The balloon is filled with fluid to keep it in place

• Radioactive seeds are inserted .

• The seed travels into the inflated balloon.

• Once the final session is over the balloon is deflated and the system is removed
 Palliative radiation therapy

• In addition to reducing the primary tumor mass, radiation is also used to reduce the symptoms
like pain and reduction in metastatic lesions.

DRUG THERAPY

It includes

• Chemotherapy

• Hormone therapy

• Immunotherapy

• Targeted therapy

CHEMOTHERAPY

• It is the use of cytotoxic drugs to destroy cancer cells

• Combination treatment is beneficial because the drugs have different mechanisms of action and
work at different phases of cell cycle.

• Chemotherapy is usually given for 3-6 months

• Common combination therapy protocols are

• CMF: Cyclophosphamide, Methotrexate and 5-fluorouracil

• AC: Doxorubicin, Cyclophosphamide

• CEF or CAF : Cyclophosphamide, Epirubicin or Doxorubicin and 5-FU

HORMONE THERAPY

• Estrogen can promote the growth of cancer cells if the cells are estrogen receptor positive

• Hormone therapy block the estrogen receptors or suppress estrogen synthesis by inhibiting
aromatase, an enzyme needed for estrogen synthesis

• Estrogen receptor blockers

• Tamoxifen

• Toremifene

• Fulvestrant

• Aromatase inhibitors

• Anastrozole

• Letrozole

• Exemestane
 • These does not block the production of estrogen by ovaries

• Estrogen receptor modulator

• It produces both estrogen-antagonistic effects on bone and estrogen-antagonistic effect on breast

tissue.

• [Link]

IMMUNOTHERAPY AND TARGETED THARAPY

• These drugs specifically target cells that have altered gene expression.

• One of these genetic changes is over expression of HER-2.

• Trastuzumab is a monoclonal antibody to HER-2.

• After the antibody attaches to the antigen, it is taken into the cells and eventually kills them.

• It can be used alone or in combination with chemotherapy drugs

NURSING MANAGEMENT

ASSESSMENT

• History of breast disorders

• Presence of nipple discharge, pain, asymmetry etc

• Size and location of the lump

• Physical characteristics of lesions

• Other subjective and objective data based on manifestations

NURSING DIAGNOSIS

• Acute pain related to surgical procedure

• Anxiety related to situational crisis

• Disturbed body image related to perceived effects of mastectomy

• Ineffective therapeutic regimen management related to lack of knowledge regarding disease

process

• Impaired physical mobility related to weakness

Preoperative management

• Metastatic workup

• Routine blood investigations

• Pre-anesthetic evaluation
 • Control of medical conditions like diabetes and hypertension

• Counselling and written informed consent

• Parts preparation- neck to mid thigh including pelvic region, axilla and arm

Post operative care

• Wound examination on post-op day 3

• Drain can be removed when it is <30ml

• An collection of fluid, aspirated under aseptic precautions

• Staples removed after 10 days

• Arm movement started in the 1st week

• Active shoulder and upper limb exercises are started from 2 weeks

POST OPERATIVE EXERCISES/ POST MASTECTOMY EXERCISE

GOAL

• To prevent contractures and muscle shortening

• Maintain muscle tone

• Improve lymph and blood circulation

• Gradual return of full range of motion with within 4 to 6 weeks

• Reduce pain in the chest wall, shoulders, neck and back

• Improve overall wellbeing

GENERAL GUIDELINES

• Begin exercises a day after the surgery.

• Plan to take pain medication 20 to 30 minutes before doing the exercises.

• Breathe deeply and often during each exercise.

• Do the exercises 3 times a day, every day, until regaining full range of motion in the arm(s).

• Do the exercises daily, so as not to forget.

• Do the exercises after breakfast, lunch and dinner.

TYPES OF EXERCISE

1. Pump It Up

2. Shoulder Circles

3. Arm Lifts
4. Shoulder Blade Squeeze

5. Wand Exercise

6. Wall Climbing

[Link] turning

[Link] tugging

7. Side Bends

[Link] It Up

This exercise helps reduce swelling after surgery by using the muscles as a pump to improve the
circulation in the affected arm (on the same side of surgery).

Instructions

• Lie on your unaffected side with your affected arm straight out, resting on top of a pillow.

• Slowly bend your elbow while making a fist at the same time.

• Next, slowly straighten your elbow while opening your fist at the same time.

• Repeat this pumping motion 15 to 25 times.

2. Shoulder Circles

This exercise can be done sitting or standing. It’s a good warm-up exercise and can help relieve tension
in the shoulders.

Instructions

• Lift both shoulders up toward your ears. Keep your chin tucked in slightly.

• Gently rotate both shoulders forward, and then slowly down and back, making a circle.

• Make 5 slow circles in one direction, then switch and make 5 slow circles in the opposite
direction.

[Link] Lifts

• This exercise can be done sitting or standing. It helps improve movement in the shoulders.

• Clasp your hands together in front of your chest. Point your elbows out. 

• Slowly lift your arms upwards until you feel a gentle stretch, but no pain.

• Hold for 5 to 10 seconds and then slowly return to the start position. 

• Repeat 5 to 10 times.

4. Shoulder Blade Squeeze

 • This exercise can be done sitting (without resting back on the chair) or standing. It helps to
stretch the chest muscles.

• Hold your arms at your side against your body with your elbows bent. 

• Slowly bring your elbows straight backwards, while squeezing your shoulder blades together to
feel a gentle stretch.

• Repeat 5 to 10 times.

[Link] Exercise/ Rod or broom stick lifting

A stick or “wand” is required to do this exercise – try a broom handle, stick or cane

• 6. Wall Climbing

• This exercise helps increase movement in the shoulder.

• Try to reach a little higher on the wall each day. This exercise is done in 2 positions

• A) facing the wall

• B) with the affected side to the wall

[Link] turning exercise

• Tie light rope to doorknob

• Stand facing the door

• Take free end of rope in hand on side of surgery

• Place other hand on hip

[Link] tugging

• Toss light rope over a shower curtain rod or doorway curtain rod

• Stand as nearly under rope as possible

• Grasp end in each hand

• Extend arm straight and away from body

• Pull the left arm up by tugging down with right arm, continue in see-sawing motion

[Link] bend

• Stand and and lift both the arms up above head level and move towards the midpoint of body

• This exercise is more advanced and can be performed after weeks.