TOPIC BREAST CANCER

PRESENTER ;SARAH NAMUTOWE

 INTRODUCTION
• Worldwide, breast cancer is the most common invasive cancer in
women. The most common form of cancer is non-invasive non-
melanoma skin cancer. Non-invasive cancers are generally easily
cured and cause very few deaths. Breast cancer comprises 22.9%
of invasive cancers in women and 16% of all female cancers
(World Cancer Report, 2008).Approximately 50% of women have
a breast problem at some point in their adult lives. The most
common sign of breast problem is a palpable mass. Most of these
lumps are benign, although finding them may produce anxiety for
the women who may fear they have cancer. (Lowdermilk, 2004).
• In Zambia, it is the second largest cancer in women after cervical
cancer (MOH, 2010).
 General objective

At the end of this lecture/ discussion, student nurses should be able to

acquire knowledge on breast cancer and be able to manage it.
SPECIFIC OBJECTIVES
By the end of this discussion, student nurses should be able to:
[Link] breast cancer
2. State the risk factors to breast cancer
3. Describe the pathophysiology breast cancer
4. Discuss the stages of breast cancer
5. State the signs and symptoms of breast cancer
6. Mention the investigations done to diagnose breast cancer
[Link] the management of breast cancer
8. State how breast cancer can be prevented
 Definition of breast cancer

• Breast cancer is a cancer originating from the

breast tissue, most commonly from the inner
lining of milk ducts or the lobules that supply
the ducts with milk. Cancers originating from
ducts are known as ductal carcinomas, while
those originating from lobules are known as
lobular carcinomas (Lowdermilk, 2004
NORMAL BREAST TISSUE
 RISK FACTORS OF BREAST CANCER

• Although the exact cause of breast cancer continues

to elude investigators, certain factors that increase a
woman’s risk for developing a malignancy have been
identified.
• Hormonal Agents
• Tumour growth may be promoted by disturbances
in hormonal balance, either by the body’s own
(endogenous) hormone production or by
administration of exogenous hormones
• Cancer of the breast is thought to depend on
endogenous hormonal levels for growth. Oral
contraceptives and prolonged oestrogen therapy are
associated with an increased incidence of breast
cancer.
• Oestrogen stimulates the production of growth factors
by normal breast epithelial cells and by cancer cells.
Oestrogen and progesterone receptors normally
present in breast epithelium, interact with growth
promoters, such as transforming growth factor α,
platelet-derived growth factor, and
• fibroblast growth factor elaborated by human
breast cancer cells, to create an autocrine
mechanism of tumour development.
• Reproductive Cycle
• Hormonal changes related to the female
reproductive cycle are also associated with
cancer
• During regenerative or proliferative phase there is
an increased level of oestrogen in the blood stream
and during secretory phase there is an increased
level of progesterone.
• Early onset of menses under age 12 and delayed
onset of menopause after age 55, nulliparity (never
giving birth), and delayed childbirth after age 30
are all associated with an increase in incidence
• Dietary Factors
• Dietary substances can be carcinogenic. The risk
of breast cancer increases with long-term
ingestion of carcinogens diet. Dietary substances
that appear to increase the risk of breast cancer
include fats, alcohol, smoked meats, nitrite-
containing foods, red and processed meats.
These foods cause mutation in DNA and interfere
with the function of tumour suppressor genes
• Family History
• Family history of breast cancer increases a woman's risk
of developing the disease. A woman is considered to be
at increased risk if the family member is a first degree
relation with early age of onset (< age 50). Women with
one, two, and three or more first-degree affected
relatives have an increased breast cancer risk when
compared with women who do not have an affected
relative. Such women are recommended to begin breast
cancer screening at an age 10 years younger than the age
at which the affected relative was diagnosed
• Chemical Agents
• About 75% of all cancers are thought to be
related to the environment. Most hazardous
chemicals produce their toxic effects by
altering DNA structure in body sites distant
• Genetic Factors
• Since the early 1990s, there have been considerable
advances in the recognition of inherited cancer
susceptibility syndromes and in the ability to isolate and
identify the inherited genetic mutation responsible for the
cancer patterns. There is mutation in genes related to
critical cell control functions, such as tumour suppression,
DNA repair mechanisms, and oncogenes Examples of these
syndromes include hereditary breast cancer syndrome
(BRCA1 and BRCA2) Women with mutations in these genes
have up to an 80 percent chance of getting breast cancer at
some point in life.
PATHOPHYSIOLOGY OF BREAST CANCER

• Breast cancer occurs when there is genetic

alteration in the deoxyribonucleic acid (DNA) of
breast epithelial cells, compromising ductal or
lobular tissue. These genetic abnormalities may
have been inherited or developed spontaneously.
• Breast cancer begins in the epithelial cells lining
the mammary glands of the breasts. The rate of
growth depends on the effect of the oestrogen and
• progesterone.
• These cancers can either be invasive (infiltrating)
or non-invasive (in situ). Invasive breast cancers
can grow into the wall of the mammary duct and
into the surrounding tissues. By far most
frequently occurring cancer of the breast is
invasive ductal carcinoma. Ductal carcinoma
originates from the lactiferous ducts and invades
surrounding breast structures.
• The tumour is usually unilateral, not well delineated, solid,
non-mobile and non-tender.
• Lobular carcinoma originates from the lobules of the breasts. It
is usually bilateral and non-palpable.
• Nipple carcinoma originates in the nipple. It usually occurs with
invasive ductal carcinoma and can cause bleeding, oozing, and
crusting nipple.
• As the tumour grows, fibrosis develops around it and can
shorten cooper’s ligaments. When cooper’s ligament is
shortened, the result is the characteristic peaud’orange (orange
skin) changes and oedema.
•
 BREAST CANCER STAGING

• Stage O
The cancer is in situ, nodes not involved and there is no metastasis
• Stage I
Tumour is ˂2cm with nodes not involved , there is no metastasis
• Stage IIA
Tumour is 0 to 2cm, nodes not involved , there is no metastasis
• Stage IIB
Tumour is 2 to 5cm, nodes not involved,
• Stage IIIA
No evidence of movable or non-movable nodes involvement, no metastasis
there is no metastasis
• Stage IIIB
Tumour of any size with direct extension to
chest wall or skin, with or without involved
internal mammary lymph nodes, there is
metastasis
• Stage IV
Any distant metastasis (include supraclavicular
nodes) Nodes involved , there is metastasis
Signs of breast cancer
• Breast cancers have no signs in an early stage
and it is estimated that 90% of women detect
lumps in the breasts of which 20% are
malignant. The clinical manifestation may
include the following;
• 1. Lump in the breast which is painless
• Thickening in the part of the breast affected
• [Link] peel like appearance
• [Link] of the axilla tail
• [Link] discharge from the nipple
• [Link] in breast size and shape
• [Link] becoming inverted
• [Link] pain in part of the breast or armpit,
and swelling beneath the armpit
 INVESTIGATIONS FOR BREAST CANCER

• The diagnosis of breast cancer is made by

‘triple assessment’
• 1. Clinical Examination
• This involves inspection and palpation of the
breast in both standing and lying position.
• a. Inspection
• The examination starts with the patient in an upright
position with careful visual inspection of masses, skin
and nipple changes, and asymmetries.
• b. Palpation
• This includes all the breast quadrants, the nipple-
areola complex, the axillary tail and the axilla. Simple
manoeuvres like stretching the arms high above the
head, tensing the pectoralis muscles may help
accentuate asymmetries and dimpling on the breast.
• 2. Bilateral Mammography
• Differentiates between benign and malignant
lesions, and recommended for breast cancer
screening.. In the absence of locally advanced
breast cancer or symptoms of metastatic
disease or biochemical abnormality, routine
radiological staging with CXR,
• CT scan and isotope bone scan, mammary
ductoscopy, Ultrasonography, Magnetic Resonance
Imaging (MRI) can be used.
• 3. Fine needle aspiration (FNA) - Cytology or Cone
Biopsy
• To obtain a biopsy for histological examination
• This combined approach to assessment has >90%
sensitivity and specificity.
• BIOSPY- procedure to remove a piece of tissue from
the body so that it can be tested in a laboratory
 MANAGEMENT OF BREAST CANCER

• Treatment for breast cancer is based on many

factors, including the type of cancer, its stage,
overall health of the patient, and patient
preferences. Most women with breast cancer
have surgery to remove the cancer and also
receive
• additional treatment in the form of chemotherapy
• Hormone therapy or radiation.
• Chemotherapy
• The administration of Poly chemotherapy about four to six
courses of treatment (3–6 months) appear to provide optimal
benefit. Popular regimes include
• Chemotherapy Combinations
• FEC - flurouracil. epirubicin and clyclophosphamide
• AC - adriamycin and clyclophosphamide
• FAC - using adriamycin instead of epirubicin CMF -
clyclophosphamide. methotrexate and fluoric
• MM - mitozantrone and methotrexate
• Cyclophosphamide (cytoxan)
• Action
• It interferes with RNA transcription, causing an imbalance of growth
that leads to cell death.
• Dosage
• 40 – 50mg/kg I.V. In divided doses over 2 – 5 days
• Side effects
• Decreased white blood cell count with increased risk of infection, hair
loss, nausea and vomiting, loss of appetite, mouth or lip sores, diarrhea,
and no menstruation.
• Fluorouracil
• Action: Inhibits DNA synthesis
• Dosage:12mg/kg I.V. Daily x 4 days
• Adriamycin (doxorubicin)
• Adriamycin is used to treat breast and other cancers. It is toxic
to cancer cells, and is administered intravenously.
• Side Effects
• Decreased white blood cell and platelet counts, increased risk
of infection, Loss of appetite, darkening of nail beds and skin
creases of hands, hair loss, nausea and vomiting, mouth sores
and, at higher doses, it may be toxic.
• Hormonal Therapy
• It is prescribed to women with ER-positive breast cancer
(oestrogen receptor) to block certain hormones that fuel
cancer growth. E.g.
• Tamoxifen
• It is prescribed to women with ER-positive
breast cancer (oestrogen receptor) to block
certain hormones that fuel cancer growth. E.g.
This drug blocks the effects of oestrogen
• Side Effects
• These include hot flushes, irregular menstrual
cycles, unusual vaginal discharge or bleeding,
irritation of skin around vagina
• Radiation therapy
• Irradiation therapy uses high-energy rays to kill cancer cells.
• Side Effects
• Acute skin reactions such as erythema, dry desquamation, and
moist desquamation.
• Then late side effect include; hyper pigmentation, atrophy,
fibrosis and necrosis.
• Management of Non-Invasive Breast Cancer
• DCIS (ductal cancer in situ) and LCIS (lobular cancer in situ ) are
rarely symptomatic although extensive pre -invasive disease
may present with a mass or thickening of breast tissue.
• LAMPECTOMY
• Lumpectomy (partial or segmental mastectomy) is defined
as complete surgical resection of a primary tumor with a
goal of achieving widely negative margins( ideally 1cm)
• Simple mastectomy with 95% cure rate is done, it’s rarely
relapse, and there is no need for axillary dissection. All the
breast tissue is removed including the nipple, areola and
the lining over the breast With wide excision alone there is
30% recurrence at 5 years and then
• Wide excision + radiotherapy there is 15% recurrence at 5
years (Journal of oncology:2000.
• This is followed by administration of drugs CMF: cyclophosphamide,
methotrexate, and 5-fluorouracil given 4-weekly for 6 cycles pectoralis major
muscle is removed.
• 2. Management of Early Breast Cancer
• MASTECTOMY; Involves complete removal of all breast tissue .
• TOTAL MASTECTOMY involve complete removal of all breast tissue to the
clavicle superiorly, the sternum medially, inframammary crease inferiorly,
and the anterior axillary line laterally, The following variants are performed;
• Modified radical mastectomy-A total mastectomy with axillary lymph node
dissection(ALND)
• Radical mastectomy-A total mastectomy plus resection of the pectoris
major(ALND)
• Extended radical mastectomy-A radical mastectomy with resection of the
internal
• mammary lymph nodes.
• Early breast cancer is defined as disease that can be completely cured
by surgery that is T1–3, N0–1 tumors. The management of this
disease comprises:
• Treatment of the breast and axilla (modified radical mastectomy)
followed by Breast reconstruction and Adjuvant therapy—Hormonal,
chemotherapy and radiotherapy
• For chemotherapy drugs include: cyclophosphamide, methotrexate,
and 5-fluorouracil given 4-weekly for 6 cycles.
• NOTE; Adjuvant treatment is an extra remedy added to the treatment
to increase its effectiveness.
• When applied before surgery it is called neo adjuvant therapy. ( Jim
Cassidy etal:2002)
• Management of Locally Advanced Breast Cancer
• Locally advanced disease is defined by the presence of infiltration of
the skin or the chest wall or fixed axillary nodes.
• Local control of the tumour and the prevention of fungation are of
major importance to the quality of life of these women.
• A combination of systemic treatment and radiotherapy is commonly
used.
• Many of these patients are elderly and have ER-positive disease that
responds to endocrine therapy with tamoxifen, aromatase inhibitors,
or progestin's
• In younger women, particularly with aggressive ‘inflammatory’ breast
cancer, primary chemotherapy is preferred. In patients with a good
response to systemic treatment surgery may be feasible.
• Management of Metastatic Breast Cancer
• Aim is palliative care
• Treatment with tamoxifen, and aromatase inhibitors will provide an
objective response in 30% of women with advanced disease, and in 50–
60% of those with ER-positive tumours. Tamoxifen for 2 to 3 years,
followed by an aromatase inhibitor (AI) to complete 5 years of treatment
• Follow-Up Tests
• Some of the tests that were done to diagnose the cancer or to find out
the stage of the cancer may be repeated.
• Some tests will be repeated in order to see how well the treatment is
working.
• Decisions about whether to continue change, or stop treatment may be
based on the results of these tests
 NURSING INTERVATIONS

• Discuss the postoperative drainage device and it use.

• Prepare the patient for the effects of chemotherapy, and
plan ahead for alopecia, fatigue.
• Administer antiemetic prophylactically, as directed, for
patients receiving chemotherapy.
• Administer I.V. fluids like ringers lactate
• Assess her pain tolerance and administer analgesics like
Brufen or morphine.
• Teach her to be cautious when moving the arm on the
operated side, and to avoid lifting heavy objects.
• Encourage her to discuss her thoughts and
feelings about her body changes.
• Help patient identify and use support persons
or family or community
• Prevention
• Preventing cancer proves to be difficult, but measures to
lower the risk can be instituted like:
• Avoid becoming overweight. Obese women produce
oestrogen in their peripheral fat.
• Keep physically active. breast cancer or who are over age
60 should talk to their doctor about the pros and cons of
estrogen-blocking drugs such as tamoxifen
• Avoid smoking. Research suggests that long-term smoking
is associated with increased risk of breast cancer in some
women.
• Breast-feed your babies for as long as
possible. Women who breast-feed their babies
for at least a year in total have a reduced risk
of developing breast cancer
• CONCLUSION
• Breast cancer is a condition that affects mostly
women, It can be treated if diagnosed early
hence the need for every woman above
40years to have a mammography done.
Treatment outcome is dependent on the
staging and heath status of the client.
 REFERENCES
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13th Edition, London, UK..
• Jim Cassidy etal, (2002) oxford hand book of oncology, 1st edition. Oxford
University Press, Great Britain
• Lowdermilk D. and Perry .T (2006).Maternity Nursing.7th Edition, St Louis Missouri.
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South Africa.
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Lansdowne, South Africa.
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