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Breast cancer is a malignant tumor that has developed from cells in the breast.Its usually begins with a formation of a small, confined tumor (lump), or as calcium deposits (microcalcifications) and then spreads through channels to the lymph nodes or through the blood stream to other organs. The tumor may also grow and invade tissue around the breast, such as the skin or chest wall. Different types of breast cancer grow and spread at different rates, some take years to spread beyond the breast while other move quickly.

Incidence

About 39,510 women will die from breast cancer in the U.S. according to American Cancer Society’s most recent estimates as of 2012 . Death rates have been decreasing since 1990 ,especially in women under 50.These decreases are thought to be the result of treatment advances, earlier detection through screening, and increased awareness.

In Asia, the Philippines is among the countries with the highest age standardized incidence rate for breast cancer. Survival rate for breast cancer in the Philippines is below 40 percent compared to the high survival rates of 80-98 percent already achieved in developed countries.

Risk factors

Family History of Breast cancer– A woman’s mother diagnosed with breast cancer before the age of 60 or she had a sister or daughter with breast cancer, her chance of developing a breast malignancy increases substantially.

Hormone Replacement Therapy– Taking estrogen supplements for menopause for lengthy period of times are at some increased risk for development of breast malignancies. While the addition of estrogen and progesterone as a hormone supplement may decrease the occurrence of endometrial cancer, it does not appear to decrease the risk of breast cancer.

Menstrual cycle-Women menses began before age of 12 and Do not experience menopause until after 55 of age have an increased risk for breast cancer

Pregnacy after Thirty-Women who do not give birth to their first child until after thirty years of age,seem to have nearly twice the risk of developing breast cancer than women who gave birth to their first child before twenty years of age.

Radiation Exposure-A Woman who has been exposed to ionizing radiation between puberty and tthirtyyears of age has twice the risk of developing malignant breast cells, than an individual that is not exposed to radiation or exposed at later time in life.

BRCA-1 or BRCA-2 genetic mutation– found risk of developing breast cancer.These genes normally produce proteins that protect from cancer. If a parent passes a defective gene, Women have 85% chance of getting breast cancer sometime during their life.

Alcohol Intake-Alcohol intake also has not been conclusively shown to increase a woman risk of breast cancer. Although studies show a slight increase in women who consume one drink a day and a greater increase among woman averaging three drinks daily.

Stages of Breast Cancer

StageDefinition
Stage 0Cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue.
Stage ICancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear).
Stage IIANo tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm)
OR
the tumor measures 2 centimeters or smaller and has spread to the axillary lymph nodes
OR
the tumor is larger than 2 but no larger than 5 centimeters and has not spread to the axillary lymph nodes.
Stage IIBThe tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodes
OR
the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes.
Stage IIIANo tumor is found in the breast. Cancer is found in axillary lymph nodes that are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone
OR
the tumor is any size. Cancer has spread to the axillary lymph nodes, which are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone.
Stage IIIBThe tumor may be any size and has spread to the chest wall and/or skin of the breast
AND
may have spread to axillary lymph nodes that are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone.Inflammatory breast cancer is considered at least stage IIIB.
Stage IIICThere may either be no sign of cancer in the breast or a tumor may be any size and may have spread to the chest wall and/or the skin of the breast
AND
the cancer has spread to lymph nodes either above or below the collarbone
AND
the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone.
Stage IVThe cancer has spread — or metastasized — to other parts of the body.
 

Assessment

The patient most often reports that she detected a painless lump or mass in her breast of that she noticed a thickening of breast tissue. Otherwise the disease most appears on a mammogram before a lesion becomes palpable.The patients health history may indicate several significant risk factors for breast cancer.

Inspection of the patient’s breast may reveal

  • Clear, milky or bloody nipple discharge
  • Nipple retraction,scantly skin around the nipple
  • Skin changes such as dimpling, peau d ‘orange or inflammation.
  • Arm edema which is also identified on inspection may indicate advance nodal involvement.

Palpation may identify

  • A hard lump mass or thickening of breast tissue
  • Palpitation of cervical supraclavicular and axillary nodes may also disclose lumps or enlargement.

Diagnostic test

  • Mammography the essential test for breast cancer can detect a tumor too small to palpate
  • Galactography is a procedure in which radioactive dye is injected into the areola before performing a mammogram.This procedure is performed when bloody nipple discharge is present.
  • Fine-needle aspiration and excisional biopsy provide cells for histologic examination to confirm the diagnosis.
  • Chest X-rays can pinpoint metastases in the chest
  • Laboratory test such as alkaline phosphatase levels and liver function can undercover distant metastases
  • Hormonal receptor assay can determine whether the tumor is estrogen or progesterone dependent.This test guides decisions to use therapy that blocks the action of the estrogen hormone that support tumor growth.

Treatment of Breast cancer

Surgery
Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:

  • Lumpectomy- Surgery to remove a tumor and a small amount of normal tissue around it.
  • Partial mastectomy-Surgery to remove the part of the breast that has cancer and some normal tissue around it. The lining over the chest muscles below the cancer may also be removed. This procedure is also called a segmental mastectomy.
  • Total mastectomy- Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or after. This is done through a separate incision.
  •  Modified radical mastectomy-Surgery to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.

Chemotherapy may be given before surgery to remove the tumor. When given before surgery, chemotherapy will shrink the tumor and reduce the amount of tissue that needs to be removed during surgery. Treatment given before surgery is called neoadjuvant therapy.

Sentinel lymph node biopsy followed by surgery
Sentinel lymph node biopsy is the removal of the sentinel lymph node during surgery. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph node the cancer is likely to spread to from the tumor. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed.

Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated

Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body. The way the chemotherapy is given depends on the type and stage of the cancer being treated

Target Treatments
Targeted treatments are drugs that attack specific cell mechanisms thought to be important for cancer cell survival and growth. This specific targeting helps spare healthy tissues and causes less severe side effects than chemotherapy.

Trastuzumab (Herceptin) is one example of a targeted treatment designed for women whose tumor cells are HER2-positive. Since trastuzumab was approved, women with HER2-positive tumors are living significantly longer.

Hormone Blockers
These treatments prevent estrogen from attaching to receptors on breast cancer cells. As a result, estrogen cannot get in the cells, and tumor growth is slowed. The treatments also reduce the amount of hormones circulating in the body that attach to estrogen or progesterone receptors. By blocking hormones, the treatments deprive tumor cells of the substances they need to grow.

Tamoxifen (Nolvadex) is the standard estrogen blocking treatment for most premenopausal women. Tamoxifen is also effective for postmenopausal women

Nursing Intervention

  • Always evaluate the patient’s feelings about her illness and determine her level of knowledge and expectations.
  • Administer analgesics for pain as needed.
  • Perform comfort measures to promote relaxation and to relieve anxiety.
  • If immobility develops late in the disease, prevent complications by frequently repositioning the patient, using a convoluted foam mattress.
  • Provide skin care particularly in bony prominences.
  • Provide measures to relive adverse effects of treatment.
  • Instruct the patient or caregiver how to manage adverse effects of treatment.
  • Watch for treatment complications, such as nausea, vomiting, anorexia, leucopenia, thrombocytopenia, gastrointestinal ulceration, and bleeding.
  • Monitor patient’s weight and nutritional intake for evidence of malnutrition.
  • Inspect the skin for redness, irritation, and skin breakdown if immobility occurs.
  • In late disease, monitor the patient’s pain level and the efficacy of administered analgesics and non-pharmacologic measures.
  • Assess the patient’s and family’s ability to cope, especially if the cancer is terminal.

Patient teaching

  • Provide clear,concise explanation of all procedure and prescribed  treatments
  • Instruct the patient or caregiver how to manage adverse effects of treatment
  • Explain the benefits and limitations of breast self examination.If patient chooses to perform the procedure teach her how to examine her breast
  • Women who have had breast cancer in one breast are higher risk for cancer in the other breast or for recurrent cancer in the chest wall.Therefore,urge the patient to continue examining the other breast and to comply with follow up treatment.
  • Refer the patient and family to hospital and community support services.

Reference :

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