Transcript Document 7148115

Relatively High estrogen
and
Low progesterone
 Development of excess fibrous
tissue
 Hyperplasia of the epithelial lining
of the mammary ducts
 Proliferation of mammary ducts
 Cyst formation
 Palpable lumps that are round, well-delineated
and freely movable
 Lumps increase in size premenstrual
 Tenderness
 Pain
 Nipple discharge
 Ultrasound
 Biopsy
◊ Aspiration
◊ Excisional
 Patient Teaching
◊ Wear good support bra
◊ Diet Therapy
Low salt
 No chocolate or caffeine
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◊ Medications
Vitamin E
 Antiestrogen - Danazol
 Diuretics
 Analgesics
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◊ Remind Patient to have a Yearly follow-up
◊ Continue to perform monthly BSE
 In teaching the patient with painful fibrocystic
breast changes about the condition, the nurse
explains that
a. All breast lumps must be biopsied to rule out malignant
changes
b. The symptoms will probably subside after menopause unless
you use HRT
c. Restrictions of coffee and chocolate and supplements of
vitamin E may relieve the discomforts
d. The lumps will become progressively larger and more
painful, eventually necessitating surgical removal
Benign lump in breast
 Not affected by menstrual cycle
 Small, painless, well-delineated, very
mobile
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Diagnosed via mammogram or biopsy
Treatment – surgical excision
Breast Cancer
•Significant health concern for women
•1 in 7 chance of being diagnosed
with Breast Cancer
•Intense feelings of shock, fear, denial
•One of the most common
malignancies in American women
◊ Female gender; ≥50 years of age
◊ Personal History
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Family history
Personal history of cancer (breast, colon, endometrial, ovarian)
◊ Hormonal factors
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Early menarche or late menopause
No pregnancies
First child after 30 years of age
◊ Weight gain and obesity after menopause
◊ High fat diet, alcohol intake
◊ Exposure to ionizing radiation
 In normal cells, BRCA1 and BRCA2 help ensure the
stability of the cell’s genetic material (DNA) and help
prevent uncontrolled cell growth.
 A woman’s lifetime risk of developing breast and/or
ovarian cancer is greatly increased if she inherits a
harmful mutation in BRCA1 or BRCA2.
Another risk – a woman who has been on combined
estrogen and progesterone therapy
 Breast Cancer arises from:
◊ Epithelial lining of ducts
◊ Epithelium of lobules
Most Breast Cancers arise from ducts
and are invasive
 Factors that affect cancer prognosis
◊ Size
◊ Axillary node involvement
◊ Tumor differentiation
◊ Human epidermal growth factor receptor 2 (HER-2)
status
HER-2 receptors are found on the inside and outside of the
Cancer cell. Receptors join together to send messages
telling cancer cells to grow and divide
 Detected as a lump
 Abnormality on mammography
 If palpable, irregular shaped, poorly delineated, nonmobile
(usually attached to chest wall), and nontender
 May have nipple discharge – bloody
 Nipple retraction
 Dimpling
Most commonly
found in the upper
outer quadrant
 Helps women to become self-aware of how their
breasts normally look and feel and to detect when
something changes.
 Should be done monthly when the breasts are non
tender, right after the end of menses
 If no longer have menses – use the first day of each
month
Step 1:
Begin by looking at your breasts
in the mirror with your shoulders
straight and your arms on your
hips.
Here's what you should look for:
Breasts that are their usual
size, shape, and color
Breasts that are evenly
shaped without visible
distortion or swelling
Use a firm, smooth touch with the first few finger pads of your hand,
keeping the fingers flat and together. Use a circular motion, about
the size of a quarter. Go around breast, up and down over breast
and in outward from nipple.
Look at breasts with arms at side and arms raised and on hips
Next, lie down and do same procedure in palpating breasts.
 DNA testing for BRCA – 1 and BRCA-2
 Mammogram / ultrasound
Mammogram showing Bilateral Invasive Ductal Carcinoma
 Biopsy
 Lymphatic mapping and sentinel lymph node
dissection (SLND)
◊ Helps surgeon identify lymph nodes that drain first
from tumor site
◊ Radioisotope and/or blue dye is injected into tumor
site
◊ Lymph nodes dissected and sent to lab for analysis
 While discussing risk factors for breast
cancer, the nurse stresses that the greatest
known risk factor for breast cancer is
a. Being a woman over 60 years of age
b. Experiencing menstruation for 40 years or more
c. Using estrogen replacement therapy during menopause
d. Having a paternal grandmother with postmenopausal
breast cancer
Surgery
Radiation Therapy
Chemotherapy
Hormonal Therapy
Biologic and Targeted Therapy
 Most common options for resectable Breast
Cancer
◊ Breast conservation surgery with radiation
therapy
◊ Modified radical mastectomy with or without
reconstruction
 Sentinel lymph node dissection (SLND) has
replaced ALND for patients who do not have
malignant cells
 ALND performed when one or more sentinel
lymph nodes contain malignant cells
 Examination of lymph nodes provides prognosis
and treatment information
 Involves removal of entire tumor with a margin of
normal tissue
 Radiation therapy is delivered to entire breast,
ending with a boost to tumor bed
 Evidence of systemic disease may warrant
chemotherapy before radiation
 Modified radical mastectomy
◊ Removal of breast and axillary lymph nodes
with preservation of the pectoralis major
muscle
◊ Patient has the option of breast reconstruction
 Primary radiation therapy
◊ Usually performed after local excision of breast mass
◊ Breast is radiated daily over ~5 to 6 weeks
◊ “Boost” treatment may be given to full breast
following primary dose
 Intraoperative Radiation Therapy
◊ Single intense dose delivered to surgery site in the operating
room
 High-dose brachytherapy
◊ Internal radiation delivered
via radioactice seeds into a
balloon catheter
◊ Balloon catheter is placed
within the lumpectomy site
◊ Treatment is over 4-5 days
 Palliative radiation therapy
◊ Used to stabilize symptomatic metastatic
lesions in such sites as
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Bone
Soft tissue organs
Brain
Chest
◊ Relieves pain
◊ Successful in controlling recurrent or metastatic
disease for long periods
 Radiation therapy side effects
◊ Fatigue
◊ Skin changes
◊ Breast edema
 Removes or blocks source of estrogen,
promoting tumor regression
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Estrogen can increase growth of BC cells if cells are
estrogen receptor positive
 Most common drug used in estrogen-receptor
positive women is:
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Tamoxifen (Nolvadex) – antiestrogen
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Side effects – decreased visual acuity, and vascular changes
Fulvestrant (Faslodex) - antiestrogen
 Hormonal therapy (cont'd)
◊ 2 advances have increased use in BC
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Hormone receptor assays developed to identify
those likely to respond to treatment
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Drugs have been developed that can inactivate
hormone-secreting glands as effectively as surgery
or radiation
 Trastuzumab (Herceptin) is a monoclonal antibody
to HER-2
 Once the antibody attaches to antigen, it is taken to
cells and eventually kills them
 It can be used alone or in combination with other
chemotherapies
 Side-effect – monitor for signs of ventricular
dysfunction and congestive heart failure.
◊ Use of cytotoxic drugs to destroy cancer
cells
◊ BC is one of the solid tumors that is most
responsive to chemotherapy
◊ Given preoperatively in some patients to
decrease size of primary tumor
 Variety of side effects since healthy cells are also
affected
 Influenced by specific drug combinations, drug
schedule, and dose of drug(s)
 Most common side effects involve
◊ Gastrointestinal tract
◊ Bone marrow
◊ Hair follicles
The patient will:
◊ Actively participate in decision-making process
related to treatment options
◊ Fully comply with therapeutic plan
◊ Manage side effects of therapy
◊ Be satisfied with support provided by significant
others and health care providers
 Prevention of Lymphedema:
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Heaviness
Pain
Impaired motor function in arm
Numbness
Paresthesia of the fingers
Cellulitis and progressive fibrosis can result
 Restoring arm function on affected side after
mastectomy and axillary lymph node dissection
is one of the most important goals
◊ Place in a semi-Fowler’s position with arm on affected side
elevated on a pillow, never dependent
◊ Flexing and extending fingers should begin in recovery room
and progressive increase in activity
◊ Blood pressure readings, venipunctures, and injections should
not be done on affected arm
◊ Use intermittent pneumatic compression sleeve or a fitted
elastic pressure gradient sleeve
◊ Postoperative arm and shoulder exercises are
instituted gradually at surgeon’s direction
◊ Exercises are designed to prevent
contractures and muscle shortening,
maintain muscle tone, and improve lymph
and blood circulation
◊ Instruct patient to protect arm from even
minor trauma (e.g., sunburn, pinprick)
Fig. 52-8
 Relieve postmastectomy pain syndrome:
◊ Chest and upper arm pain, tingling down arm
◊ Numbness, shooting or prickling pain
◊ Unbearable itching persisting beyond
3-month healing time
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Treatment includes
◊ Nonsteroidal antiinflammatory drugs
◊ Antidepressants
◊ Topical lidocaine patches or EMLA
 Postoperative discomfort can be minimized
by administering analgesics ~30 minutes
prior to exercises
 When showering is appropriate, warm
water has a soothing effect and decreases
joint stiffness
 Psychologic care
◊ All aspects of care must include sensitivity to
woman’s effort to cope
◊ Nurse can help by:
Assisting her to develop a positive but realistic
attitude
 Helping her identify sources of support and
strength
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 Must be follow-up for rest of life at regular
intervals
 Professional examinations every
6 months for 2 years, then annually
 Practice monthly breast self examinations
(BSE) on both breasts or remaining breast
 A patient had a radical mastectomy with
lymph node dissection. Post op nursing care
focused on restoring arm functioning would
include
a. Use of heating pads or blankets to increase circulation
b. Daily application of ice packs to minimize the risk of
lymphedema
c. Compression bandaging with sleeves or stocking for acute
swelling
d. Frequent and sustained exercises with the arm in a
dependent position
Chest prior to Implants
Breast implants placed in pocket under
pertoralis muscle and
musculocutaneous skin flap applied
 Musculocutaneous flap most often taken from
abdomen or back is used in reconstruction
 As part of the final stage of reconstruction,
the nipple and areola are reconstructed
The tissue expander starts out with
minimal inflation.
Gradually filled with water weekly to
stretch the skin and muscle
Tissue expander in place
after mastectomy
 Capsular formation
◊ Part of bodies natural defense mechanism to form
a fibrous capsule around the implant
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Infection
Hematoma
Skin ulceration
Hypertropic scar formation
 To prevent capsular formation following
breast reconstruction with implants, the nurse
teaches the patient to
a. Gently massage the area around the implant
b. Bind the breasts tightly with elastic bandage
c. Exercise the arm on the affected side to promote drainage
d. Avoid strenuous exercise until implant healing has
occurred.