Download Key Points for Chapter 52

Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7th edition
Key Points
Chapter 52: Nursing Management: Breast Disorders

Screening guidelines for early detection of breast cancer are yearly mammograms starting
at age 40, and clinical breast examinations every 3 years for women between ages 20 and
30 and every year for women beginning at age 40.

Women should report any breast changes promptly to their health care provider.

Breast self-examination is an option for women.

Women at increased breast cancer risk (family history, genetic tendency, past breast
cancer) should talk with their health care provider about benefits and limitations of
starting mammography screening earlier, having additional tests (breast ultrasound), or
having more frequent examinations.

Mammography is used to visualize internal structures of the breast using x-rays. This
procedure can detect tumors and cysts not felt by palpation.

Ultrasound is another procedure used to differentiate a benign tumor from a malignant
tumor. It is useful for women with fibrocystic changes whose breasts are very dense.

Definitive diagnosis of breast cancer is made by histologic examination of biopsied
tissue. Biopsy techniques include fine-needle aspiration (FNA) biopsy, stereotactic or
handheld core biopsy, and open surgical biopsy.

Mastalgia (breast pain):
o Mastalgia is the most common breast-related benign complaint in women.
o It is described as diffuse breast tenderness or heaviness.
o Breast pain may last 2 to 3 days or most of month.
o Symptoms often decrease with menopause.
o Some relief may occur with caffeine and dietary fat reduction; hormonal therapy,
taking vitamins, and gamma-linolenic acid (evening primrose oil); and wearing of
support bra.

Mastitis:
o Mastitis is a breast inflammatory condition that occurs most frequently in
lactating women.
o Lactational mastitis manifests as a localized area that is erythematous, painful,
and tender to palpation.
o Fever is usually present. Infection develops when organisms, usually
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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staphylococci, gain access to breast through cracked nipple.
o In its early stages, mastitis can be cured with antibiotics.

Fibrocystic changes in breast:
o Fibrocystic changes is a common benign condition characterized by changes in
breast tissue including development of excess fibrous tissue, hyperplasia of
epithelial lining of mammary ducts, proliferation of mammary ducts, and cyst
formation.
o These changes produce pain by nerve irritation from edema in connective tissue
and by fibrosis from nerve pinching.
o Types of treatment that might help fibrocystic breast disease include use of good
support bra, dietary therapy (low-salt diet, restriction of methylxanthines such as
coffee and chocolate), vitamin E therapy, analgesics, danazol, diuretics, hormone
therapy, and antiestrogen therapy.
o Fibroadenoma is a common cause of benign breast lumps in young women. A
possible cause may be increased estrogen sensitivity in localized area of breast.
Treatment includes surgical excision or cryoablation.
o Gynecomastia is a transient, noninflammatory enlargement of one or both breasts
and is the most common benign breast problem in men.
BREAST CANCER
 Breast cancer is the most common malignancy in American women except for skin
cancer.

Although the etiology of breast cancer is not completely understood, a number of factors
are thought to relate to breast cancer including a family history, environmental factors,
genetics, early menarche and late menopause, and age 60 or over. However, most women
who develop breast cancer have no identifiable risk factors.

Noninvasive breast cancers include ductal carcinoma in situ (DCIS) and lobular
carcinoma in situ (LCIS).
o DCIS tends to be unilateral and most likely would progress to invasive breast
cancer if left untreated.
o LCIS is a risk factor for developing breast cancer, but it is not known to be a
premalignant lesion. No treatment is necessary for LCIS. Tamoxifen may be
given as a chemoprevention.

Paget’s disease:
o Paget’s disease is a rare breast malignancy characterized by a persistent lesion of
the nipple and areola with or without a palpable mass.
o Treatment is a simple or modified radical mastectomy.

Inflammatory breast cancer:
o Inflammatory breast cancer is the most malignant form of all breast cancers.
o The skin of the breast looks red, feels warm, with a thickened appearance
described as resembling an orange peel (peau d’orange).
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o Metastases occur early and widely. Radiation, chemotherapy, and hormone
therapy are more likely to be used for treatment than surgery.

Breast cancer is detected as a lump or mammographic abnormality in the breast. It occurs
most often in upper, outer quadrant of breast.

If palpable, breast cancer is usually hard, and may be irregularly shaped, poorly
delineated, nonmobile, and nontender. Nipple discharge may also be present.

In addition to earlier listed tests, other tests useful in predicting risk of recurrence or
metastatic breast disease include axillary lymph node status, tumor size, estrogen and
progesterone receptor status, and cell proliferative indices.

Patients with breast cancer should discuss all treatment options with their health care
provider, including local excision, mastectomy with breast reconstruction, breastconserving treatment (lumpectomy), radiation therapy, and/or tamoxifen.

Common options for resectable breast cancer include breast conservation surgery with
radiation therapy and modified radical mastectomy with or without reconstruction.

Breast conservation surgery (lumpectomy) involves removal of entire tumor along with a
margin of normal tissue. Modified radical mastectomy includes removal of breast and
axillary lymph nodes, but it preserves pectoralis major muscle.

Lymphedema can occur due to surgical excision or radiation of lymph nodes. Symptoms
are heaviness, pain, impaired motor function in the arm, and numbness and paresthesia of
the fingers as a result of lymphedema.

Following surgery, radiation therapy is delivered to the entire breast, ending with a boost
to the tumor bed. If there is evidence of systemic disease, then chemotherapy may be
given before radiation therapy.

Radiation therapy may be used for breast cancer as a primary treatment to prevent local
breast recurrences after breast conservation surgery, adjuvant treatment following
mastectomy to prevent local and nodal recurrences, and palliative treatment for pain
caused by local recurrence and metastases.

Breast cancer is one of the solid tumors most responsive to chemotherapy with the use of
combinations of drugs, which is clearly superior to use of single drug therapy.

Hormonal therapy removes or blocks the source of estrogen, thus promoting tumor
regression.

Nursing interventions at time of breast cancer diagnosis include exploring woman’s usual
decision-making patterns, helping the woman accurately evaluate advantages and
disadvantages of options, and providing information and support relevant to treatment
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decisions.

The woman with breast conservation surgery usually has an uneventful postoperative
course with only a moderate amount of pain. If an axillary lymph node dissection or
mastectomy is done, drains are often left in place.

Postoperative discomfort is minimized by administering analgesics 30 minutes before
initiating exercises. With showering, the flow of warm water over the involved shoulder
often has a soothing effect and reduces joint stiffness.

Mammoplasty:
o Mammoplasty is a surgical change in size or shape of the breast.
o It may be done electively for cosmetic purposes to either augment or reduce the
size of breasts or to reconstruct the breast after mastectomy.
o In augmentation, an implant is placed in a surgically created pocket between the
capsule of the breast and the pectoral fascia.
o Reduction mammoplasty is performed by resecting wedges of tissue from upper
and lower quadrants of breast.

Breast reconstructive surgery may be done simultaneously with mastectomy or some time
afterward to achieve symmetry and to restore or preserve body image.
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Lewis: Medical-Surgical Nursing, 7th Edition
New Type of Genetic Test Approved for Breast Cancer Patients
Relates to Chapter 52: Nursing Management: Breast Disorders
The U.S. Food and Drug Administration (FDA) has approved a novel genetic test for determining whether
patients with breast cancer are good candidates for treatment with the drug trastuzumab (Herceptin). The
SPOT-Light HER2 CISH test kit measures the number of copies of the HER-2 gene in tumor tissue. This
gene regulates the growth of cancer cells.
A healthy breast cell has two copies of the HER-2 gene, which sends a signal to cells, telling them when
to grow, divide, and make repairs. Patients with breast cancer may have more copies of this HER-2 gene,
prompting them to overproduce HER-2 protein so that more signals are sent to breast cells. As a result,
the cells grow and divide much too quickly.
The SPOT-Light test counts the number of HER-2 genes in a small sample of removed tumor. The
removed piece is stained with a chemical that causes any HER-2 genes in the sample to change color.
This color change can be visualized under a standard microscope, eliminating the need for the more
expensive and complex fluorescent microscopes required to read assays already on the market. Unlike
existing tests, the SPOT-Light test allows laboratories to store the tissue for future reference.
Patients who over-produce HER-2 protein are typically treated with the drug trastuzumab, which targets
HER-2 protein production. This helps to stop the growth of HER-2 cancer cells.
For more information, see www.fda.gov/cdrh/mda/docs/p050040.html.
August 2008
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.