Download What is a Mastectomy?

Breast Cancer
Katherine MacGillivray & Melissa Poirier
Objectives
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Discuss breast cancer statistics in Canada and Nova Scotia.
Overview of the breasts anatomy and physiology.
Discuss risk factors for breast cancer and how to minimize those risks.
Discuss differences between benign, non-invasive and invasive breast
disease.
Brief overview of breast cancer in men.
Discuss types of lymph node involvement.
Discuss screening options for breast cancer.
Discuss diagnostic tests used for breast cancer.
Discuss grading & staging of breast cancer.
What are the treatment options for breast cancer?
Discuss complications and prognosis of breast cancer.
Discuss pre/postoperative nursing diagnosis and interventions .
Canadian Statistics for 2012
 In Canada, 200 men & 23,000 women will be diagnosed
with breast cancer in 2012.
 Of that, 50 men & 5100 women will succumb to the
disease.
 Breast cancer accounts for 26% of new cancer cases in
Canadian women.
 Approximately 62 Canadian women are diagnosed with
breast cancer daily.
 Approximately 14 Canadian women die daily of breast
cancer.
 1 in 9 women will develop breast cancer in their lifetime
and 1 in 29 will die from it.
Statistics in Nova Scotia for 2012
 An estimated 740 women will be diagnosed with breast
cancer.
 An estimated 160 women will die of breast cancer.
 100 out of every 100,000 women of NS will be diagnosed
with breast cancer.
 Of 100,000 deaths, 20 women will die as the result of
breast cancer.
 In Nova Scotia, there is limited data available for breast
cancer in men. Men succumb to prostate, colorectal and
lung cancers.
Breast A & P
 Male and female breast
develop at the same rate till
puberty.
 Located between the 2nd & 6th
ribs.
 Tail of Spence extends into the
axilla.
 Cooper’s ligaments support
the breast to the chest wall.
 Each breast contains 12-20
lobes.
Risk Factors
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Personal Health History
Family Health History
Certain Genome Changes
Radiation Therapy to the Chest
Reproductive and Menstruation History
Race
Being Overweight or Obese after Menopause
Lack of Physical Activity
Alcohol Use
Smoking
Age
Minimizing Your Risk
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Lose excess weight.
Be physically active.
Limit your intake of alcohol.
Breastfeed your baby.
Quit smoking.
Talk to your doctor about the risks and benefits of
hormone replacement therapy (HRT).
 Reduce exposure to chemicals
Benign Proliferative Breast Disease
 Atypical Hyperplasia
 Benign
 Abnormal proliferation of cells
 Increased risk of breast cancer
 Lobular Carcinoma in Situ
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Benign
Proliferation of cells in the lobules
Unable to be diagnosed with a Mammogram
Increased risk of breast cancer
Lobular Carcinoma in Situ
Breast profile:
A Ducts
B Lobules
C Dilated section of
duct to hold milk
D Nipple
E Fat
F Pectoralis major
muscle
G Chest wall/rib cage
Enlargement
A Normal lobular cells
B Lobular cancer cells
C Basement membrane
Types of Breast Cancer:
Non-Invasive vs. Invasive
 Non-Invasive Cancer
 Ductal Carcinoma in Situ
 Invasive Cancer
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Infiltrating Ductal Carcinoma
Infiltrating Lobular Carcinoma
Medullary Carcinoma
Mucinous Carcinoma
Tubular Ductal Carcinoma
Inflammatory Carcinoma
Paget’s Disease
Ductal Carcinoma in Situ
Breast profile:
A Ducts
B Lobules
C Dilated section of duct to
hold milk
D Nipple
E Fat
F Pectoralis major muscle
G Chest wall/rib cage
Enlargement
A Normal duct cells
B Ductal cancer cells
C Basement membrane
D Lumen (center of duct)
Non-Invasive (In Situ) Cell Growth
Subtypes
Non-invasive cancer is grouped into four subcategories,
based on how the cancer cells grow relative to each
other, within the center of the milk duct:
 Solid
 Cribriform
 Papillary
 Comedo
Solid:
There is wall-to wall cell growth
 A - Cancer cells
 B - Basement
membrane
Cribriform:
There are holes between groups of cancer cells, making it look
like Swiss cheese.
 A - Cancer Cells
 B - Basement membrane
 C - Lumen (center of duct)
Papillary:
The cells grow in fingerlike projections, toward the inside of
the duct.
 A - Cancer cells
 B - Basement membrane
 C - Lumen
Comedo:
There are areas of “necrosis”, which is debris from dead cancer cell; this
indicates that a tumor is growing so fast that some of the tumor will wither
and die because there is not enough blood to feed all of the cells.
 A - Living cancer cells
 B - Dying cancer cells
 C - Cell debris (necrosis)
 D - Basement
membrane
* Referred to as high
grade noninvasive
cancer- fast growing
Invasive Cancers
Most Common:
Infiltrating Ductal Carcinoma
Infiltrating Lobular Carcinoma
Invasive Ductal Carcinoma
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Breast profile:
A ducts
B lobules
C dilated section of duct to hold
milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage
Enlargement:
 A normal duct cells
 B ductal cancer cells breaking
through the basement
membrane
 C basement membrane
Invasive Lobular Carcinoma
Breast profile:
 A ducts
 B lobules
 C dilated section of
duct to hold milk
 D nipple
 E fat
 F pectoralis major
muscle
 G chest wall/rib cage
Enlargement:
 A normal cells
 B lobular cancer cells
breaking through the
basement membrane
 C basement
membrane
Other Invasive Carcinomas
 Medullary Carcinoma
 Mucinous Carcinoma
 Tubular Ductal Carcinoma
 Inflammatory Carcinoma
 Paget’s Disease
Men & Breast Cancer
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Less than 1% of breast cancers happen to men in Canada;
however the number is increasing
Men over the age of 60 are most often diagnosed with
breast cancer
Risk factors, diagnosis, staging and treatment are the
same as in women
Risk factors include: mumps, radiation exposure &
decreased testosterone levels.
Most common is ductal carcinoma – found in breast ducts
Symptoms include a small painless lump, discharge from
nipple, inverted nipple and skin ulceration
Adverse feelings related to “manhood” and sexuality,
having a “women’s disease”
Lymph Node Involvement
 Some breast cancers spread to the lymph nodes
under a woman's arm.
 Microscopic examination:
 Lymph node involvement = positive
 Lymph node clear of cancer = negative
 Connection between the number of lymph nodes
involved & aggressiveness of cancer's personality.
 Knowing how many lymph nodes are involved will
help identify appropriate treatment.
Lymph Nodes
 Three types of lymph node involvement
1. Minimal (or microscopic) lymph node involvement:
- Small number of cancer cells in lymph nodes.
2. Significant (or macroscopic) involvement:
-A particular lymph node or group of nodes has
become involved with the cancer. Can often
felt by hand or seen without a microscope.
3. Extra-capsular extension:
-A breast cancer tumor takes over a whole lymph
node and spills beyond the wall of the lymph
node into the surrounding fat.
Lymph Nodes
 In most cases, the more extensive the lymph node
involvement, the more aggressive the cancer. But the
extent of disease within a particular lymph node is
less important than the total number of lymph nodes
affected. The more lymph nodes that are involved,
the more threatening the cancer may be.
 Doctors use the following categories to describe the
overall level of lymph node involvement:
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No lymph nodes involved
1–3 nodes involved
4–9 nodes involved
10 or more nodes involved.
Has Cancer Invaded Lymph or
Blood Vessels?
A blood vessels
B lymphatic channels
Enlargement
A Normal duct cell
B Cancer cells
C Basement membrane
D Lymphatic channel
E Blood vessel
F Breast tissue
Breast Cancer Tissue
Report to Physician ASAP
Screening
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SBE (self-breast examination)
Mammography
Self Breast Examination
 Self Breast Exams are an important way to find a
breast cancer early.
 Not every cancer can be found this way, but it is
critical to become familiar with your breasts in
order to identify an abnormality
 SBE should be done once a month approximately
1wk after your menstrual period
Self Breast Exam cont’d
 Lumps
 most women have lumps or lumpy areas in the breast that
may be the result of Fibroadenomas or Cysts
 8 out of 10 lumps removed from the breast are benign
 Upper/outer area(armpit) - most prominent lumps/bumps
 Lower half - sandy/pebbly beach
 Underneath nipple - collection of large grains
 Other parts - lumpy bowl of oatmeal
Studies show that regular breast
self-exams, combined with an
annual exam by a doctor,
improves the chances of
detecting cancer early.
Steps to a Self Breast Exam:
Step 1
 Look in the mirror, shoulders straight
and arms on your hips.
 Look for size, shape, and colour of
breasts, is there any distortion or
swelling present
 Changes to report: dimpling,
puckering, bulging of the skin,
change in nipple position, inverted
nipple, redness, soreness, rash or
swelling.
Step 2
 Raise your arms
above your head
and look for the
same changes.
Step 3
 Still standing at the mirror, look for any
discharge/fluid coming from your nipples.
 Changes to report: any fluid coming out of 1 or
both nipples (unless you are lactating). Could
be watery, milky, yellow or bloody.
Step 4
 Lie down on the bed and
palpate breasts using pads
of a few fingers.
 Use a firm smooth touch
in a circular motion.
 Cover entire breast –
collar bone to top of
stomach, armpit to
sternum.
 Make sure to follow a
pattern so to cover all
area of the breasts.
Step 5
 Sit or stand and
palpate the breast in
the same manner as
step 4.
 Changes to report:
lumps, bumps,
irregularities
Mammography
 Breast imaging technique
 Identifies non-palpable masses and diagnoses palpable
masses
 Procedure takes approximately 15 minutes
 Breast is compressed from top to bottom, and side to side
 New and old mammograms are compared
 Radiation exposure is equivalent to 1 hour in the sun
 Canadian Cancer Society recommends women to have a
mammogram every 2 years between 50 & 69 years of age.
 Women at high risk and under 50 should speak with the HCP
 http://www.youtube.com/watch?v=Y-GmNmPeqHQ
EXPERT QUOTE
"The biggest misconception about mammography is that
it picks up every breast cancer. In fact, mammography
misses at least 10 percent of breast cancer. So if you feel a
lump that doesn't show up on a mammogram, bring it to
your doctor's attention. Get it evaluated."
—Susan Orel, M.D.
Diagnosis for Breast Cancer
 Procedures for tissue analysis:
 Percutaneous Biopsy
 Fine-Needle Aspiration
 Core Needle Biopsy
 Guided Core Biopsy
 Surgical Biopsy
 Excisional Biopsy
 Incisional Biopsy
Needle Biopsy
Excisional Biopsy
Grading
Grade
Description
1
Low grade – slow growing, less likely to spread
2
Moderate grade
3
High grade – tend to grow quickly, more likely to spread
Staging
Stage Description
0
There are two kinds of stage 0 breast cancer:
Ductal carcinoma in situ (DCIS): Abnormal cells are in the lining of a milk duct and have
not spread outside the duct.
Lobular carcinoma in situ (LCIS): Abnormal cells are in the lining of a lobule.
1
Tumour is 2 cm or smaller and the cancer has not spread outside the breast.
2
Tumour is 2 to 5 cm, or cancer has spread to the lymph nodes, or both.
3
Cancer has spread to the lymph nodes and may have spread to nearby tissues such as
the muscle or skin.
4
Cancer has spread to distant parts of the body.
Treatment
 Surgery
 Chemotherapy
 Radiation
 Adjunctive Therapy
 Alternative Therapy
Breast Sparing Surgery: Lumpectomy &
Partial Mastectomy
Lumpectomy vs. Mastectomy
Modified Radical Mastectomy
Radical Mastectomy
Total Mastectomy
TRAM Flap Reconstruction
Complications
 Infection
 Lymphedema
 Hematoma/Seroma Formation
 Allergic Reaction
Lymphedema
Lymphedema is the buildup of fluid in the arm.
About 10-20% of women
will develop this especially
if more than 10 lymph
nodes were removed.
Lymphedema
How to Prevent Lymphedema
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Talk to HCP if experiencing symptoms of lymphedema
Keep skin and nails clean
Avoid blocking the flow of fluid through the body
Keep blood from pooling in affected limb
Exercise
Prognosis
 Two most important factors when determining the
prognosis of breast cancer:
 Size of tumour
 Spread of tumour
 Excessive number of copies of certain genes
 Excessive amounts of the genes protein products
Preoperative Nursing Diagnosis
 Deficient knowledge
 Anxiety
 Fear
 Risk for ineffective coping
 Decisional conflict
Preoperative Nursing Interventions
 Provide education and preparation for surgical
treatments
 Reduce fear and anxiety and improve coping ability
 Promote decision-making ability
Postoperative Nursing Diagnoses
 Acute pain
 Disturbed sensory perception
 Disturbed body image
 Risk for impaired adjustment
 Risk for ineffective coping for individual and family
 Deficient knowledge
 Risk for sexual dysfunction
 Risk for infection
Postoperative Nursing Interventions
 Relieving pain and discomfort
 Managing postoperative sensations
 Promoting a positive body image
 Promote positive adjustment and coping
 Improving sexual function
 Monitor for complications
Case Study
Mrs. X, a 59 year old female with a family history of breast cancer
recently found a small palpable mass in the upper outer quadrant
of her left breast, she also noticed some slight dimpling upon a
breast self exam. When she notified her doctor, he preformed a
fine needle aspiration biopsy for tissue analysis. Mrs. X’s results
showed she had an infiltrating ductal carcinoma, which is an
invasive cancer. Mrs. X’s doctor staged her cancer as T1N1M0.
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How often and when should one perform a breast self
exam?
If Mrs. X’s breast cancer was genetically inherited, which
gene(s)would most likely have a mutation?
Interpret T1N1M0
Case Study Cont’d
Mrs. X was scheduled for a modified radical mastectomy (removal
of entire breast tissue, nipple – areola complex and axillary lymph
nodes). She met with a plastic surgeon to explore the option of
breast reconstructive surgery but has decided to wait until after
her surgery to decide. Mrs. X’s mother and sister both have
undergone the same surgery and she has a very supportive
husband. Mrs. X confides in you, the RN, that she is still anxious
regarding her upcoming surgery.
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What are some preoperative nursing interventions you
would do?
What are some postoperative nursing interventions you
would do?
References
 Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., &
Bare, B. G. (2010). Textbook of Canadian medicalsurgical nursing (2nd ed). Philadelphia, Pennsylvania:
Wolters Kluwer Health/Lippincott Williams & Wilkins.
 www.breastcancer.org
 www.cancer.ca
 www.cancer.gov