Download Breast Cancer

Detect Breast Ca Early
• Mammogram
Breast Cancer
• Detect lumps early, before palpable
• Biannually 4040-49 y/o, Annually >50 y/o
• Clinical BSE
Breast Disorders
• HCP examines breasts and axillary area
• Annually > 40y/o
• Self BSE
• 2 steps look and palpate
• Once/month, a few days after menses
• Post menopausal, same time each month
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of
Breast Cancer
• If palpable, BC is
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Hard
Irregularly shaped
Poorly delineated
Nonmobile
Nontender
Staging Breast Cancer
• Stage 0
• Abnormal cells lining the lobule
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Seldom becomes invasive
5 year survival 100%
• Stage 1
• Tumor cells in breast, no metastases
• 5 year survival 98%
• Stage II
• Tumor is 2 - 5 cm across and spread to axillary
lymph nodes
• 5 year survival 88%
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
1
Staging Breast Cancer
• Stage III
• Large in size but confined to breast and
axillary lymph nodes
• 5 year survival 50%
• Stage IV
• Metastatic cancer that has spread to
other parts of body
• 5 year survival 15%
Diagnostic Studies
• History including risk factors
• Physical examination including breast and
lymphatics
• Mammography
• Ultrasound
• MRI
• PET
• Biopsy
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Diagnostics
Pathology Report
• Tumor grade
• Grade 1 = Well differentiated (cells appear
normal and are not growing rapidly)
• Grade 2 = Moderately differentiated (cells
appear slightly different than normal and stick
together)
• Grade 3 = Poorly differentiated (cells are
irregularly shaped, stuck together and may
grow and spread more aggressively than other
grades)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Diagnostics
Pathology Report
• Hormone receptor status
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Helps guide treatment
Estrogen and Progesterone Receptors
ER+ and/or PR+
Treat with Tamoxifen or aromatase inhibitors
•
May stop tumor growth
• HER2/neu (human epidural growth factor receptor)
• Benefit from trastuzumab (Herceptin) therapy
• 20
20--30% of all BC
• Aggressive cancer
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
2
Diagnostic Studies
• Lymphatic mapping
and sentinel lymph
node dissection
(SLND)
• Prognosis worsens
when cancer spreads
to the lymph nodes
& as the number of
cancerous nodes
increases.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Treatment options
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Surgery
Radiation
Chemotherapy
py
Tamoxifen, aromatase inhibitors,
Trastuzumab (Herceptin)
Emerging Therapies
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Prognostic factors considered when
treatment decisions are made
• Staging of BC
• TNM system
• Tumor size (T)
• Nodal involvement (N)
• Presence of metastasis (M)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Lymphedema
• Accumulation of lymph in soft tissues
• Can occur as a result of excision or
radiation of lymph nodes
• When axillary
i
nodes cannot return
lymph fluid to central circulation, fluid
accumulates in arm, causing
obstructive pressure on veins and
venous return
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3
Nursing Implementation
Acute Intervention
Lymphedema
• S/S
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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 ALND is
priority goal
• Place in a semisemi-Fowler’s position with
arm on affected side elevated on a pillow
• Flexing and extending fingers should
begin in recovery room and progressive
increase in activity should be encouraged
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Treatment
Lymphedema
• No cure
• Can restore some mobility and reduce pain
& swelling
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Compression bandages or sleeves
Exercise (close & open fist)
Massage therapy
PT
Elevate arm
• New treatment
• Decongestive physiotherapy
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Preventing Lymphedema
• Reduce the risk of injury or infection to the arm:
• Use the unaffected arm when having blood drawn,
getting injections or having blood pressure taken.
• Avoid lifting or carrying heavy bags, purses or other
objects with the at
at--risk arm.
arm
• Protect the arm from sunburn and avoid excess heat
such as saunas, hot baths or tanning.
• Avoid any type of injury, including scratches and
bruises, to the atat-risk arm.
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Use an electric razor, not a blade, to shave the underarm.
Wear gloves when doing house or garden work.
Keep the affected hand well moisturized.
• Rest the atat-risk arm in an elevated position (above the
heart Copyright
or shoulder).
© 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
4
Surgical Therapy
Radiation
Postmastectomy Pain Syndrome
• Caused by a number of factors
• Most common theory for its onset is
injury to intercostobrachial nerves
• Used with breast conserving surgery or
• Palliative treatment for pain caused by local
recurrence and metastases
• Treatment includes
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Nonsteroidal antiinflammatory drugs
Antidepressants
Topical lidocaine patches
Antiseizure drugs (neurontin)
• Possible side effects of radiation and surgery
•
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Breast soreness, breast edema, skin reactions, arm
swelling, sensory changes in breast and arm, fatigue
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Adjuvant Therapy
Adjuvant Therapy
Radiation Therapy
Radiation Therapy
• 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
• High
High--dose brachytherapy
• Internal radiation delivered using a
multicatheter implant
• radioactive seed delivered into each catheter to
treat target area
• treatment takes ~5 to 6 weeks
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
• Palliative radiation therapy
• Used to stabilize symptomatic metastatic lesions
in such sites as
Bone
Soft tissue organs
• Brain
• Chest
•
•
• Relieves pain
• Successful in controlling recurrent or
metastatic disease for long periods
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
5
Adjuvant Therapies
Adjuvant Therapies
Systemic Therapies
Systemic Therapies
• Goal is to destroy tumor cells that may
have spread undetected to distant sites
• Adjuvant therapy to primary local
treatment can decrease rate of
recurrence and increase length of
survival
• Chemotherapy
• Hormonal therapy
• Chemotherapy
• Use of cytotoxic drugs to destroy cancer cells
• BC responsive to chemotherapy
postop
p after surgery
g y and radiation
• chemo used p
to lower risk of recurrence (early dx)
• Given preoperatively in some patients to
decrease size of primary tumor
• In metastatic cancer used preoperatively to
reduce cancercancer-related symptoms & prolong
survival
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Adjuvant Therapies
Adjuvant Therapies
Systemic Therapies
Systemic Therapies
• Chemotherapy
• Variety of side effects since healthy cells
are also affected
• Influenced by specific drug combinations,
combinations
drug schedule, and dose of drug(s)
• Most common side effects involve
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•
•
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Gastrointestinal tract
Bone marrow
Hair follicles
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
• Hormonal therapy
• 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
• Estrogen deprivation can occur by
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Block receptor on the cell surface (tamoxifen)
Inhibit estrogen production (aromatase inhibitors)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
6
Targeted Therapies
Herceptin
• Advantages
• Destroy cancer cells with minimal effect
on healthy cells.
• Disadvantage
• Many cancers are not eligible for
treatment with these therapies
Targeted Therapies
• Trastuzumab (Herceptin) is a monoclonal
antibody to HERHER-2
• 20
20--30% BC patients are HER2/neu positive
• Once the antibody attaches to antigen,
antigen it is
taken to cells where it slows or stops the
growth of cells
• Clinical trials
• Chemotherapy plus trastuzumab cut the chance
of cancer recurrence in half compared to
chemotherapy alone
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
CAM Therapies
• Talk with HCP
• help ensure that CAM therapies are integrated
with conventional treatments and prevent harmful
combinations.
• Use in addition to conventional therapy
• Conventional therapies have proven benefits.
Replacing with lessless-studied CAM therapies can
increase the risk that a cancer will return or
progress.
• Take the initiative
• Learn about therapies.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
CAM Therapies
• Be wary of wild claims
• If CAM is said to cure cancer; check the scientific
evidence
• Don’t equate
q
natural with safe
• poison ivy, poisonous mushrooms and rattlesnakes
• Use reputable brands
• Look for the stamp USP verified
• Use licensed CAM provider
• A license to practice indicates providers have
passed licensing requirements in their CAM fields.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
7
Nursing Management
• History of breast disorder assists in
establishing diagnoses
• Presence of nipple discharge
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Color consistency
Color,
consistency, from one or both
Pain
Growth of lump
Breast asymmetry
Correlation with menstrual cycle
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
• Size and location of lump or lumps
should be carefully documented
• Subjective and objective data
• Physical
i characteristics
i i off lesion
i
• Consistency
• Mobility
• Shape
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Diagnoses
• Varies related to care of a patient
diagnosed with breast cancer
• Following diagnoses, prior to
treatment plan being selected
selected, & after
treatment
• Decisional conflict
• Fear
• Disturbed body image
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Planning
• Overall goals
• Actively participate in decisiondecision-making
process related to treatment options
• Fully comply with therapeutic plan
• Manage side effects of adjuvant therapy
• Be satisfied with support provided by
significant others and health care
providers
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
8
Nursing Implementation
• Recommended Medical Care After Treatment
• Medical history and physical exam
• Every four to six months for five years, then every
12 months
• Mammogram
Weight and Diet
• Obesity and weight gain after treatment
have been linked to poorer survival and
cancer recurrence
breast conserving surgery and radiation: Six months
after radiation therapy ends, then every six to 12
months
• mastectomy: Every 12 months
•
• Pelvic exam/Pap smear: Every 12 months for
women taking tamoxifen
• Bone health exams
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Implementation
Psychologic Care
Nursing Implementation
• The nurse can
• Provide support by sitting with patient and ask
them to share their story, their concerns
Help accurately evaluate advantages and
di d
disadvantages
t
off options
ti
• Provide relevant and sufficient information
• Assisting her to develop a positive but realistic
attitude
• Helping her identify sources of support and strength
to her
•
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
• Psychologic care
• Nurse can help by
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Encourage her to verbalize her anger and
fears
Promoting open communication of thoughts
and feelings
Providing accurate and complete answers
Offering information about community
resources
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
9
Nursing Implementation
Psychologic Care
• Most people who live through dx, tx, &
recovery will express sadness, fear, anger, &
confusion
p
is healthy
y & it may
y
• Emotional expression
increase immune system function
• Signs of depression
• inability to find joy in activities that used to
bring pleasure, persistent sad mood, loss of
interest in work or hobbies, prolonged
insomnia, withdrawal from friends and family,
feelings of hopelessness and worthlessness
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Implementation
Psychologic Care
• Support of family, friends and
participation in a cancer support
group improve quality of life
• Research shows women who are socially
connected cope better with BC and may
experience better disease outcomes
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