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Breast Disorders
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Copyright © 2008 Lippincott Williams & Wilkins.
Breast Disorders
• Overview of anatomy of the breast
• Cultural and psychosocial considerations
• Breast cancer is a major health problem
• In the U.S., more than 215,000 women
and 1,450 men develop breast cancer
annually, and more than 40,000 die
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Anatomy of the Breast
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Assessment
• Health history
• Physical assessment
– Inspection
– Palpation
• Upright and supine
• Axillary and clavicular areas as well as breasts
– The male breast
• Inspection, and palpation of axillae
• Assess for gynecomastia
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Guidelines for Early Detection of
Breast Cancer
• Women in their 20s and 30s: clinical breast exam
at least every 3 years, then preferably annually
after age 40
• Mammography annually beginning at age 40
• Women at increased risk may have earlier initial
screening, shorter screening intervals, or
additional screening procedures such as
ultrasound and MRI
• Teach women in their 20s the benefits and
limitations of breast self-examination (BSE)
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Breast Self-Examination
• Provide instruction to women regarding BSE
• Instructions should be provided to men if there is a
family history of breast cancer
• Encourage BSE but do not overemphasize it
• Instructional materials can be obtained from the
American Cancer Society and The National
Cancer Institute
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Lymph Nodes
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Teaching Breast SelfExamination
• Best performed days 5 to 7 days after first day
of menses or once monthly for postmenopausal
women
• Review the feel of normal breast tissue and
ways or identify changes
• Routine BSE helps patients become familiar
with their own “normal abnormalities”
• Demonstrate the examination technique
• Encourage the patient to perform a BSE
demonstration on herself or on a breast model
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Breast Self-Examination
• Stand in front of a
mirror
• Check both breasts
for anything unusual
• Look for discharge
from the nipple and
puckering, dimpling,
or scaling of the skin
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Breast Self-Examination (cont.)
• Watch closely in
the mirror as you
clasp your hands,
bend your head,
and press your
hands forward
• Note any change in
the contour or your
breasts
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Breast Self-Examination (cont.)
• Next, press your
hands firmly on
your hips and bow
slightly toward the
mirror as you pull
your shoulders and
elbows forward
• Note any change in
the contour of your 11
breasts
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Breast Self-Examination (cont.)
• Raise your left arm; using
2 or 3 fingers, feel your
left breast carefully and
thoroughly
• Beginning at the outer
edge, press the flat part of
your fingers in small
circles, moving the circles
slowly around the breast
• Gradually work toward the
nipple
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• Cover the whole breast
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Breast Self-Examination (cont.)
• Feel for any lumps or
masses.
• Repeat on the right breast;
step 4 should be repeated
lying down
• Lie flat on your back with
your left arm over you
head and a pillow or folded
towel under the left
shoulder
• Use the same circular
motion
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Repeat
on the right breast
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& Wilkins.
Teaching Breast SelfExamination
• Part of the examination may be done in the
shower with soapy hands to glide over the breast
and focus on underlying tissue
• Note the importance of including the area between
the breast and underarm, and the underarm itself
• Discuss reporting of any changes
• Describe the goals, methods of instruction, and
methods of evaluation for a teaching plan for BSE
• List resources for information and materials
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Diagnostic Tests
• Mammography
– Yearly starting at 40; earlier for high-risk women
– Certified facility
• Galactography
– Dye injected into ductal opening followed by
mammogram
• Ultrasonography
– Helps to distinguish fluid-filled cysts from other lesions
– Good for dense breasts
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Diagnostic tests
• Magnetic resonance imaging (MRI)
– Highly sensitive
– Most useful with proven breast cancer to assess
extent; also detects occult breast cancer
• Biopsies
– Percutaneous: fine-needle aspiration and core
biopsies
– Surgical biopsies
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Mammography
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Conditions affecting the nipple
• Nipple discharge
– May be r/t many causes, including carcinoma, papilloma,
pituatary adenoma, cystic breasts, medications (including
OCP)
– May be normal with expression
– Warrants investigation if green, malodorous, persistent,
spontaneous, bloody, unilateral
• Evaluated via galactogram or biopsy
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Benign Conditions of the
Breast
• Mastitis
– Inflammation or infection of breast tissueusually breast feeding women
– Dull to severe pain in affected area,
possilbe purulent discharge
– Treatment is antibiotics and cold
compresses
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Benign conditions of the
breast
• Cysts
– Fluid filled sacs that develop as breast ducts
dilate; estrogen thought to play a role
– Age 30-50
– Cysts usually left alone once they are confirmed
nonmalignant
• Fibroadenomas
– Firm, movable benign tumors
– Nontender, sometimes removed to r/o malignancy
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Benign conditions of the
breast
• Fibrocystic changes
– Characterized by excessive fibrous tissue,
hyperplasia of the ductal epithelial lining, and cyst
formation
• Results in pain and nerve irritation
• Influenced by hormones
– Manifests as numerous palpable lumps - round,
well delineated, movable; may be tender
– Lumps change size with hormone changes
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Breast cancer
• Lifetime risk for women: 1 in 8; most diagnosed
after 50
• Types
– Ductal carcinoma in situ
– Invasive breast cancer
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•
•
•
•
•
•
Infiltrating ductal carcinoma (75%)
Infiltrating lobular carcinoma (5%)
Medullary carcinoma
Mucinous carcinoma
Tubular ductal carcinoma
Inflammatory carcinoma
Paget disease
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Risk Factors for Breast Cancer
• Female gender
• Increasing age
• Personal and family history including genetic mutations
– BRCA 1 and 2
– 5-10%
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•
•
•
•
•
•
Hormonal factors (nullparity, 1st child>30, HT)
Exposure to radiation
History of benign proliferative breast disease
Obesity
High-fat diet (controversial)
Alcohol intake
?Smoking
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Protective factors - breast
cancer
• Regular exercise
• Breastfeeding
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Prevention in the high risk
patient
• Long term surveillence
• Chemoprevention
• Prophylactic mastectomy
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Clinical manifestions of breast
cancer
Most often found in the upper outer quadrant
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• Lesions are nontender, fixed, hard with
irregular borders
• Advanced signs may include skin dimpling,
nipple retraction, skin ulceration, peau
d’orange
QuickTime™ and a
decompressor
are needed to see this picture.
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Prognosis for breast cancer
• Most dependent on tumor size and whether it
has spread to the lymph nodes
– The smaller the tumor, the better prognosis
– Most common route of regional spread is axillary
lymph nodes; distant metastasis can affect any
organ system
– 5 year survival by staging (0-4)
• I - 98%
• IIIA - 56%
• IV - 16%
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Surgical Management—Breast
Cancer
• Breast conservation treatment
– Removal of entire tumor
• Total mastectomy
– Removal of breasts, pectoral muscles, axillary lymph nodes,
fat/adjacent tisue
• Modified radical mastectomy
– Remove breast and axillary nodes
• Sentinel node biopsy and axillary lymph node dissection
• Breast reconstruction surgery
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Breast Reconstruction With
Tissue Expander
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Breast Reconstruction With
TRAM
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Breast Reconstruction—
Latissimus Dorsi Flap
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Adjuvant Nonsurgical
Management of Breast Cancer
• Radiation therapy: external beam (weeks)
, brachytherapy (days)
• Chemotherapy
• Hormonal therapy
– Estrogen and progesterone receptor assay
– Selective estrogen receptor modulators
(SERMs): tamoxifen
– Aromatase inhibitors: anastrozole, letrozole,
and exemestane
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Nursing Process—Assessment of
the Patient Undergoing Breast
Cancer Surgery
• How is the patient responding to her diagnosis?
• What coping mechanisms does she find helpful?
• What psychological or emotional supports does
she have and use?
• Is there a partner, family member, or friend
available to assist in making treatment choices?
• What are her educational needs?
• Is she experiencing any discomfort?
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Nursing Process—Preoperative
Diagnosis of the Patient
Undergoing Breast Cancer
Surgery
• Deficient knowledge
• Anxiety
• Fear
• Risk for ineffective
coping
• Decisional conflict
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Nursing Process—Postoperative
Diagnosis of the Patient
Undergoing Breast Cancer
Surgery
• Pain
• Disturbed sensory perception
• Disturbed body image
• Self-care deficit
• Risk for sexual dysfunction
• Deficient knowledge
– Drain management
– Arm exercises
– Hand and arm care
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Collaborative Problems/Potential
Complications
• Lymphedema (10-30%)
– Results if functioning lymphatic channels are inadequate to
ensure a return flow of lymph fluid to general circulation
– Different from transient edema
• Hematoma/seroma formation
– Collection of blood or fluid inside the cavity
• Infection
– Risk is higher in patients with immunosuppression
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QuickTime™ and a
decompressor
are needed to see this picture.
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Nursing Process—Planning the
Care of the Patient Undergoing
Breast Cancer Surgery
• Major goals may include:
– Increased knowledge about the disease and
its treatment
– Reduction of preoperative and postoperative
fear, anxiety, and emotional stress
– Improvement of decision-making ability and
improvement of coping skills
– Improvement in sexual function
– Absence of complications
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Preoperative Interventions
• Review and reinforce information on treatment
options
• Prepare patient regarding what to expect before,
during, and after surgery
• Inform patient regarding surgical drain, arm and
shoulder mobility, and range-of-motion exercises
• Maintain open communications
• Provide patient with realistic expectations
• Support coping
• Involve or provide information for supportive
services and resources
• Support patient decisions
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Postoperative Interventions
• Monitoring and managing postoperative complications
– Lymphedema, hematoma, infection, as well as general
complications related to surgery
• Inform patient regarding common postoperative sensations
• Pain management
• Promoting a positive body image
– Provide bra with breast form
• Support coping and adjustment
• Provide counseling and referral
• See NCP 52-1
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Hand and Arm Care
• Potential for lymphedema formation after axilliary lymph
node dissection (ALND)
• Patient education
• Prevention is vital; follow guidelines for the rest of life
• No blood pressure, injections, or blood draws in the
affected arm
• Perform exercises 3X a day for 20 minutes to increase
circulation and muscle strength, prevent stiffness and
contractures, and restore ROM
• A mild analgesic or a warm shower may be helpful prior to
exercise
• Initial limitation of lifting (over 5 to 10 lbs) and activity
• Prevention of ANY injury and infection
• May require elasticCopyright
sleeve
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Exercises After Breast Surgery
Wall climbing
Rod lifting
Rope turning
Pulley tugging
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Drain Management
• May need home care referral to assist
with drain management
• Drains are usually removed when
drainage is less than 30 mL in a 24hour period; usually occurs in 7 to 10
days
• Drain site and incision care
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Teaching self-care
• Report symptoms/signs - infection, swelling,
hematoma,
• Drain management
• Incision care
– Usually can shower and wash incision site after
day 2
– May have to wait until drain is removed if present
– Incision should heal after 4-6 weeks
– ROM exercises until full ROM is restored (4-6 wks)
• Follow up care
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Quality of life and survivorship
• Long term survivors have difficulty with issues
pertaining to sexuality and menopausal symptoms
– Estrogen withdrawal from chemo-induced menopause
and hromonal treatments may lead to severe symptoms
– Hormone therapy is contraindicated
– Chemotherapeutic agents may cause impaired cognitive
functioning and cardiac side effects
– Long term effects of radiation may include pneumonitis
– Psychological sequelae
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Diseases of the Male Breast
• <1% of all breast cancers; average age 67
years
• Early detection is rare due to rarity of the
disease
• Signs may include painless lump beneath the
areola, nipple retraction, bloody discharge, or
skin ulceration
• Total mastectomy is indicated, with possible
adjuvant chemotherapy and radiation
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