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An-Najah National University
Faculty of Nursing
Dr. Aidah Abu Elsoud Alkaissi
2017-05-23
1

Breast cancer is a growth of abnormal cells usually
within the ducts (which carry the milk to the
nipple) or lobules (glands for milk production) of the
breast.

In more advanced stages of the disease, these out-ofcontrol cells invade nearby tissues or travel
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throughout
the body to other tissues or organs. 2
?:

How does breast cancer develop?
1. Normal ducts
2. Intraductal Hyperplasia
3. Atypical Ductal Hyperplasia
4. Ductal Carcinoma In Situ
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5. Invasive Ductal Cancer
3
Epidemiology
Incidence and prevalence

Each year the disease is diagnosed in over one million women
worldwide and is the cause of death in over 400,000 women.

Breast cancer can occur in men, although the incidence is
much lower, amounting to around 1% of all breast cancers.

Breast cancer remains the leading cancer in black women in
the USA, overall they have an incidence rate nearly 20%
lower than that of American white women.
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Epidemiology of Breast
Cancer in Palestine

Cancer incidence rate among Palestinian women
is 15.1 per 100,000 women.

According to the statistics since 1998 up to
now, the oncology center in Palestine
reports approximately 280 women breast
cancer yearly (57% out of them in West
Bank and 43% in Gaza Strip).
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State of the Evidence
What Is the Connection Between
the Environment and Breast Cancer?

Breast cancer arises from a complicated
mix of multiple factors, which may include
inherited or acquired genetic mutations,
altered gene expression and/or exposures
to external agents that affect genes or the
production of estrogen or other hormones.
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
Age; Nearly 80% of all newly diagnosed invasive
breast cancer cases occur in women aged 50 and
older and is less common in premenopausal women.

Family history of breast cancer.

Paget´s disease accounts for 1% of all breast CA,
is associated with an infiltrating, and intraductal
carcinoma.
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. Genetic factors; some cancers have a genetic
component and can be inherited.

It is estimated that between 5 and 10% of breast cancer can
be attributed to one of two predisposing genes:

BRCA1 on chromosome 17.
BRCA2 on chromosome 13.
Mutations in these genes are associated with a
lifetime

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
A mutation in the gene which causes a high risk of
cancer does not necessarily mean cancer will develop;
nor does it predict at what age the cancer may
appear.

The development of the disease may also be affected
by the environment and interaction with other genes.
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
Hormone factors:


Early menarche women who started their period
before 12 years of age.
Late menopause women who go through
menopause after age 55.
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
Pregnancy history: women who have their
first child after the age of 30 or who have had
fewer pregnancies or no pregnancies.

Breast density: women with less fatty, denser
breasts, which are normally older women, have
an increased chance of breast cancer.
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
Obesity after menopause women who were
overweight based on a body mass index (BMI) greater
than 25 are 1 to 2 times more likely to die from breast
cancer than women with a normal BMI.
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
Ionizing radiation; In 2005, the National Toxicology
Program classified X radiation and gamma radiation
as known human carcinogens.

Compelling scientific evidence points to some of the
100,000 synthetic chemicals in use today as
contributing to the development of breast cancer,
either by altering hormone function or gene
expression.
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
There is broad agreement that exposure over
time to estrogens in the body increases the
risk of breast cancer.

Hormone replacement therapy (HRT) and
hormones in oral contraceptives increase this
risk.
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Volume 356:1670-1674
Number 16, 2007
The Decrease in Breast-Cancer Incidence in 2003 in
the United States

In this study, it was concluded that:

The decrease in breast-cancer incidence
seems to be related to drop in the use of
hormone-replacement therapy among
postmenopausal women.
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
Early life exposure to high levels of polycyclic
aromatic hydrocarbons (PAHs), present in tobacco
smoke and other air pollution, increased the risk of
premenopausal breast cancer in a case-control study
of more than 3,200 women (Calabrese 2003).

A study of 21,000 Japanese women concluded that
smoking, both active and passive, increases the
risk of developing breast cancer in premenopausal
women (Markey 2001).
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
Pesticides, fuels, household products especially
cleaning agents, detergents, plastics (including
food packaging, toys, credit cards and
rainwear) are risk factors.

Solvents in the electronics, fabricated metal,
printing chemical, textile and clothing
industries are also risk factors.
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
Diesel exhaust, soot and fumes from combustion of
diesel and other fuels, and from grilling meat and
fish.

Chemical industries, in air and water pollution, and
some cosmetics products.

“Chew toys” marketed for infants and also in some
varieties of nail polish, perfumes, skin moisturizers,
and flavorings.
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
Antibiotics used on poultry and hormones injected
into cattle, sheep and hogs.

A growing body of evidence implicates nonionizing radiation (electromagnetic fields and
radio-frequency radiation as possible contributors
to the development of breast cancer.

Microwaves, radio waves, radar are examples of
nonionizing radiation.
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Mass, a puckering, thickening or subtle change
in breast manifest as painless, firm, fixed lesion
with poorly defined contour.

It can be found anywhere in the breast in
most common in the upper outer quadrant.


Nipple retraction, or unusual discharge.
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
Skin inflammation and thus is known as inflammatory
breast cancer.

Changes in the appearance or shape of the breast
can raise suspicions of breast cancer.
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
Tumors are classified histologically according to
tissue Characteristics and staged clinically
according to tumor size, nodal involvement,
and presence of metastasis.

It is recommended that estrogen and
progesteron receptor analysis be performed on
surgical specimens
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
Information about the presence and
abscence of estrogen and progesteron
receptors can be used in predicting tumor
responsiveness to hormonal manipulation

High levels of both receptors improve the
prognosis and increase the likelihood of
remission
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Diagnosis methods for
breast cancer
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Strategies for increasing the participation of women
in community breast cancer screening (Review)
Bonll X et al. 2007 The Cochrane Collaboration.

Strategies for reducing breast cancer mortality
in western countries have focused on
screening, at least for women aged 50 to 69
years.

One of the requirements of any community
screening program is to achieve a high
participation rate, which is related to methods of
invitation.
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
The evidence favoured active strategies for
inviting women into community breast
cancer screening services:



letter of invitation
mailed educational material
letter of invitation plus phone call
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Breast SelfExaminations
Screening

Clinical breast
exams and breast
self-examinations
are two more
ways to screen for
breast cancer
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Conventionell
Mammography
Screening

A mammogram is an xray of the breast, may
find tumors that are too
small to feel.

May find ductal carcinoma
in situ, abnormal cells in
the lining of a breast duct,
which may become
invasive cancer in some
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women.
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Digital Mammography: The Promise of Improved
Breast Cancer Detection
Kevin D. Evans, PhD, RT(R)(M)(BD), RDMS, RVS, FSDMS
*Director/Assistant Professor, Radiologic Sciences and Therapy Division, The Ohio State University, Columbus, Ohio.
Address correspondence to: Kevin D. Evans, PhD, RT(R)(M)(BD), RDMS,RVS, FSDMS, Director/Assistant Professor, Radiologic Sciences and Therapy Division, The Ohio State University, 453 West 10th Avenue, 340 A. Atwell Hall, Columbus, OH 43210. E-mail: [email protected].
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Evidenced-Based Practice: Full-Field
Digital Mammography- Screening
Advantages:
 Accommodate most patients
regardless of breast size.

Reduces the number of images
required and decreases radiation
exposure.

The higher resolution enables
radiologists to see more detail
within the soft tissue of the
breast; this can lead to a more
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accurate
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Ultrasonography- Diagnosis

Ultrasonography is
useful as a diagnostic
adjunct to differentiate
cystic from solid tissue
in women with
nonspecific thichening
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BiopsyDiagosis


If the clinical breast exam,
mammogram or ultrasound
shows an area of possible
concern, a biopsy is usually
the next step.

A biopsy is the removal of
cells or tissues of concern so
that they can be viewed
under a microscope and
further tested by a
pathologist.
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Thin, hollow needle is inserted into the suspicious
growth and cells are withdrawn for laboratory analysis.
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


Invasive method of collecting
large numbers of cells from the
breast milk ducts, where the
majority of breast cancers
(95%) originate.

Then, externally applied
nipple aspiration techniques
or external pressure applied
to the breast were used to
collect samples of the ductal
fluid.

Finding atypical cells
provides unique information
about a woman’s personal
risk for developing breast
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cancer.
Wash saline through its natural
opening in the nipple into a
breast duct using indwelling
hair-like single lumen catheters.
After the fluid was introduced
into the duct, the fluid
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introduction
catheters were
removed.
At-risk women may be
eligible for participation of

If they are between the ages of 35 to 70 years.

If they have a known BRCA1 or BRCA2 gene
mutation.

Participants must have a family history of breast
cancer (multiple family members) or other risk factors.

Mammograms
and physical examinations must prove
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normal.

To determine if the
breast cancer has
spread to the lungs.
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 A common place for
breast cancer to
spread is to the bones.
 A bone scan is often
done to assure there is
no detectable
metastasis to the
bones.
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positron emission
mammography (a PEM scan)
Advantages:

The PEM system’s camera
and detectors are closer to
the area affected with
cancer, which produces a
very sharp, detailed image of
tumors and cancerous tissue.

With PEM, cancers can be
seen as small as 1.5 – 2mm,
about
the width of a grain of
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rice
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
MRI combines the use of
powerful magnets and radio
wave pulses.

Used to detect breast cancer
in some women at higher
risk

MRI can also be used
before surgery to identify
areas of the breast affected
by the tumor.
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CT Images Faster Than Traditional Scanners
2006, Jian Zhang,

Researchers at the
University of North
Carolina developed a new
method to create computed
tomography (CT) images
using carbon nanotube xrays that works much faster
than traditional scanners
and uses less peak power.
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CT Images Faster Than Traditional
Scanners 2006, Jian Zhang,

"The current Computerized
axial tomography scanners
take images sequentially,
which is slow and
inefficient.

Using the nanotube x-ray
technology, the feasibility
of multiplexing - taking
multiple images at the same
time,"
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
Carbon nanotubes,
made of layers of
carbon atoms, can be as
small as one nanometer
- one billionth of a
meter - in diameter.
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Treatment Options for Breast
Cancer

The proper treatment protocol will depend on a
number of factors, including:
Size of the tumor.
 Stage of the disease.
 Type of breast cancer.
 Estrogen-receptor status and progesterone receptor
levels.
 Patient’s age, general health and menopausal status

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Progesterone Receptor Status Significantly Improves
Outcome Prediction Over Estrogen Receptor Status
Alone for Adjuvant Endocrine Therapy in Two Large
Breast Cancer Databases . Journal of Clinical Oncology, Vol
21, Issue 10 (May), 2003: 1973-1979

women with Estrogen receptor (ER)-positive tumors derive
significant benefit from 5 years of tamoxifen in reducing
the odds of recurrence and death.

Whereas women with ER-negative tumors do not. This
benefit is directly proportional to the level of ER, with
patients with higher tumor ER levels deriving the greatest
benefit from therapy.
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
Women with systemically untreated ERpositive/PgR-positive tumors have better clinical
outcomes compared with women with ERnegative/PgR-negative tumors,
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P. V. Maynard. Estrogen Receptor Assay in Primary
Breast Cancer and Early Recurrence of the Disease.
CANCER RESEARCH 38. 4292-4295. 2006.
In this study:

It was found that poorly differentiated
estrogen receptor-negative tumors recurred
earlier than poorly differentiated receptorpositive tumors and had a very unfavorable
prognosis.
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
Radical mastectomy (removal of the entire breast,
underlying muscles and all axillary nodes) rarely is
used today as a primary surgical therapy unless
breast cancer is advanced at the time of DX
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
Modified surgical techniques (mastectomy plus
axillary dissection or lumpectomy for breast
conservation) accompanied by chemotherapy or
radiation therapy have acheived outcomes
comparable with those obtained with radical
surgery methods
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Tamoxifen (Nolvadex®)

Tamoxifen is a nonsteroidal antiestrogen that
binds to estrogen receptors and blocks the effects
of estrogen on the growth of malignant cells in
the breast. Tamoxifen blocks a tumor's ability to
use estrogen

Studies shown decreased cancer recurrence,
decreased mortality rates, increased 5-year
survival rates in women with estrogen receptor
positive tissue samples who have been treated
with
the drug
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Aromatase Inhibitors

Lower the amount of estrogen in post-menopausal
women who have hormone-receptor-positive breast
cancer.

The hormone estrogen delivers growth signals to the
hormone receptors. With less estrogen in the body, the
hormone receptors receive fewer growth signals, and
cancer growth can be slowed down or stopped.
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Aromatase Inhibitors

Before menopause, the ovaries produce most of a woman's
estrogen, so reducing estrogen from other sources has little or no
effect.

But in post-menopausal women, most of the body's estrogen is
made from another hormone, androgen.

Aromatase inhibitors stop the enzyme called aromatase from
turning androgen into estrogen, lowering the amount of estrogen
produced OUTSIDE the ovaries. That means less estrogen in the
bloodstream, less estrogen reaching estrogen receptors, and less
cancer cell growth.
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
The three aromatase inhibitors have some
similar and some different indications for use:


Arimidex is approved by the FDA for women with
early-stage disease right after surgery.
Aromasin is approved by the FDA for women with
early-stage disease who have completed two to
three years of tamoxifen.
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
Femara is approved by the FDA for
women with early-stage disease right after
surgery. Femara is also approved by the
FDA for women with early-stage disease
who have completed five years of
tamoxifen.

All three aromatase inhibitors are also
approved for women with advanced
(metastatic) disease.
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Autologous Bone Marrow
Trasplantation and Peripheral
Stem Cell Transplantation

Are experimental therapies that may be
used for the RX of advanced disease or in
women at increased risk for recurrence
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Preventive Surgery
Women at extremely high risk for breast cancer, such
as those with BRCA gene mutations and a strong
family history of the disease, may consider
preventive surgery.
This may include preventive mastectomy or •
oophorectomy (removal of the ovaries).
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Targeting Protein S14 In Breast
Cancer Treatment, 2006

Recently scientists from the University of Manchester
have discovered a protein potentially involved in the
spread or "metastatic progression" of tumors.

Their findings could lead to new approaches to
treating breast cancer as blocking the protein's
actions has the potential to stop malignant cells
migrating. "What scientist have identified is a new
role for a protein called LPP,".
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Progress In Understanding
Of Breast-Cancer Cell
Migration
2006

"Until now, this protein was only thought to function at the cell
periphery but it was shown that it works in conjunction with another
protein - PEA3 - in the cell nucleus".

"PEA3 has already been implicated in the spread of breast cancer but
scientists have found that the LPP molecule is essential for the correct
function of PEA3".

"If scientists can target the LPP protein and stop it from working in
malignant cells, we will have a possible new route to treatment
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New Options In
Breast Cancer

Lapatinib (Tykerb) is a new breast cancer drug
currently undergoing for patients with breast cancer
who have over expression of (human epidermal
growth factor receptor-2 (HER2) gene, which
promotes the growth of cancer cells.

HER2-positive breast cancers tend to be more
aggressive than other types of breast cancer.
They're also less responsive to hormone treatment.
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
A new clinical study has demonstrated
that Lapatinib is an effective treatment
for breast cancer patients who may
have HER2 gene over expression and
are not controlled by Herceptin, which
is the most common drug used in that
setting.........
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Nursing Management

Nursing Diagnosis: Fear and ineffective
coping related to the diagnosis of breast
cancer, its treatment, and prognosis.

Goal: Reduction of emotional stress, fear, and
anxiety.
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Nursing Management

Nursing Diagnosis: Disturbed body image
related to nature of surgery and side effects
of radiation and/or chemotherapy.

Goal: Realistic adaptation to changes that
will occur relative to treatment modalities.
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Nursing Management

Nursing Diagnosis: Acute pain related to
tissue trauma from incision.

Goal: Absence of pain and discomfort.
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Nursing Management

Nursing Diagnosis: Dressing/grooming,
bathing/hygiene self-care deficit related to
partial immobility of upper extremity on side of
breast surgery.

Goal: Avoidance of impaired mobility and
achievement of self-care to the fullest
possible level.
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Nursing Management

Nursing Diagnosis: Possible sexual
dysfunction related to loss of body part and
fear of partner’s reaction to this loss.

Goal: Identification of alternative
satisfying/acceptable sexual experience.
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Nursing Management

Collaborative Problem: Infection, injury,
lymphedema, neurovascular deficits.

Goal: Avoidance of complications.
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The following life styles may contribute to a
decreased risk of disease development:

Limiting alcohol consumption.
 Maintaining a healthy weight.
 Consulting a physician regarding alternatives
to take estrogen or other hormones.
 Incorporating physical activity into daily life.
 Eating foods high in fiber and low in fat.
 Eating plenty of fruits and vegetables.
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Breast cancer news, 2007
Addressing Problem of Breast Cancer
Prevention
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
A new study in the "Journal of Clinical Oncology"
reinforces current evidence showing that women
with breast cancer can greatly reduce their risk of
recurrence by:


eating a healthy plant-based diet rich in fruits and
vegetables
making other healthy lifestyle choices
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
"Women coping with breast cancer deserve to know that
plant-based diets and regular exercise can spell the
difference between life and death,"

"In the battle against breast cancer, fruits, vegetables, and
other low-fat vegetarian foods may be our most powerful
weapons.

Let women know that diet changes and exercise can help
them beat this terrible disease".
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
The new study, conducted by scientists with the University
of California, tracked dietary patterns and exercise habits
among about 1,500 women who were diagnosed with earlystage breast cancer

It observed that the death rate for women who consumed a
high-fiber diet rich in fruits and vegetables and practiced
good exercise habits was 44% lower than the rate for
women who exercised little and ate few plant-based foods.
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