Med-Surg: Chapter 65: Breast Cancer

Question 1

Cancer if the breast

Answer 1

• mostly occurs in women
• second most common cause of caner-related deaths in women
• single greatest risk factor: woman’s age

Question 2

Risk Factors

Answer 2

• age
• higher number of ovulatory cycles in their lifetime
• early menarche
• late menopause
• lack of pregnancy and live childbirth before the age of 30; only pregnancies resulting in a live birth lower the breast cancer risk
• family hx of a first degree relative
• benign, noncancerous breast disease that is proliferative; those with quickly growing cells such as hyperplasia, have an increased risk
• excessive alcohol use, inactivity, obesity, and the use of hormones

Question 3

Genetic Testing to Assess Breast Cancer Risk

Answer 3

-genetic testing provides an opportunity for women to learn whether they have a family hx of breast cancer caused by an inherited gene mutation
>two gene mutations: BReast CAncer gene (BRCA) 1 and BRCA 2
-can be done by a simple blood test
>indicated for patients who are at high-risk:

Question 4

Cancer

Answer 4

condition in which the cells of the body grow and divide abnormally and uncontrollably
-cells can invade nearby tissues and spread to other areas through the bloodstream and lymphatic system

Question 5

The First Stage: Stage 0

Answer 5

• in-situ lesion of ductal carcinoma in situ (DCIS); ductal lesions occur in and are limited to the lining of the milk ducts
• Lobular carcinoma in situ (LCIS); lobular lesions occurring in the lobules where milk is produced
• DCIS and LCIS place the patient at higher risk for developing invasive breast cancer; invasive lesions are those that spread to other areas or organ systems

Question 6

Stage I of breast cancer

Answer 6

• tumor 2cm or less
• no lymph node spread
• no distant metastasis

Question 7

Stage II of Breast Cancer

Answer 7

• tumor may increase in size
• possible spread to nearby lymph nodes
• no distant metastasis

Question 8

Stage III of Breast Cancer

Answer 8

• tumor may increase in size
• possible spread to lymph nodes, chest wall, or skin
• no distant metastasis

Question 9

Stage IV of breast cancer

Answer 9

• tumor of any size with direct extension to chest wall or skin
• with distant metastasis

Question 10

Stages of Breast Cancer

Answer 10

> Stage 0:

• in situ lesions (DCIS)
• no lymph node
• no metastasis

> Stage I:

• tumor 2 cm or less
• no lymph node
• no metastasis

> Stage II:

• tumor may increase in size
• possible spread to nearby lymph nodes
• no metastasis

> Stage III:

• tumor may increase in size
• tumor may spread to chest wall, lymph nodes, or skin
• no metastasis

> Stage IV:

• Tumor of any size
• lymph node spread
• metastasis

Question 11

Clinical Manifestations

Answer 11

• new mass or lump
• cancerous masses: hard, irregular, and painless; may be soft, rounded, and tender
• changes in shape of the breast or swelling
• changes such as peeling, flaking, pitting, dimpling, or redness
• changes in nipple such as inversion, thickening of the tissue, or drainage

Question 12

Diagnostic Tests

Answer 12

-mammography
-ultrasonography
-magnetic resonance imaging (MRI)
-if necessary, biopsy
>patients may have breast cancer detected as part of routine screening mammography or mammography with MRI, or may present with a specific complaint that leads to the discovery of the tumor through diagnostic imaging
>once mammography detects a suspicious area, ultrasonography may be used to further define the area; the area will be recommended for biopsy if it is deemed suspicious on imaging
>Biopsy results will be definitive for diagnosis

Question 13

Results from what will be definitive for diagnosis

Answer 13

biopsy

Question 14

What may be indicated if the initial diagnostics indicate the tumor may be invasive?

Answer 14

a sentinel node biopsy

-this may help determine the extent or stage of breast cancer

Question 15

Sentinel Node

Answer 15

the first lymph node to which cancer cells travel if they are to spread
-in breast cancer, generally found in the axilla but may be more center if the cancer is in the center of the chest
-injecting a radioactive substance or blue dye near the tumor and tracking it to the first node determines the sentinel node(s)
>if the sentinel lymph node is found to be free of cancer, it may not be necessary to proceed with removal of further lymph nodes
-if has cancer cells, more complete removal of the lymph nodes for evaluation, and axillary lymph node dissection may be completed

Question 16

What happens after a diagnosis is made?

Answer 16

-laboratory data that may be obtained: a complete blood count (CBC) with platelets
-liver function tests
-chest x-ray
>CT of the abdomen and a bone scan if stage II or higher

Question 17

Treatment

Answer 17

surgery, chemotherapy, and radiation

Question 18

Surgery Alternatives

Answer 18

• breast conservation therapy (lumpectomy)

- total mastectomy

Question 19

Chemotherapy Options

Answer 19

• Adjuvant chemotherapy, which is administered after surgery to destroy any remaining cancer cells
• Neoadjuvant chemotherapy, administered before/prior to the surgical procedure in an attempt to shrink the tumor

Question 20

Treatment for In Situ Lesions

Answer 20

• Lobular carcinoma in situ (LCIS) is not considered a precursor for invasive breast cancer and therefore has no directed treatment; directed at risk-reduction strategies b/c these women are at an increased risk of developing invasive breast cancer
• Ductal Carcinoma in situ (DCIS) requires surgical treatment; lesions more than 4 cm require mastectomy
• lesions of intermediate size that can be removed with clear margins can be considered for mastectomy or breast conservation therapy
• small DCIS can be excised if the lesion without radiation therapy
• Tamoxifen (Nolvadex), antiestrogen therapy, reduces risk of local recurrence in women undergoing breast conservation therapy

Question 21

Treatment for Early-stage Invasive Cancers

Answer 21

• cancers smaller than 1 cm with clinically negative axilla treated with surgical excision
• patients with large tumors that have comorbidities or no spread to axillary nodes may have surgical excision
• mastectomy and breast conservation can be considered
• radiation therapy recommended for patients undergoing breast conservation therapy
• tumors at least 1 cm in size or with axillary node involvement are recommended to have cytotoxic adjuvant chemotherapy
• if hormone receptor positive, endocrine therapy (aromatase inhibitor or tamoxifen) after completion of cytotoxic therapy

Question 22

Treatment for Immediate or Advanced Stage Cancers (operable)

Answer 22

• preoperative neoadjuvant chemotherapy first line treatment unless has underlying comorbidities that preclude use of chemotherapy
• after chemotherapy, tumor is reassessed to evaluate the potential of breast conservation therapy as a result of tumor response to chemotherapy
• chemotherapy recommended after surgical treatment in all patients; followed by or done concurrently with radiation therapy
• if tumor is hormone receptor-positive, endocrine therapy offered for 5 to 10 years

Question 23

Treatment for Locally advance and Inoperable Cancers

Answer 23

• undergo neoadjuvant chemotherapy as initial treatment
• if tumor responds to chemotherapy and becomes operable= undergo modified radical mastectomy
• if responds dramatically = can be offered breast conservation therapy
• if tumor does not respond to initial chemotherapy= switched to another chemotherapy regimen before surgery attempted
• all patients should be offered postoperative chemotherapy and radiation to the breast or chest wall; in these cases immediate breast reconstruction is not encouraged

Question 24

Treatment for Local Recurrence and Systemic Metastases

Answer 24

• if undergone initial breast conservation therapy; complete mastectomy is next step
• if tumor not initially operable, chemotherapy may be considered
• when not previously undergone radiation, surgical excision is done followed by chemotherapy and radiation

Question 25

Complications of Treatment

Answer 25

- wound infection and dehiscence - immobility side effects of surgery such as pulmonary embolism and pneumonia - long-term complaints: shoulder immobility, pain, and lymphedema

Question 26

Lymphedema

Answer 26

occurs because of the removal of the axillary lymph nodes and subsequent scarring, resulting in disruption of lymph drainage in the arm -result is swelling of the arm

Question 27

Once Chemotherapy has begun, the patient may experience a variety of side effects associated with the cytotoxic drugs

Answer 27

- hair loss - nausea - vomiting - mouth pain - diarrhea or constipation - peripheral neuropathy - rash - nail changes - decreased WBC count with possible subsequent fever - may result in premature ovarian failure which may lead to bone loss and loss of fertility - possible long-term risk of myelodysplastic syndrome (dysfunctional blood cells)

Question 28

Radiation Side Effects

Answer 28

- redness with patchy desquamation (shedding of the outer skin layers) of the treated skin - skin may also itch but does not have a "burning" sensation - breast swelling and discoloration may continue for 6 months after treatment but usually resolves in 12 to 18 months - pneumonitis, a nonproductive cough with a chest x-ray demonstrating an infiltrate in the radiated area may develop 6 weeks to 6 months after treatment completion - radiation to the myocardium may lead to latent (15-20 years) cardiac morbidity and mortality

Question 29

Nursing Management: Assessment and Analysis

Answer 29

- initial clinical manifestations are associated with the presence of a tumor, noting a lump in the breast, skin changes and nipple changes - later manifestations associated with treatment - due to the killing of all rapidly dividing cells, chemotherapy may result in hair loss, nausea, vomiting, mouth pain, diarrhea or constipation, peripheral neuropathy, rash, and nail changes - decreased WBC count - lymph node removal may result in lymphedema or swelling of the arm on the affected side due to blockages in lymph flow - radiation causes skin changes: irritation, redness, itchiness, or burning - breast swelling - nonproductive cough with lung an infiltrate

Question 30

Nursing Interventions: Assessments

Answer 30

>Vital Signs - elevated BP and rapid pulse can be a sign of pain or anxiety - elevated temperature and pulse indicative of infection >Pain -should verbalize their pain on a rating scale to help understand their pain level and to ensure adequate treatment >Daily weight - give an idea of the nutritional status - drastic weight loss indicates a nutritional deficit >Intake and Output -allows evaluation for tolerance of oral liquids and foods and an evaluation of vomiting >Wound evaluation -good wound evaluation detects the early signs of infection such as redness, warmth, and increased or purulent drainage >Skin evaluation -inspect any radiated skin for radiation side effects such as irritation, redness, itchiness, or burning >Monitor CBC and metabolic profile -due to its cytotoxic effects, chemotherapy may result in decreased WBC counts, decreased hemoglobin and hematocrit, and elevations in liver enzymes >Assess mood and nonverbal cues - at great risk for psychological issues - patients with depression are often withdrawn or offer other nonverbal cues that indicate pain, depression, and anxiety

Question 31

Nursing Interventions: Actions

Answer 31

>Give chemotherapeutic drugs as ordered -indicated for invasive breast cancer >Give pain medications as ordered -provides pain relief allowing the patient to more fully participate in activities of daily living >Give antiemetics as ordered -help to relieve nausea and vomiting, promoting adequate nutritional intake >Have the patient cough and deep breathe postoperatively -prevents atelectasis and pneumonia >Keep the wound clean and dry -aids in wound healing and helps prevent infection >Encourage Verbalization -important to actively involve patients in their care

Question 32

Teaching

Answer 32

``` >explain treatment course >medications and treatment side effects >wound care >nutritional counseling >support groups >breast cancer screening with mammography ```

Question 33

Breast Cancer Screening with Mammography

Answer 33

- women ages 40-44 may begin annual screening - women ages 45-54 should have annual screening - women ages >55 can maintain yearly or move to biannual; screening should continue as long as the woman is in good health

Question 34

Evaluating care outcomes

Answer 34

- adequate treatment - those with advanced-stage cancer are still able to achieve prolongation of their life while balancing quality of life - patient undergoing treatment will have immediate needs associated with surgery, chemotherapy, and radiation - the well managed patient should be able to manage any nausea and vomiting in a way that allows her to maintain adequate nutrition and weight - surgical sites should heal without infection - scarring and lymphedema should be kept to a minimum through appropriate therapy - psychosocial support provided throughout tx helps to manage anxiety and depression

Question 35

Breast Cancer Tx Options

Answer 35

- Breast Conservation Surgery (lumpectomy) - Modified radical mastectomy - Axillary lymph node staging - Chemotherapy - Radiation Therapy

Question 36

Breast Cancer Tx Options: Breast conservation surgery (lumpectomy)

Answer 36

removes only the involved breast tissue and a minimal surrounding margin with the best possible cosmetic preservation of the breast - option in early-stage disease or advanced disease that has been reduced by chemotherapy - used in conjunction with postoperative radiation and chemotherapy

Question 37

Breast Cancer Tx Options: Modified Radical Mastectomy

Answer 37

removal of the entire breast tissue - option in early-stage disease or more advanced disease that has been reduced by chemotherapy - used in conjunction with chemotherapy and may or may not require postoperative radiation

Question 38

Breast Cancer Tx Options: Axillary lymph node staging

Answer 38

removal of axillary lymph nodes - done with invasive breast cancer and some noninvasive - recent advances allow for removal of only the first lymph node from the tumor (sentinel node) - other nodes are then removed only if the sentinel node is positive

Question 39

Breast Cancer Tx Options: Chemotherapy

Answer 39

drugs used to treat cancer | -may be used prior to surgery or after

Question 40

Breast Cancer Tx Options: Radiation Therapy

Answer 40

radiation directed at the tumor and surrounding tissue to treat cancer -typically done after surgery for lumpectomy or inflammatory breast disease, for recurrence, or for palliation in advanced disease

Question 41

Breast Cancer: Risk factors, S/S, and Metastasis

Answer 41

``` >Risk Factors: endocrine disrupters: -early menses -late menarche -nulliparity and -late first child -genetic propensity (BRCA1, BRCA2) -obesity, high-fat diet ``` >S/S: - breast mass - axillary node enlargement - asynchrony of breasts - nipple discharge >Metastasis -bone, lung, lymph nodes, liver, brain