Breast Cancer

Front 1

Incidence

Back 1

*Most common form cancer in women (except skin cancer)
*Race: White higher incidence after 40, Black higher under 40
*Age: highest age 75-79
*ACS expects an estimated 212,920 new cases in 2006, 1500 in men

Front 2

Incidence

Back 2

*1 in 7 women will develop breast cancer. Estimated 40,970 deaths in 2006
*5 year survival:
localized=96%
regional=77%
distant metastasis=21%

Front 3

Risk Factors (not modifiable)

Back 3

*Age and gender
*Family Hx.
*Age at pregnancy (over the age of 30)
*Early menarche <12yrs./late menopause
*Cultural/Ethnic (black higher than white)

Front 4

Risk Factors (not modifiable)

Back 4

*BRCA1 & BRCA@ genes (+ result with gene = 80% chance of getting breast cancer
*ER-PR positive or negative
*Personal hx of breast, colon, endometrial or ovarian cancer
*Dense bone structure-may be predictor of who gets breast cancer

Front 5

Cultural

Back 5

*Black women and Hispanic women diagnosed at a later stage and have a lower survival rate
*Whites have a higher incidence than non-whites

Front 6

Modifiable Risk Factors

Back 6

*Postmenopausal obesity
*Alcohol consumption (2 or more drinks/day
*Physical mobility (decreased mobility)
*Use of postmenopausal hormones (long-term use)
*Exposure to ionizing radiation

Front 7

Prevention/Detection: ACS revised guidelines since 2003

Back 7

*Dropped recommendation that all women perform BSE monthly
*Age 40+
-annual mammogram
-annual clinical breast examination
-Monthly BSE (optional)

Front 8

ACS guidelines cont.

Back 8

Age 20-39:
-Clinical breast exam q. 3 years
-Monthly BSE (optional)

Front 9

Pathophysiology

Back 9

*Infiltrating ductal carcinoma is most common 70-80%
*Infiltrating lobular carcinoma are less common 10-15%
*in situ=noninvasive (4-6%)

Front 10

In Situ Breast Cancer

Back 10

*Non-invasive breast cancer
*May be ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)
*A pre-infiltrating cancer, advances to more aggressive disease
*With early detection, more women diagnosed with in situ
*4-6% of breast cancers

Front 11

Pathophysiology (Don't need to know for exam_4)

Back 11

*Paget's disease: malignancy of nipples and areola, tx is modified radical mastectomy
*Inflammatory Breast Cancer: rare, aggressive, skin orange peel appearance, mets early, tx. chemo, radiation and hormones

Front 12

Pathophysiology

Back 12

*May spread to regional lymph nodes (axillary/supraclavicular)
*Can also metastasize to lungs, liver, bone (spine), and brain

Front 13

Clinical Manifestations

Back 13

*Most common = lump (lump hard, irregular not painful)
*Some have only +mammogram
*Usually no pain
*Skin dimpling, enlarged breast, nipple retraction, skin irritation or thickening, nipple discharge

Front 14

Diagnostic Studies

Back 14

*Inspection & Palpation
*Mamography (GOLD STANDARD)
*MRI (2004-may be more sensitive and find cancer in younger women but some false)
*Ultrasound (US=can detect between solid and cyst
*CXR and Bone Scan

Front 15

KNOW THIS SLIDE

Back 15

*Node status is important to assessing prognosis and need for adjunct treatment

Front 16

Biopsy - GOLD STANDARD

Back 16

*Wide needle biopsy - Core (more than one sample)
*Surgical biopsy - excisional biopsy or lumpectomy
*SENTINAL NODE BIOPSY - in place of axillary dissection
*Ductal Lavage = create smear

Front 17

Care After Biopsy

Back 17

*Small dressing 2-3 days
*Surgical bra 2-3 days
*Analgesics for pain
*Told when and by whom the test results will be given

Front 18

5-year Relative Survival Rate by Stage

Back 18

Stage 0 - 100%
Stage I - 98%
Stage IIA - 88%
Stage IIB - 76%
Stage IIIA - 56%
Stage IIIB - 49%
Stage IV - 16%

Front 19

Early Stage Breast Cancer

Back 19

In stage 0, cancer cells are present in either the lining of a breast lobule or a duct, but have not spread to the surrounding fatty tissue. This stage is also called ductal carcinoma in situ, or DCIS

Front 20

Treatment of DCIS

Back 20

*Breast-conserving surgery and radiation therapy, with or without tamoxifen.
*Total mastectomy with or without tamoxifen (estrogen blocker)
*Breast-conserving surgery without radiation therapy. A large national clinical trial comparing breast-conserving surgery and tamoxifen with or without radiation therapy is currently under way. (many clinical trials)

Front 21

Early Stage Breast Cancer:
Stage I
Invasive breast cancer = tumor <2cm

Back 21

*In stage I, cancer has spread from the lobules or ducts to nearby tissue in the breast. At this stage and beyond, breast cancer is considered to be invasive. The tumor is 2cm or less in diameter (approximately 1 inch or less); cancer has not spread to the lymph nodes

Front 22

Early Stage Breast Cancer:
Stage II

Back 22

*In stage II, the tumor can range from 2cm to <5cm in diameter (approximately 1 to 2 inches); sometimes cancer may have spread to the lymph nodes.

Front 23

Early Stage Breast Cancer:
Stage IIIA

Back 23

*In stage IIIA, the tumor is 5cm or greater in diameter (approximately 2 inches or greater); or the tumor may be of any size where cancer cells have grown extensively into axillary (underarm) lymph nodes.

Front 24

Treatment Options Early Stage

Back 24

*Local-regional treatment:
*Breast-conserving therapy (lumpectomy, breast irradiation, and surgical staging of the axilla). Includes SLN biopsy.
*Modified radical mastectomy (removal of the entire breast with level I-II axillary dissection) with or without breast reconstruction.

Front 25

Treatment Options Early Stage

Back 25

*Adjuvant radiation therapy postmastectomy in axillary node-positive tumors:
*For 1 to 3 nodes: unclear role for regional radiation (infra/supraclavicular nodes, internal mammary nodes, axillary nodes, and chest wall).
*For more than 4 nodes or extranodal involvement: regional radiation is advised.

Front 26

Advanced Breast Cancer

Back 26

*In stage IIIB, known as locally advanced cancer; tumor may be of any size, but has spread into the skin of the breast or tissues of the chest wall.
*In stage IV, known as metastatic; cancer has spread from the breast to other parts of the body, such as bone, liver, lung, or brain.

Front 27

Staging and Prognosis: High Risk
(If you have one of these you're at high risk)

Back 27

*Tumor size: >2cm
*ER/PR status: Negative (tumor not fed by estrogen)
*Node: Positive
*Age: <50 and pre-menopausal
*Presence of BRCA-1 and BRCA-2 mutation
*Positive Her 2 neu status (over-expression)

Front 28

Treatment Procedure/Modalities

Back 28

Medical:
-Hormonal Therapy
-Chemotherapy
-Biologic Therapy
-Radiation
Surgical Options:
-ANY COMBINATION OF ABOVE - depends on pt, surgeon etc.

Front 29

Hormonal Therapy ONLY USED IF SOMEONE IS ESTROGEN POSITIVE

Back 29

*Four benefits for pre/post menopausal women (TAMOXIFEN ACCOMPLISHES THESE BENEFITS)
-reduce recurrence
-halt progression of metastasis
-reduce risk of CA in other breast
-prevent osteoporosis

Front 30

Hormonal Therapy

Back 30

*SERMs - selective estrogen-receptor modulators
*Aromatase Inhibitors - monoclonal antibodies
*Used in ER/PR +patients

Front 31

Selective Estrogen Receptor Modulators (BLOCKS ESTROGEN AT LEVEL OF OVARIES)

Back 31

*SERMs, or selective estrogen-receptor modulators, block the action of estrogen in the breast and certain other tissues by occupying estrogen receptors inside cells.
*SERMs block (or selectively inhibit) estrogen receptors in breast cells. Therefore, cells don't get the signals they need to grow and multiply
*Tamoxifen (Nolvadex), Raloxifene (evista), Torimifene (Fareston), One injectable

Front 32

Aromatase Inhibitors

Back 32

*Postmenopausal women ONLY - inhibits aromatase, enzyme that synthesizes endogenous estrogen, prevents estrogen production at level of ovaries.
*Others: letrozol (Femara), Anastrozol (Arimidex), Emestane (Aromasin)

Front 33

Androgens from adrenal glands and ovaries

Back 33

Androgens from adrenal glands and ovaries are changed into estrogen by aromatase in breast. This estrogen causes too much cell growth.
Aromatase Inhibitors can't be given to young women.
Estrogen+ need to be on a drug for 5 years.
>55 take Aromatase instead of Tamoxifen (less side effects than Tamoxifen)

Front 34

Aromatase Inhibitors

Back 34

*Used with early and advanced breast cancer
*Recently approved for post-menopausal women instead of Tamoxifen
*MUST BE POST MENOPAUSAL (IMPORTANT TO KNOW!)

Front 35

Side Effects: SERMs (i.e. Tamoxifen)

Back 35

SERMs-Tamoxifen
-Hot flashes
-Weight gain/fluid retention
-DVT
-Endometrial cancer
-N/V

Front 36

Side Effects: Aromatase Inhibitors (i.e. Arimidex)

Back 36

Generally well-tolerated
Much better compliance
Increase in osteoporosis long term
*Nausea
*Headache
*Hot Flashes

Front 37

Chemotherapy: MGH

Back 37

*Cytoxan/Adriamycin every 14 days for 4 cycles
*Based on prognosis: lg. tumor, +lymph nodes, -ER/PR status
*Taxol: for +nodes, -ER/PR
**KNOW THAT IT'S A COMBINATION OF DRUGS. DON'T HAVE TO KNOW SPECIFIC NAME OF DRUGS.**

Front 38

Chemotherapy: ACS(American Cancer Society)

Back 38

Combinations of:
cyclophosphamide (cytoxan)
methotrexate
flourouracil (5-FU)
doxorubicin (adriamycin)
epirubicin (Ellence)
paclitaxel (taxol)
8 cycles every 2 weeks
Higher doses of chemotherapy
Support for WBC count. Example: Neulasta

Front 39

Biological Therapy: Herceptin
(only treatment for HER-2-neu oncogene)

Back 39

*Monoclonal Antibody works against HER-2-neu oncogene over-expressed by breast CA cells
*Seen in 25% of patients, cells more agressive
*It is FDA approved for met. breast CA.
EVERYONE HAS THIS GENE BUT IT IS OVER-EXPRESSED BY BREAST CANCER CELLS.

Front 40

Side Effects: Herceptin

Back 40

*Infusion complications: fever, rigors, rash, SOB (recall hypersensitivity, Benadryl/steroids)
*Flu-like syndrome with first few doses
**Cardiac damage that resembles CHF**
*(Other Chema add to cardiac problems/radiation to chest
STRUGGLE IS DOES THE RISK OUTWEIGH THE BENEFIT?

Front 41

When is radiation used?

Back 41

*To shrink a large tumor to operable size-Neo-adjuvant therapy
*Adjuvant therapy following lumpectomy
*Palliative tx. for pain caused by local recurrence and mets.
Radiation given +nodes and breast-conserving therapy
Younger women almost always have chemotherapy for micrometastasis

Front 42

Types of Radiation Therapy

Back 42

*External Beam: Daily treatment over 4-6 weeks. (investigational dose dense Bid) #1 S/E overwhelming fatigue
*Brachytherapy: radioactive seeds inserted into breast where tumor was removed, tx over 5 days.
*Palliative: to areas of metastatic disease to relieve pain

Front 43

Surgical Intervention

Back 43

*Breast conservation with radiation therapy (effective as mastectomy, no difference in survival)
*1. Lumpectomy
*2. Lumpectomy with axillary node dissection
*3. Partial mastectomy

Front 44

Lumpectomy

Back 44

*Tumor must be <5cm
*Node status important
*JP 1-3 days
*Radiation or Chemo may follow for 2 weeks

Front 45

Modified Mastectomy

Back 45

*Total Mastectomy - removal of entire breast (no lymph nodes or muscles)
*Modified Radical Mastectomy - most common if breast removed, also skin, lymph nodes, axillary dissection
*Radical Mastectomy - rarely done, entire breast, nodes and pectoral muscles modified = the pectoral muscle is left intact

Front 46

Sequelae/Complications (Post Mastectomy)

Back 46

*Pain (recall)
*Infection/Lymphedema prone to infection due to node dissection. Place sign above bed: No blood draws, IV's, Injections, or BP in affected arm see (care of arm in handout)
*Bleeding-JP to prevent fluid buildup; not to exceed 300cc in 24 hours

Front 47

Lymphedema

Back 47

*Can develop within first 6 weeks up to 30 years after surgery for breast cancer.
*Caused by surgery or radiation that destroys lymph nodes in axilla
*Common complication includes cellulitis, infection

Front 48

Sequelae/Complications

Back 48

*Neurovascular compromise: nerve damage due to axillary dissection, may experience numbness and tingling...may be permanent
*Impaired shoulder mobility; begin passive ROM immediately Post-op, PT and OT (see exercises)

Front 49

Breast Reconstruction Surgery

Back 49

*Done during surgery or immediately following, or delayed 3-6 months
1. Implants (not inserted until after radiation therapy complete)
Silicone or saline filled "shell"
Possiblility of complications

Front 50

Breast Reconstruction Surgery (cont.)

Back 50

2. Autologous Tissue Breast Reconstruction (flap)
Transplants skin from other part of body to "rebuild" new breast
Many different types of flaps
Requires specially trained microsurgeon and skilled nursing staff

Front 51

TRAM Flap

Back 51

*Transverse Rectus Abdominus Myocutaneous Flap: requires skin, fat, muscle be taken from abdomen and sculpted to match original breast shape and size
*Superior Gluteal Free Flap-tissue taken from upper buttock region to create new breast (cut from gluteal muscle)
**BIGGEST CONCERN IS PERFUSION**

Front 52

Complications of Reconstructive Surgery

Back 52

*Bleeding, hematoma
*Infection
*Insufficient blood circulation to graft
*Formation of fibrous scar tissue
*Abdominal wall weakness or hernia
*Upper extremity immobility

Front 53

Nursing Care Post-Op

Back 53

*Assess for infection: drainage, fever
*Monitor JP drainage: report >50cc/hr
**Position off of wound site**
*Avoid pressure on op site: no bra, no heavy lifting
*Report any signs of impaired circulation to op area: mottling or coolness (keep room over 70°

Front 54

Nursing Process/Role

Back 54

*Psychosocial integrity
*Refer to community services
*Wellness community
*See Nursing Care Plan

Front 55

Current Trends and Research

Back 55

*Many clinical trials are underway
*Urine test dev. @ Children's
*New gene test for reoccurrence risk
*http://clinicaltrials.cancer.org
*www.cancer.org
*www.nabco.or
*www.breastcancerinfo.com