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55 Cards in this Set

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Incidence
*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
Incidence
*1 in 7 women will develop breast cancer. Estimated 40,970 deaths in 2006
*5 year survival:
localized=96%
regional=77%
distant metastasis=21%
Risk Factors (not modifiable)
*Age and gender
*Family Hx.
*Age at pregnancy (over the age of 30)
*Early menarche <12yrs./late menopause
*Cultural/Ethnic (black higher than white)
Risk Factors (not modifiable)
*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
Cultural
*Black women and Hispanic women diagnosed at a later stage and have a lower survival rate
*Whites have a higher incidence than non-whites
Modifiable Risk Factors
*Postmenopausal obesity
*Alcohol consumption (2 or more drinks/day
*Physical mobility (decreased mobility)
*Use of postmenopausal hormones (long-term use)
*Exposure to ionizing radiation
Prevention/Detection: ACS revised guidelines since 2003
*Dropped recommendation that all women perform BSE monthly
*Age 40+
-annual mammogram
-annual clinical breast examination
-Monthly BSE (optional)
ACS guidelines cont.
Age 20-39:
-Clinical breast exam q. 3 years
-Monthly BSE (optional)
Pathophysiology
*Infiltrating ductal carcinoma is most common 70-80%
*Infiltrating lobular carcinoma are less common 10-15%
*in situ=noninvasive (4-6%)
In Situ Breast Cancer
*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
Pathophysiology (Don't need to know for exam_4)
*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
Pathophysiology
*May spread to regional lymph nodes (axillary/supraclavicular)
*Can also metastasize to lungs, liver, bone (spine), and brain
Clinical Manifestations
*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
Diagnostic Studies
*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
KNOW THIS SLIDE
*Node status is important to assessing prognosis and need for adjunct treatment
Biopsy - GOLD STANDARD
*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
Care After Biopsy
*Small dressing 2-3 days
*Surgical bra 2-3 days
*Analgesics for pain
*Told when and by whom the test results will be given
5-year Relative Survival Rate by Stage
Stage 0 - 100%
Stage I - 98%
Stage IIA - 88%
Stage IIB - 76%
Stage IIIA - 56%
Stage IIIB - 49%
Stage IV - 16%
Early Stage Breast Cancer
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
Treatment of DCIS
*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)
Early Stage Breast Cancer:
Stage I
Invasive breast cancer = tumor <2cm
*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
Early Stage Breast Cancer:
Stage II
*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.
Early Stage Breast Cancer:
Stage IIIA
*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.
Treatment Options Early Stage
*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.
Treatment Options Early Stage
*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.
Advanced Breast Cancer
*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.
Staging and Prognosis: High Risk
(If you have one of these you're at high risk)
*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)
Treatment Procedure/Modalities
Medical:
-Hormonal Therapy
-Chemotherapy
-Biologic Therapy
-Radiation
Surgical Options:
-ANY COMBINATION OF ABOVE - depends on pt, surgeon etc.
Hormonal Therapy ONLY USED IF SOMEONE IS ESTROGEN POSITIVE
*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
Hormonal Therapy
*SERMs - selective estrogen-receptor modulators
*Aromatase Inhibitors - monoclonal antibodies
*Used in ER/PR +patients
Selective Estrogen Receptor Modulators (BLOCKS ESTROGEN AT LEVEL OF OVARIES)
*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
Aromatase Inhibitors
*Postmenopausal women ONLY - inhibits aromatase, enzyme that synthesizes endogenous estrogen, prevents estrogen production at level of ovaries.
*Others: letrozol (Femara), Anastrozol (Arimidex), Emestane (Aromasin)
Androgens from adrenal glands and ovaries
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)
Aromatase Inhibitors
*Used with early and advanced breast cancer
*Recently approved for post-menopausal women instead of Tamoxifen
*MUST BE POST MENOPAUSAL (IMPORTANT TO KNOW!)
Side Effects: SERMs (i.e. Tamoxifen)
SERMs-Tamoxifen
-Hot flashes
-Weight gain/fluid retention
-DVT
-Endometrial cancer
-N/V
Side Effects: Aromatase Inhibitors (i.e. Arimidex)
Generally well-tolerated
Much better compliance
Increase in osteoporosis long term
*Nausea
*Headache
*Hot Flashes
Chemotherapy: MGH
*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.**
Chemotherapy: ACS(American Cancer Society)
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
Biological Therapy: Herceptin
(only treatment for HER-2-neu oncogene)
*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.
Side Effects: Herceptin
*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?
When is radiation used?
*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
Types of Radiation Therapy
*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
Surgical Intervention
*Breast conservation with radiation therapy (effective as mastectomy, no difference in survival)
*1. Lumpectomy
*2. Lumpectomy with axillary node dissection
*3. Partial mastectomy
Lumpectomy
*Tumor must be <5cm
*Node status important
*JP 1-3 days
*Radiation or Chemo may follow for 2 weeks
Modified Mastectomy
*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
Sequelae/Complications (Post Mastectomy)
*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
Lymphedema
*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
Sequelae/Complications
*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)
Breast Reconstruction Surgery
*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
Breast Reconstruction Surgery (cont.)
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
TRAM Flap
*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**
Complications of Reconstructive Surgery
*Bleeding, hematoma
*Infection
*Insufficient blood circulation to graft
*Formation of fibrous scar tissue
*Abdominal wall weakness or hernia
*Upper extremity immobility
Nursing Care Post-Op
*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°
Nursing Process/Role
*Psychosocial integrity
*Refer to community services
*Wellness community
*See Nursing Care Plan
Current Trends and Research
*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