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02.11 Breast Cancer

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Overview

  1. Breast Anatomy- men and women
    1. Lobules- where milk is made
    2. Ducts- takes milk to nipple
  2. Cancer Anatomy
    1. Abnormal Cells
    2. Loss of Apoptosis= Overgrowth
  3. Breast Cancer
    1. An overgrowth of abnormal cells in, or from, the breast
    2. Second most common cancer in women behind skin cancer
      1. 1% of diagnoses are in men, survival rate similar to women, but usually later diagnosis

Nursing Points

General

  1. 3 Main Types of Breast Cancer
    1. Lobular Carcinoma- From the Lobules
    2. Ductal Carcinoma- From the Ducts
    3. Inflammatory
      1. rare, only 1-5%, aggressive
  2. Location
    1. Invasive
      1. Spread to surrounding tissues
    2. Noninvasive
      1. Only in duct or lobule
    3. In Situ
      1. Other name for Noninvasive meaning ‘in place’ (i.e. DCIS)
  3. Grading
    1. How differentiated (abnormal) the cells are
      1. GX (unknown) to G3 (very abnormal)
  4. Staging
    1. How far the cancer cells have spread
      1. 0- in situ or noninvasive to IV- distant metastasis
      2. Recurrent- cancer that has come back after treatment
  5. Cellular Testing
    1. Estrogen Receptors (ER)
    2. Progesterone Receptors (PR)
    3. HER2/NEU
      1. Protein involved in normal cell growth, may be overproduced in cancer cells

Assessment

  1. Breast exam (no evidence for self-breast exams, clinical with routine care)
    1. Lump in breast or armpit
    2. Asymmetry
    3. Breast or Skin that is inflamed (red/itchy), dimpled, scaly or puckered
    4. Nipple changes or discharge (inverted)
    5. Peau d’orange (orange peel skin)
      1. Trademark sign of Inflammatory BC
  2. Imaging
    1. Mammogram
    2. Ultrasound
    3. MRI
  3. Metastasis (most common sites)
    1. Bone Mets
      1. Bone pain
      2. Hypercalcemia
    2. Liver Mets
      1. Ascites
      2. Jaundice
      3. RUQ pain
    3. Brain Mets
      1. Altered Mental Status
      2. Headache
    4. Lung Mets
      1. Dsypnea
  4. Risk Factors
    1. Non-modifiable
      1. Older age
      2. Family History
      3. Genetic mutations
        1. BRCA 1/2
        2. Prophylactic mastectomy
      4. History of benign or malignant breast conditions
        1. XRT to breast can increase risk
      5. Dense Breasts
      6. Estrogen Exposure
        1. Early menarche / Late menopause
        2. Older at first birth or nulliparous
        3. Estrogen HRT
    2. Modifiable
      1. Obesity / Sedentary lifestyle
      2. Alcohol consumption
      3. Estrogen based HRT and OCP
    3. Protective Factors
      1. Early Pregnancy
      2. Breast Feeding
      3. Certain HRT and OCP- unclear cause

Therapeutic Management

  1. Treatment modalities
    1. Surgery
      1. Lumpectomy
      2. Mastectomy (unilateral or bilateral)
      3. Lymph node dissection
      4. Reconstruction
        1. Implants
        2. Autologous Tissue (Flaps)
        3. Prosthesis
    2. Radiation
    3. Chemotherapy
    4. Targeted Therapy
    5. Immunomodulating Therapy
    6. Hormone therapy
  2. Symptom Management
    1. Chemotherapy-related
      1. Peripheral neuropathy
      2. Pancytopenia
      3. Hair loss
      4. Nausea
      5. Weight Loss/Gain
    2. Surgery-related
      1. Lymphedema – lymph node dissection
      2. Body image disruption
      3. Pain control
    3. Radiation-related
      1. Skin rash, breakdown and infection
      2. Pain at site
    4. Targeted and Immunomodulating
      1. Depends on drugs- different side effects
    5. Hormone-related
      1. Hair loss
      2. Mood swings
      3. Hot flashes
      4. Pseudomenopause

Nursing Concepts

  1. Evidence-Based Practice
    1. Research is ongoing and we need to stay current on best practice
  2. Hormone Regulation
    1. Link to ERT
  3. Cellular Regulation
    1. Loss of cellular differentiation

Patient Education

  1. Know Your Risk Factors
    1. Genetics
    2. Modifiable
    3. Non-Modifiable
  2. Know your Cancer
    1. Location- ductal vs lobular
    2. Local Spread- invasive vs noninvasive/in situ
    3. Grade- how different are my cells
    4. Staging- how far has it spread in my body
    5. Testing- what tests were done and what are the results
  3. Know your Treatment and Side Effects
    1. What Treatments will I get and in what order
    2. What are the specific side effects to my treatments?

Reference Links

Study Tools

Video Transcript

Hi guys, it’s Stephanie. And today we are talking about breast cancer. So there are different types of breast cancer, and this relates to where in the breast it’s formed. So if it’s in these, lobules here, that’s called lobular breast cancer over here in the ducts, it’s called ductal breast cancer. And then there’s also a third type called inflammatory that actually forms here too, but it presents much differently and it’s not commonly seen. Breast cancer is further defined as invasive or noninvasive. You’ll hear in situ also if it has spread at all, it’s called invasive. The stage of breast cancer is determined also by how different the cells are. And then there are different receptors on tumors. Those can be estrogen-progesterone or HER-2. You’ll hear it called. And this helps guide how we can treat cancer. If they don’t have any of those, you’ll hear it called triple-negative breast cancer. 

And that’s more difficult to treat. So breast cancer is the second most common cancer in women behind skin cancer. It does occur in men. And I just want to point out if you have a man who has breast cancer, you might notice that they feel kind of ashamed. I’ve noticed that in the men that I’ve cared for, who have breast cancer. So it’s just important to let them know they’re not the only person. They’re not the only man to have had breast cancer. Survival, like many cancers, is so much better if it’s caught early, it’s up to 98%. If it’s caught in stage one and 16%, if caught in stage four. So obviously you want to catch it early. And that leads me into why screening is so important. So we teach our patients to be aware of their breast tissue. So this term breast self-awareness has replaced breast self-exams, and that’s just noticing your breast tissue and how it changes. 

Mammograms are huge. So we want to encourage our patients to get their yearly mammograms. This is near and dear to my heart. I’ve seen many patients do well because breast cancer was caught early on their mammograms and even more near and dear to my heart because my mom had breast cancer that was caught in stage one because she got her annual mammogram and she’s doing fantastic. Some patients are at higher risk of breast cancer and their screening is more specific. So they might be getting MRIs or ultrasound screens. And we’ll talk about what those risk factors are. So some risk factors are non-modifiable meaning we cannot change them. Age, most breast cancers are diagnosed between the age of 55 and 64. So older age puts you at higher risk. Also, family history and genetics are huge for breast cancer. 

One of the specific genes we’re talking about is the BRACA gene. That’s linked to several cancers, but breast cancers in one of the huge ones. If you have a positive BRACA one or two gene, and you have a family history of breast cancer, you might undergo prophylactic mastectomy. Our patients might have their breasts removed to prevent breast cancer from forming. Also, patients with dense breast tissue are at higher risk of breast cancer and prolonged estrogen exposure is related to breast cancer. So that would be patients who have their periods early in life and menopause late, or also if they haven’t had children or if they haven’t breastfed. Those are some things that have been linked to breast cancer. Okay. Some risk factors are modifiable. That would be obesity and sedentary, lifestyle, alcohol consumption, and then back to the estrogen. This is referring to people who consume hormone replacement therapy and oral contraceptives with estrogen in them. 

So what to look for in someone who has breast cancer?  Breast changes are a big one. This diagram shows some of the changes. So as cancer grows around this area, you can feel a lump if there’s a tumor or skin dimpling,  as the vasculature changes and the blood supply and lymph supply changes, you’re going to notice changes in skin texture. You might have drainage from the nipple, or the nipple can kind of pull in. You’ll see that sometimes. So really changes to the nipples or the breasts are things we need to teach our patients to look out for. Okay. Metastasis would be, if cancer has spread, there are certain places it tends to spread to, the bone is one of them. And a big thing with this would be bone pain. Also, they might have high calcium as the bones break down, they release the calcium. If it’s spread to the liver, the patients might have ascites. We talk more about the pathophysiology of that in the liver cancer lesson. Also, maybe jaundice, if it’s spread to the brain, we might have altered mental status, vision changes, or headache. If spread to the lungs, we will see shortness of breath, maybe even fluid around the lungs would be something that you might see. Treatment for breast cancer varies of course, like many cancers, depending on this stage, surgery is something that is often done. They might have a lumpectomy for a localized tumor. In this case, they’ll just have a portion of the breast removed. They might also have a mastectomy if they have the whole breast removed and that might be bilateral or unilateral. So when breasts or two are removed, they might have their lymph nodes removed to test them for cancer. Or if we know there’s cancer, then they will be removed. And then they also might have reconstruction surgery. Not all patients decide to go through reconstructive surgery, but many patients do. So that’s something else that we’ll be treating recovery from. Patients also might undergo radiation or chemotherapy, and this can be before or after surgery, depending on their cancer. And then they also might undergo targeted and hormone replacement therapy to treat their cancer. And we’ll talk more about the side effects of those here. So let’s talk about symptom management related to treatment surgery. A lot of times when people have surgery, they have JP drains. We need to teach our patients how to manage that. Of course, there’s surgical incisions, pain, risk of infection, that sort of thing. And then specific to breast cancer surgery would be lymphedema if they’ve had a lymph node removed. So this would happen because the lymph that usually flows to the lymph node and is drained, can’t. But if we don’t have this lymph node, that fluid, that usually would be drained here, pools down here. So we get swelling in the extremities. So to prevent this, we have limb restrictions.

So that means no venipuncture, so no blood draws, no IV starts, no blood pressure on that affected extremity. We also teach our patients to wear compression sleeves, range of motion, keeping that extremity elevated. I do see this less and less because we’ve had more improvements with surgery. So this is something we see less often, but it can be debilitating. I have seen patients that have very severe lymphedema. Radiation is another treatment, the biggest thing I see with radiation is skin irritation or radiation burns. And we just need to teach our patients to keep that area dry and clean, and it will heal on its own. Unfortunately, there’s not much we can do for those radiation burns. Chemotherapy is going to have the side effects of killing fast-growing cells. So we’re going to have the hair loss, nausea, vomiting, diarrhea, and then, with chemotherapy, we’ll have the pancytopenia. And just a reminder, that’s all the blood cells are low, right? Because our bone marrow is affected by the chemo. So that’s decreased white blood cells, decreased platelets,, and decreased hemoglobin. Targeted and hormone therapy, targeted therapy is usually tolerated pretty well. Hormone therapy can cause patients to have pseudo menopause. So that is mood swings, hot flashes. And people are actually on this for five years. This hormone therapy is an estrogen blocker. So they’re on this for a long time. It can also cause changes to your bone growth so they can get osteoporosis from that. Patient education. We want to make sure our patients know what their risk factors are for cancer, what type of cancer they have, and then specifically what treatment they are going through. Concepts related to breast cancer. We want to make sure we are staying up to date on evidence-based practice.

Hormone regulation is another big one. Here we are talking about estrogen replacement therapy. These cancers are often related to hormones. And then cellular regulation with any cancer, right? Something went wrong in this cellular regulation. All right, guys, let’s talk about some key points. So we encourage our patients to get their mammograms, know their risk factors, know what treatment they are getting because their side effects will vary based on that. And then lymphedema is specific to breast cancer and we need to educate our patients about that. That’s all I have guys go out and be your best self today and as always happy nursing.

 

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