BREAST CANCER

Breast cancer is the most common cancer in women, accounting for 32% of all cases
of female cancers. It is the leading cause of death for women ages 20-59 and is second to
lung cancer as the leading cause of cancer deaths in women. This increase is due in part to
more precise diagnostic methods that enable earlier detection of smaller tumors, but may also
be related to the increased use of hormone replacement therapy and the increased prevalence
of obesity in women. Although rare, breast cancer does occur in men.
INCIDENCE
Breast cancer incidence has risen consistently over the past 25 years. The life time
risk of breast cancer has increased from 5.5 %( 1 in every 18 women) to 13 %( 1 in every 8
women) in the past 40 years. This increasing incidence affects predominantly women
younger than 55 years of age and African American women younger than 45 years of age. In
2000, the death rate was 32% higher in African American women than in white women.

ETIOLOGY
Etiology
The cause of breast cancer is not known. Many women are anxious about their risk for
breast cancer, and many tend to overestimate their risk. Even though genetic, hormonal, or
biochemical factors are likely to be involved, 70% of women with breast cancer have no known
risk factors.
Age and Ethnicity
All women are at risk for breast cancer, and the most important single risk factor is age.
Risk increases with age, although the rate of increase slows after menopause.
Asian women born in Asia have a very low lifetime risk of breast cancer, but their
daughters born in North America have the same lifetime risk of breast cancer as for
American white women.
Ovarian and Hormonal Function
Early menarche and late menopause lead to an increased total lifetime number of
ovulatory menstrual cycles and a corresponding30% to 50% increase in breast cancer risk.
The women who experiences natural menopause before age 45 years has a risk for breast
cancer that is half that of the women whose menopause occurs after age 55 years.
Both nulliparity age older than 30 years at first live birth are associated with a nearly
doubled risk of subsequent breast cancer.
The use of hormone replacement therapy (HRT) has significant increase in risk for breast
cancer
Benign Breast Disease
Benign breast disease is not any more common in women with other risk factors for breast
cancer.
Family History
Family history is one of the known risk factors for breast cancer.
Environmental and Dietary Factors
An increased incidence of breast cancer has been reported in woman who
received mantle radiation for the treatment of Hodgkins disease,
Alcohol intake is the best-established dietary risk factor for breast cancer in
epidemiologic studies.
There is a possibility that the influence of dietary fat, obesity, and high
calorie intake may impact post menopausal breast cancer.

PATHOPHYSIOLOGY
Breast cancer may arise from the epithelium of the duct system anywhere from the
nipple end of major lactiferous ducts to the terminal duct unit which is in the breast lobule.
The pathologist sometimes finds carcinoma which is entirely at the in-situ stage ether by
chance in biopsies for a supposed benign condition, or following bleeding from the nipple, or
in sub clinical lesions detected by mammography. By the time of frank clinical presentation
malignant cells have infiltrated the breast tissue-invasive breast carcinoma.
The microscopical appearances vary from a well-differentiated pattern with obvious
transition from in-situ carcinoma, usually ductal and only uncommonly lobular, to anaplastic
where the breast is invaded by strands or clumps of anaplastic spheroidal or polygonal cells
which often excite a considerable degree of stromal fibroplastic reaction. Careful examination
of multiple blocks from a given tumor usually shows a variety of histological appearances.
Less common types include colloid carcinoma whose cells produce abundant mucin, and
medullary carcinoma with solid sheets of large cells often associated with a marked
lymphocytic reaction. Invasive lobular cancer is commonly multifocal and or bilateral.
THE SPREAD OF MAMMARY CARCINOMA
Local Spread: The tumor increases in size and invades other portions of the breast. It
tends to involve the skin and to penetrate the pectoral muscles, and even the chest
wall.
Lymphatic Spread: Occurs in two ways: by emboli, composed of carcinoma cells,
being swept along the lymphatic vessels by the lymph stream; and by permeation, that
is, actual growth of columns of cancer cells along the lumina of the lymphatic
channels. The axillary lymphnodes and the internal mammary lymph nodes are
involved comparatively earlier. Later, the supraclavicular lymph nodes, the opposite
breast, and the mediastinum, are possible resting places for itinerant carcinoma cells.
Finally, they may be found in lymph nodes even farther a field.
Spread by the Bloodstream: It is by this route that skeletal metastases occur (in
order of frequency) in the lumbar vertebrae, femur, thorasic vertebrae, and the skull;
they are generally osteolytic, pathological fractures occurring most often in a rib or a
vertebra. In most instances it is by way of the blood stream that metastases arrive in
the liver, lung fields or brain from the breast, but secondary deposits may also be
carried to the liver via the lymphatics within the rectus sheath and the falciform
ligament. The adrenal glands and the ovaries are also common sites for blood-borne
metastases.
Clinical Types of Carcinoma of Breast
It is difficult to give anyone growth a distinct classification, and clinical significance may
be minimal. However, because the tumor may present in such a wide variety of ways, it is
relevant to recognize certain clinical types:
DCIS Ductal Carcinoma In Situ- Ductal carcinoma in situ (DCIS) is the most
common type of non-invasive breast cancer. Ductal means that the cancer starts inside
the milk ducts, carcinoma refers to any cancer that begins in the skin or other tissues
(including breast tissue) that cover or line the internal organs, and in situ means "in its
original place." DCIS is called "non-invasive" because it hasnt spread beyond the
milk duct into any normal surrounding breast tissue. DCIS isnt life-threatening, but
having DCIS can increase the risk of developing an invasive breast cancer later on.
IDC Invasive Ductal Carcinoma - invasive ductal carcinoma (IDC), sometimes
called infiltrating ductal carcinoma, is the most common type of breast cancer. About
80% of all breast cancers are invasive ductal carcinomas.

IDC - Less Common Types
There are some types of invasive ductal carcinoma that happen less commonly than
others. In these cancers, the cells can look and behave somewhat differently than
invasive ductal carcinoma cells usually do
Tubular Carcinoma of the Breast
Medullary Carcinoma of the Breast
Mucinous Carcinoma of the Breast
Papillary Carcinoma of the Breast
Cribriform Carcinoma of the Breast

ILC Invasive Lobular Carcinoma- Invasive lobular carcinoma (ILC), sometimes
called infiltrating lobular carcinoma, is the second most common type of breast cancer
after invasive ductal carcinoma (cancer that begins in the milk-carrying ducts and
spreads beyond it. Invasive lobular carcinoma refers to cancer that has broken
through the wall of the lobule and begun to invade the tissues of the breast
Inflammatory Breast Cancer- Inflammatory breast cancer (IBC) is a rare and
aggressive form of breast cancer. Inflammatory breast cancer usually starts with the
reddening and swelling of the breast instead of a distinct lump.
LCIS Lobular Carcinoma In Situ- Lobular carcinoma in situ (LCIS) is an area (or
areas) of abnormal cell growth that increases a persons risk of developing invasive
breast cancer later on in life. Lobular means that the abnormal cells start growing in
the lobules, the milk-producing glands at the end of breast ducts.
Paget's Disease of the Nipple- Paget's disease of the nipple is a rare form of breast
cancer in which cancer cells collect in or around the nipple. The cancer usually affects
the ducts of the nipple first (small milk-carrying tubes), then spreads to the nipple
surface and the areola (the dark circle of skin around the nipple). The nipple and
areola often become scaly, red, itchy, and irritated.
Phyllodes Tumors of the Breast- Phyllodes tumors of the breast are rare, accounting
for less than 1% of all breast tumors. The name "phyllodes," which is taken from the
Greek language and means "leaflike," refers to that fact that the tumor cells grow in a
leaflike pattern. Other names for these tumors are phylloides tumor and cystosarcoma
phyllodes. Phyllodes tumors tend to grow quickly, but they rarely spread outside the
breast.
Recurrent and Metastatic Breast Cancer

CLINICAL MANIFESTATIONS
Clinical manifestations
Swelling in the armpit.
Pain or tenderness in the breast.
A lump in the breast, is often the first apparent symptom of breast cancer, breast lumps are
usually painless, although some may cause a prickly sensation. Lumps are usually visible on a
mammogram long before they can be seen or felt.
A noticeable flattening or indentation on the breast which may indicate a tumor that cannot be
seen or felt.
Any change in the contour, texture or temperature of the breast, reddish, pitted surface like the
skin of an orange (called peu de orange) is symptomatic of advanced breast cancer.
A change in the nipple, such as an indrawn or dimpled look, itching or burning sensation, or
ulceration, scaling of the nipple is symptomatic of Paget's disease, a localized cancer.
Unusual discharge from the nipple that may be clear, bloody or of another color, usually caused
by benign conditions but possibly due to cancer.


COMPLICATIONS
The main complication of breast cancer is recurrence. Recurrence may be local or regional
(skin or soft tissue near the mastectomy site, axillary or internal mammary lymph nodes) or
distant (most commonly involving the bone, lung, brain and liver).However, metastatic
diseases can be found in any distant site.
Widely disseminated or met static disease involves the growth of colonies of
cancerous breast cells in parts of the body distant from the breast. Metastasis primarily occurs
through the lymphatic, principally those of the axilla. However, cancer can spread to other
parts of the body without invading the axillary nodes even when the primary breast tumor is
small. Even in node-negative breast cancer, there is a possibility of distant metastasis.
DIAGNOSTIC STUDIES
Breast Self-Examination
Breast Self-Examination (BSE) instruction can be performed during assessment as part of
the physical examination; it can be taught in any setting, either to individuals or groups.



Women should begin practicing BSE at the time of their first gynecologic examination,
which usually occurs in their late teens or early 20s. A lesson in the BSE should include the
following: optimal timing for BSE(5 to 7 days after menses begin for premenopausal women and
one monthly for post menopausal women).Patients who have had breast surgery for the treatment
of breast cancer are carefully instructed to examine themselves for any nodules or changes in their
breasts or along the chest wall that may indicate a recurrence of the disease.
Mammography
Mammography is a breast imaging technique that can detect nonpalpable lesions and assist
in diagnosing palpable masses. The procedure takes about 20 minutes and can be performed in an
x-ray department or independent imaging center. Two views are taken of each breast: a
craniocaudal view and a mediolateral oblique view. For these views, the breast is mechanically
compressed from top to bottom and side to side.
Galactography
Galactography is a mammographic diagnostic procedure that involves injection of less
than 1 ml of radiopaque material through a canula inserted into a ductal opening on the areola,
following by a mammogram. It is performed when the patient has a bloody nipple discharge on
expression, spontaneous nipple discharge, or a solitary dilated duct noted on mammography.
Ultrasonography
Ultrasonography is used in conjunction with mammography to distinguish fluid-filled
cysts from other lesions. A transducer is used to transmit high-frequency sound waves through the
skin and into the breast, and an echo signal is measured. This technique is 95% to 99% accurate in
diagnosing cysts.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) of the breast is promising tool for use in diagnosing
breast conditions. MRI of the breast can be helpful in determining the exact size of a lesion. Other
uses include identifying occult breast cancer, determining the tumors response to chemotherapy.
Fine Needle Aspiration
Fine needle aspiration is an outpatient procedure usually initiated when mammography,
ultrasonography, or palpation detects a lesion. A surgeon performs the procedure when there is a
palpable lesion. Surgeon inserts a 21- or 22-gauge needle attached to a syringe into the site to be
sampled and withdraw tissue or fluid into the needle. This is sent to the laboratory for analysis.
Stereotactic biopsy
It is an outpatient procedure, is performed for nonpalpable lesions found on
mammography. The lesion to be sampled is located with the aid of a computer. A core needle is
inserted and samples of tissue are taken for pathologic examination.
Surgical Biopsy
It is the most common out patient surgical procedure. The procedure is done using local
anesthesia, moderate sedation, or, both. This involves excising the lesion and sending it to the
laboratory for pathologic examination.
Excisional Biopsy
Excisional biopsy is the usual procedure for any palpable mass. The entire lesion, plus a
margin of surrounding tissue, is removed. This type of biopsy is also called lumpectomy.
Incisional biopsy
Incisional biopsy is done when tissue sampling alone is required; this is done both to
confirm a diagnosis and to determine the hormonal receptor status. This procedure is often
performed in woman with locally advanced breast cancer or in cancer patients with a suspicion of
recurrent disease.
Tru-cut core biopsy
In a tru-cut core biopsy, the surgeon uses a special large-lumen needle to remove a core of
tissue. This procedure is used when a tumor is relatively large and close to the skin surface and
the surgeon suspects that the lesion is a carcinoma.
Wire needle localization
It is a technique used when mammography detects minute, pinpoint calcifications (indicating a
potential malignancy) or non palpable lesions and a biopsy is necessary. A long thin wire is
inserted through a needle before the excisional biopsy under mammographic guidance to ensure
that the wire tip designates the area to undergo biopsy. The patient is then taken to the operating
room, where the surgeon follows the wire down and excises the area around the wire tip.
CLINICAL STAGING OF CARCINOMA OF THE BREAST
TNM classification: The International Union against Cancer has recommended a staging system
known as TNM (tumor, nodes, and metastases).

American Joint Committee on Staging for Breast Cancer Tumor-Node _Metastasis
Primary tumor (T)
T0 No tumor evident
TIs Carcinoma in situ
TImic Less than 1mm in greatest dimension
TIa 1-5mm
TIb 6-10mm
TIc 11-20mm
T2 21-50mm
T3 >50mm
T4 Tumor of any size with direct extension to chest wall or skin
T4a Extension to chest wall
T4b Edema or ulceration of the skin of the breast
T4c Both T4a and T4b
T4d Inflammatory carcinoma
TX Primary tumor cannot be assessed
Regional Lymph nodes (N)
N0 No regional lymphnode metastasis
pNI Metastasis to 1-3 axillary lymphnodes and internal mammary nodes
identified by sentinel node biopsy
pN2 metastasis to 4-9 ipsilateral axillary lymph nodes or clinically apparent internal
mammary nodes
pN2 Metastasis to 10 or more ipsilateral axillary lymph nodes; clinically apparent
internal mammary nodes and one or more axillary nodes; or ipsilateral supraclavicular lymph
nodes
NX Regional lymph node cannot be assessed

Distant Metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
MX Distant metastasis cannot be assessed


Stage TNM 10-year overall survival
0 Tis N0 M0 95
1 TI N0 M0 88
IIA T0 NI M0
TI NI M0
T2 N0 M0
62
IIB T2 N1 M0
T3 N0 M0
62
IIIA T0 N2 M0
TI N2 M0
T2 N2 M0
T3 NI M0
T3 N3 M0
29
IIIB T4 N 0M0
T4 NI M0
T4 N2 M0
29
IIIC Any T N3 M0 29
IV Any T, Any N, MI 7

TREATMENT OF CANCER OF THE BREAST
Treatment is based on many factors, including:
Type and stage of the cancer
Whether the cancer is sensitive to certain hormones
Whether the cancer overproduces (overexpresses) a gene called HER2/neu
Surgical Therapy
Breast conservation surgery with radiation therapy and modified radical mastectomy
with or without reconstruction are currently the most common options for respectable breast
cancer. Most women diagnosed with early-stage breast cancer are candidates for either
treatment choice.

Surgical Treatment of Breast Cancer

Surgical procedure Description
Breast-conserving procedures:
Lumpectomy
Wide excision
Partial mastectomy
Segmental mastectomy
Quandrantectomy
Relatively synonymous terms to describe
removal of varying amounts of breast
tissue, including the malignant tissue and
some surrounding tissue to ensure clear
margins; axillary lymph nodes are also
removed with these procedures, if the
cancer was of the invasive type.
Axillary lymph node dissection Removal of some or all fat-enmeshed
axillary lymph nodes for determination of
extend of disease spread; the single most
important determinant for prognosis and
need for adjuvant treatment.
Total mastectomy Removal of the breast tissue only; this
procedure is generally done for the
treatment of carcinoma in situ, typically
ductal.
Modified radical mastectomy Removal of the breast tissue and axillary
lymph node dissection; the pectoralis major
and minor muscles remain intact.
Radical mastectomy Removal of the breast tissue along with
pectoralis major and minor muscles in
conjunction with an axillary lymph node
dissection.




Adjuvant Therapy
The decision to recommend adjuvant (additional) therapy after surgery depends on the
stage of the disease, menstrual status and age, cancer cell characteristics, presence or absence
of estrogen and/or receptors, progesterone, and other preexisting health problems that can
complicate treatment. Adjuvant therapies include radiation therapy after breast conservation
surgery and systemic therapies such as chemotherapy and hormonal therapy.
Radiation Therapy: Radiation therapy may be used for breast cancer as
Primary treatment to prevent local breast recurrences after breast conservation
surgery.
Adjuvant treatment following mastectomy to prevent local and nodal
recurrences
Palliative treatment for pain caused by local recurrence and metastasis
Primary Radiation Therapy: When radiation therapy is the primary treatment, it
is usually performed after local excision of the breast mass. The breast is radiated daily over
the course of approximately 5 to 6 weeks.
High-dose brachytherapy: Brachytherapy (internal radiation) is a procedure that
is an alternative to traditional radiation treatment for early-stage breast cancer. For, many
years, internal radiation therapy has primarily been delivered using a multicatheter implant
method that requires many catheters to be placed in the breast. After placement, a radioactive
seed is delivered into each catheter to treat the target area.
Palliative Radiation Therapy: In addition to reducing the primary tumor mass with a
resultant decrease in pain, radiation therapy is also used to stabilize symptomatic metastatic
lesions in such sites as bone, soft tissue organs, brain, and the chest. Radiation therapy
relieves pain and is often successful in controlling recurrent or metastatic disease for long
periods.
Systemic therapy
The goal of systemic therapy is to destroy tumor cells that may have spread
undetected to distant sites. Systemic therapy as an adjuvant to primary local treatment can
decrease the rate of recurrence and increase the length of survival. Because of the high risk
for recurrent disease, nearly all women with evidence of node involvement is found.
Weighing the different risk factors to determine the need for adjuvant therapy in a node-
negative patient is a complex process.
Chemotherapy: Chemotherapy refers to the use of cytotoxic drugs to destroy cancer
cells. Breast cancer is one of the solid tumors that is the most responsive to chemotherapy.
Hormonal therapy: Estrogen can promote the growth of breast cancer cells if the
cells are estrogen receptor positive. Hormonal therapy removes or blocks the source of
estrogen, thus promoting regression.
Tamoxifen (Nolvadex) has been the hormonal agent of the choice in estrogen
receptor-positive women with all stages of breast cancer for the past 30 years.
Biologic and Targeted Therapy: Trastuzumab (Herceptin) is a monoclonal antibody
to HER-2. After the antibody attaches to the antigen, it is taken into the cells and eventually
kills them. It can be used alone or in combination with other chemotherapy, such as docetaxel
(Taxotere), to treat patients with metastatic breast cancer whose tumors overexpress HER-2
typically have a poorer prognosis. The drug can be used for treatment at any stage of disease
following surgery or diagnosis of metastatic disease.
BREAST RECONSTRUCTION
Breast reconstructive surgery may be done simultaneously with a mastectomy or
sometime afterward to achieve symmetry and to restore or preserve body image. Indications:
The main indication for breast reconstruction is to improve the womens self image and
regain a sense of normality.
Types of Reconstruction
Breast Implants and Tissue Expansion: Breast implants are placed in a pocket
under the pectoralis muscle, which protects the implant and provides soft tissue coverage
over the implant. Implants can be placed either at the time of mastectomy or later.
Musculocutaneous Flap Procedure: If insufficient muscle is left after mastectomy
or if the chest wall has been radiated, the persons own tissue may be used to repair he soft
tissue defects. Musculocutaneous flaps are most often taken from the back or the abdomen. In
the latissimus dorsi musculocutaneous flap, a block of skin and muscle from the patients
back is used to replace tissue removed during mastectomy. A small implant may be needed
beneath the flap to gain reasonable breast shape and size. A disadvantage of this technique is
an additional scar on the back.

Nipple-Areolar Reconstruction: the majority of patients who have breas
reconstruction also have nipple-areolar reconstruction. Nipple reconstruction gives the
reconstructed breast a much more natural appearance. Nipple-areolar reconstruction is
usually done a few months after breast reconstruction. Tissue to construct a nipple may be
taken from the opposite breast or from a small flap of tissue on the reconstructed breast
mound. The areola may be grafted from the labia, skin in the area of the groin, or lower
abdominal skin, or it may be tattooed with a permanent pigmented dye. In some patients a
small implant may be placed under the completed nipple-areolar reconstruction to add
additional projection.

NURSING MANAGEMENT
Possible nursing diagnosis includes the following:
Fear related to diagnosis of breast cancer
Decisional conflict related to lack of knowledge about treatment options and
their effects
Disturbed body image telated to anticipated physical and emotional effects of
treatment modalities
Postoperative Care

Assess the clients psychological reaction to the surgery. Also, inspect the wound and
drains, assess for the presence of clinical manifestations of infection and pain, and perform
routine postoperative care.
Possible nursing diagnoses include:
Acute pain related to surgical procedure as evidenced by verbalization of pain
at operative area
Anxiety related to situational crisis and unpredictable outcome secondary to
diagnosis of cancer as evidenced by insomnia, crying and questioning of
prognosis
Disturbed body image related to perceived effects of mastectomy as evidenced
by verbalization of concern about appearance and feelings of loss of
femininity and refusal to view incision
Ineffective therapeutic regimen management related to lack of knowledge
regarding disease process and postoperative care as evidenced by frequent
questions about disease and treatment, follow-up care
Impaired physical mobility related to weakness and muscle loss as evidenced
by limitation in movement of upper extremity on surgical side
Risk for lymphedema related to impaired lymphatic drainage and lack of
knowledge of preventive measures