Problems of the Breast

What is normal, or to be expected during a breast exam?

common to have one breast larger than the other.
Slight variation common

What should you look for during a breast exam?

Inspect for color, venous pattern, edema or thickening
Note any dimpling

What breast change is only common for a pregnant woman?

venous prominence (the veins are more visible)-common in women who are pregnant or lactating-should be considered abnormal if not.

Breast Inspection Palpation

Axillary and clavicular areas-enlarged nodes can mean infection, cancer
Palpate entire surface and axillary tail

When should a woman perform a breast exam?

If still reproductive age: should do breast exam a week after menstrual cycle; those that are post-menopausal can do their breast exams any time of the month.

How should you perform a breast inspection?

lie flat; feel in small circles around breast
If a woman has implants-it can be hard to tell if breast cancer is present.

How often should women have a clinical breast exam?

20-39 is every 3 years
40 and older is every year

What is peau d'orange?

Caused by interference with lymphatic drainage
Breast has orange peel appearance
Skin pores enlarge
Skin becomes thick, hard, immobile
Discoloration may occur
May be noted on areola

What does US dx in the breasts?

differentiates fluid-filled cysts from solid masses

Fine Needle Aspiration Biopsy

to remove fluid or tissue fragments; this will tell if there are cancer cells in the area

Core Needle biopsy

Allows for the removal of larger tissue samples

Open, surgical biopsy

to remove lump: post op: assess bleeding and edema directly after surgery; wear properly supporting bra for at least 2 weeks continuously; not binding-just supportive; avoid cold temperatures-nipples become erect and it causes stress to the breast.

Mammogram

patient teaching before: no powders, ointments, deodorants (they could calcification marks on the actual picture). If you are still of reproductive age-don't want to schedule a mammogram during cycle because it would be extremely uncomfortable.

Fine Needle Aspiration: Indications for Surgical Biopsy

Suspicious mass persisting thru cycle; if they have a family hx of breast cancer. Bloody aspirate from cyst
Failure of a cyst to disappear after aspiration; Paget's. Skin edema & erythema; Suspicious mammogram; they could also have done an MRI

Paget's Disease s/s

Nipple ulceration, crusting, serous or serosanguineous discharge, which is a form of cancer that is in the mammary ducts

Nursing Considerations for diagnostic procedures of the breast

Explaining procedures is important
What to expect
How long before results are known
Reinforce explanations
All women will feel anxious
Encourage them to express feelings (how do you feel? What are your thoughts?)

Characteristics of Fibrocystic breast changes

Benign breast disease
Often occur before menopause
Early stage - fibrosis
Latter stages - feel like multiple, smooth, well-delineated nodules
May be present bilaterally

Fibrocystic Breast Changes s/s

Pain and tenderness - most common symptom
Most noticsable premenstrual
Often bilateral
Round shape
Soft, firm, mobile
Improve during pregnancy and lactation

Tx of Fibrocystic Breast Changes

Medical treatment is not standardized
May treat with Medroxyprogesterone acetate (form of progesterone), Tamoxifen, Danazol-meds block estrogen.

Lifestyle and dietary changes for tx of fibrocystic breast changes

so they can just do lifestyle things: take NSAIDs for pain, avoid chocolate, caffeine, tobacco, and tea-and watch salt in diet during time frame (b/c during menstruation the body may hold on to fluid). Wear a support bra and apply heat to breast

Fibroadenoma

Most common benign tumor-unilateral
Occur most often during adolescence and early 20's
Firm, freely mobile nodule

Fibroadenoma info contd.

Do not change with cycle-but increase in size during pregnancy, and decrease in size as the woman ages.
Located in upper outer quadrant
Treat by observing or remove to determine if malignant
Usually only one nodule; not painful; appearance has nothing to

Ductal Estasia. (DE)

Usually occurs to perimenopausal women. It's very similar to breast Ca, needs to be ruled out

DE results in inflammatory process...

causes nipple discharge-could be blood, serous looking; may experience burning pain, itching, or palpable mass behind the nipple.

DE s/s

Results in firm, irregular mass-non-movable
Enlarged axillary nodes
Nipple retraction and discharge-discharge may be white, brown, green or purple; thick and sticky

Intraductal Papilloma (IP)

wart that gets into ductal system
Typically develops just before menopause
Most lesions occur in areola

IP Dx

Ultrasound and diagnostic mammography to diagnosis-ductogram common way of making dx along w/mammography and core biopsy.

IP s/s

Causes serous or bloody discharge from nipple

IP Tx

Treat by excising (removal) and follow-up

Malignant Tumors of the Breast
Incidence:

Risk rises after age 50 (mammogram is started around 40-5; if you have an increased risk due to family hx or if you have ominous s/s: started at age 20-30).
Less common, but may occur in men
2nd only to lung cancer as the leading cause of cancer deaths in

Risk factors for breast cancer

BRAC1 and 2 genes
Race
Early Menarche
Nulliparity
Family Hx
Lifestyle factors

BRAC 1 and 2 Genes

looking for genetic mutations; BRCA 1-more breast; BRCA 2-breast and ovaries. Some women are having prophylactic mastectomies to prevent cancer if these genes are found; this test is extremely expensive and most insurance companies won't pay. Also may get

Race

Breast Ca is more common amongst white bitches but death rate is higher amongst african americans

nulliparity or first pregnancy after age 30

breast cancer is mostly driven by estrogen-if you've never had a baby, you've had constant menstrual cycles-and more exposure to estrogen.

family hx

(if mom/sister had it)-even looking at fathers-men do have a possibility of getting breast cancer

early menarche

< 12 years old; Late menopause - > 50 years old: (due to longer exposure to hormones)

lifestyle

high fat diet, excessive alcohol consumption (boosts estrogen level in body), physical inactivity (causes person to have more fatty tissue).

pathophysiology of breast cancer

80% is infiltrating ductal Ca
Originates in epithelial lining of mammary ducts
Growth is irregular
Eventually invades lymph
Metastasis occurs when cancer cells spread by both blood and lymph
Most commonly to lungs, liver, bone

Sentinel Node Biopsy (SNB) Dx

Removes only 1 or 2 key lymph nodes to evaluate spread
Radioactive dye (bluish color) injected near tumor site which identifies sentinel nodes, if the node picks up the dye, and then more nodes may need to be removed.
If the cancer has not spread to the s

SNB Staging

Necessary to understand severity
Based on TNM system (tumor node metastasis)
Stages guide treatment, prognosis
Range from 0 (carcinoma in situ) to 4 (metastatic disease); 0-better prognosis; 4-bad prognosis.

SNB s/s

Usually occurs as single mass
Usually non-tender
Irregular shape
Firm, hard, embedded in surrounding tissue (fixed)
Unilateral venous prominence
Peau d'orange (edema)
Nipple changes may occur
Inverted, Erythema, Discharge, Thickening, scaling erosion

SNB Tx

Combination of surgical excision and adjuvant therapy
Surgical procedures - lumpectomy, simple mastectomy, modified radical mastectomy
Adjuvant therapies - radiation, chemo, hormonal, immunotherapy
Breast reconstruction

conservation tx

Wide local excision - lumpectomy (more localized area removed), quadrantectomy (larger area removed)
Cleans margins of small tumors
Some axillary nodes removed
Radiation or some form adjuvant therapy

simple mastectomy

Removal of entire breast
Axillary dissection omitted, though some lymph nodes may be removed
Leaves small amount of breast tissue
Requires regular follow-up

modified radical

Removal of breast tissue, axillary nodes, some chest muscles
Recommended if large primary lesion found in small breast, cosmetic limitations, if radiation tx contraindicated, to avoid recurrences, or as prophylaxis
Decreased ROM-going to need physical the

radical mastectomy

Removal of breast tissue, pectoralis major & minor muscles, axillary lymph nodes
Decisions for breast conserving therapy vary widely
Not used very much

Nursing Care following sx tx of breasat cancer

Care similar for breast conserving surgery & modified radical
Discharged soon after surgery: Most discharged home with drain in place: document color/amount of fluid; wash hands when dealing with it; s/s of infection;

pt education re phantom limb

Nerve trauma with phantom sensations may occur (tingling sensation in arm or mastectomy site itself).

pt education re JP drain

teach them how to empty the drain-if using JP drain-keep bulb compressed and measure/empty drainage.

axillary dissection nursing considerations

(going in and taking out lymph nodes) can result in impaired arm & shoulder mobility, lymphedema (to avoid lymphedema: don't pick up heavy objects (no more than 10 lbs), have it elevated right after surgeries, exercises: squeeze ball, twist ropes, ROM exe

radiation therapy

Uses high-energy rays to destroy cancer cells
May be used to reduce tumor size before surgery or be used to destroy remaining tumor cells after manipulation and handling during surgery
May burn skin
Lymphedema more likely to occur if axillary nodes are tr

radiation therapy nursing considerations and pt ed.

internal (brachytherapy-putting active radiation seeds directly into area; care: they are isolated, nurses who are pregnant/breastfeeding shouldn't take care of patient w/this because it can be transferred to baby if in utero or through breast milk.

how do you limit radiation exposure to hospital staff and others

nurses should wear exposure badges to monitor the amount of radiation they are receiving, care should be clustered to limit exposure, supplies should be contained w/in room until they are discharged, they can't have any visitors due to exposure to radiati

external radiation care

don't wash of marks, good skin care, limit exposure to sun); immune system decreased: avoid crowds.

more nursing considerations re radiation therapy

Generally well tolerated
SE usually consists of fatigue and skin reaction
Avoid exposing treated area to sun
Recommended guidelines include a breast physical examination q 4-6 months for 5 years and then yearly; a mammogram is recommended 6 months after r

chemotherapy

Standard tx for premenopausal patients and those with lymph node involvement
Most common meds are taxol and Adriamycin
Kills rapidly dividing cells; causes alopecia

chemotherapy s/s

bleeding (bleeding precautions), immunosuppression, fatigue

for decreased WBC...
for decreased RBC...

may get nepogen
may get epogen

chemo pt ed re nausea and mouth care

avoid smells that may cause increased nausea in patient (don't eat malodorous foods, no perfume around them); provide good mouth care (frequent rinses of the mouth w/water and saline)-chemo can cause stomatitis.

if of reproductive age...

if they are of a reproductive age- they should be on birth control-can't do chemo when pregnant.

when is hormonal therapy indicated?

Prescribed for estrogen receptor-positive tumors

What is the most commonly prescribed hormone drug for breast cancer tx?

Tamoxifen most often, taken daily for 5 years; s/e: abnormal vaginal bleeding
Tamoxifen binds estrogen receptors, stops it from producing estrogen; BUT increases risk for endometrial cancer because it doesn't bind with those receptor sites.

Raloxifene (Evista)

is estrogen modifier that can be used to prevent breast cancer in high risk postmenopausal women. Also used for to reduce osteoporosis in menopausal women.

Bilateral oopherectomy...

has been noted to benefit women dx w/their first breast cancer before the age of 50 by reducing exposure to endogenous estrogen.

Immunotherapy

Trastuzumab (Herceptin) 1st monoclonal antibody therapy approved for breast cancer.
Blocks the effect of a protein produced by the tumor. Thus, inhibits cell growth

breast construction nursing considerations

Trastuzumab (Herceptin) 1st monoclonal antibody therapy approved for breast cancer.
Blocks the effect of a protein produced by the tumor. Thus, inhibits cell growth

tissue expansion method

put in an implant with a valve on it to gradually increase the size to stretch the tissue; either can leave that implant in or put a new one in once expansion is finished. Can use silicone or saline implants -placed under the chest muscle vs. on top of it

muscle flap grafts

(contraindicated in diabetics or those who have an autoimmune disease (lupus))
TRAM Flap Reconstruction (Delayed TRAM) and Latissimus dorsi flap method (LAT): major surgeries; need to make sure they have good circulation; have to have ability for good wou

psychosocial concerns of a breast modification sx to combat breast ca

Very stressful time
Feelings of uncertainty, lack of information, conflicting information
Multiple physicians involved (oncologist, internal med/primary physician, plastic surgeon)
Concerns include
Fear of death
Side effects of treatment
Effect on body im

effects of stress

Sleep disturbances-either sleep too much or not at all
Eating disorders-either eat too much or not at all
Marital strain
Difficulty working

nursing considerations re breast sx

Dependent on nurse for psychological support
Feel loss of control
Information decreases anxiety
Refer to "Reach for Recovery" and "Encore" if appropriate

drainage tubes

should be emptied at least q 8 hours and PRN.

exercises following sx

for the hand, arm and wrist) to be done in the immediate post-op period and compression arm sleeves: arm exercises are encouraged at least 4 times daily; exercise is increased as tolerated and is stopped at the point of pain. Initially the woman alternati

patient teaching following sx

No lotions, ointments, or deodorants on the side of the mastectomy until it is completely healed; tell them to wear a loose fitting, non-wire bra until the area is healed-usually for about 6-8 weeks; no needle sticks, BPs, no shaving on that side, sponge

Galactorrhea

a bilaterally spontaneous, milky, sticky discharge.

Galactorrhea is caused by...

Caused by: pregnancy, or increased prolactin levels
Increased prolactin levels caused by: thyroid disorder, pituitary tumor, coitus, eating, stress, trauma, or chest wall surgery.

Meds that cause galactorrhea...

tricyclic antidepressants, phenothiazines, narcotics, antiemetic, antihypertensive medications, and OCP.

best time to assess serum prolactin level...

between 8am and 10am