|Year : 2017 | Volume
| Issue : 2 | Page : 64-78
Shalini Chandran1, Anbu S Kumar2, Anandha R Jacob3, Reena George3, Sudha Kuppuswamy4, Leena Jared4, Suseela Rajkumar5, Silvia Rani5
1 Reader, College of Nursing, CMC, Vellore, India
2 Retd. Professor, College of Nursing, CMC, Vellore, India
3 Professor, College of Nursing, CMC, Vellore, India
4 Breast Care Nurse, CMC, Vellore, India
5 Charge Nurse, CMC, Vellore, India
|Date of Web Publication||9-Jun-2020|
Source of Support: None, Conflict of Interest: None
Breast cancer is one of the most feared illnesses and a major health problem for women. Many women believe that their risk for breast cancer is greater than their risk for any other type of illness. Greater knowledge of breast cancer will lead to early detection which is associated with higher long-term survival rates. This article gives an overview about breast cancer and its management. A case report is presented and the nursing care has been discussed in detail.
Keywords: breast cancer, women, major health problem
|How to cite this article:|
Chandran S, Kumar AS, Jacob AR, George R, Kuppuswamy S, Jared L, Rajkumar S, Rani S. Breast cancer. Indian J Cont Nsg Edn 2017;18:64-78
|How to cite this URL:|
Chandran S, Kumar AS, Jacob AR, George R, Kuppuswamy S, Jared L, Rajkumar S, Rani S. Breast cancer. Indian J Cont Nsg Edn [serial online] 2017 [cited 2021 Jan 24];18:64-78. Available from: https://www.ijcne.org/text.asp?2017/18/2/64/286272
| Introduction|| |
Breast cancer refers to a malignant tumour that has developed from cells in the breast. It is the leading cause of death due to cancer for women aged 20 to 59 and is second to lung cancer (Yarbro, Wujcik, & Gobel, 2011). In US, an average woman has a 12.5% lifetime risk of being diagnosed with breast cancer (Messersmith, Singer, & Ciesemier, 2015). In India the incidence of breast cancer is 30 per 100,000 women. In urban areas 1 in 28 women suffer from breast cancer and in rural the incidence is 1 in 60 (Lewis, Dirksen, Heitkemper, & Bucher, 2015).
| Review of Anatomy and physiology|| |
Breasts are mammary glands located between the second and sixth ribs over the pectoralis major muscle from the sternum to the midaxillary line on either side. The breast contains glandular, ductal, fibrous and fatty tissue. The tail of Spence is an area of breast tissue that extends into the axilla. Cooper’s ligaments or suspensory ligaments are connective tissue that support the breast on the chest wall. Each breast consists of 12 to 20 cone-shaped lobes that are made of lobules containing clusters of milk-secreting glands termed alveoli which end in a duct. All of the ducts in each lobule empty into an ampulla, which then opens into the nipple after narrowing.
The arterial blood supply is by the lateral mammary artery and the lateral thoracic artery. The venous drainage is by the lateral mammary vein and the lateral thoracic vein. The 3 types of lymphatic drainages are cutaneous drainage (from the skin), areolar drainage (from areola and nipple) and glandular drainage (from deep glandular tissue). The nerve supply is from the anterior lateral branches of the 4th to 6th intercostal nerves. The functions of the mammary glands are synthesis, secretion and ejection of milk (lactation) (Tortora, & Derrickson, 2011).
|Figure 2: Lymphatic drainage of the breast (Source: Lymphatic system, 2004)|
Click here to view
| Risk factors|| |
While there is no single, specific factor identified as cause for carcinoma breast, evidence suggests a combination of genetic, hormonal and environmental factors contributing to the development of cancer breast. These factors are:
- Family History - Although 20-30% of women with breast cancer have at least one relative with a history of breast cancer, only 5-10% of women with breast cancer have an identifiable hereditary predisposition. Other predisposing characteristics are one or more relatives with breast or ovarian cancer, breast cancer occurring in a relative younger than 50 years and male relatives with breast cancer (Katz, 2017). A systematic review and meta-analysis of risk factors for breast cancer in 4049 year old women indicated that having first degree relatives with breast cancer are associated with 2-fold or more increased breast cancer risk (Nelson et al, 2012).
- Genetic Factors - (BRCA1 and BRCA2 mutations) - The BRCA1 and BRCA2 genes located on chromosomes 17 and 13, respectively are believed to be tumor suppressor genes and mutation of these genes account for the majority of autosomal dominant inherited breast cancers. Women who inherit a mutation in the BRCA1 or BRCA2 gene have an estimated 50-80% lifetime risk of developing breast cancer.
- Gender - Lifetime risk in females is 1:8 and in males it is 1:1000 (Shah, Rosso & Nathanson, 2014).
- Age- Risk for cancer breast increases with age. Risk at 40 years of age is 1:217 as compared to 1:10 at the age of 80.
- Race and Ethnicity - White and black women have a higher incidence of breast cancer than Hispanic, Asian/Pacific Islander and Native American women.
- Neoplastic and Benign Risk Factors - Neoplastic conditions that increase the risk of breast cancer include previous breast cancer, ovarian cancer, endometrial cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS). Benign breast conditions that slightly increase the risk of breast cancer are hyperplasia and complex fibroadenoma (Katz, 2017).
- Hormonal Factors - Evidence suggests that an increased risk of 1.24 times for 10 years’ use of oral contraceptives (Collaborative group, 1996). An increased risk of breast cancer incidence and mortality is seen with the use of postmenopausal Hormonal Replacement Therapy (HRT). Risk is increased 1.35 times for 5 or more years of HRT use, normalizing 5 years after discontinuing (Chlebowski et al., 2010).
- Menstrual and Obstetric History - Factors that increase the number of menstrual cycles increases the risk of breast cancer due to increased estrogen exposure. These factors are menarche at a younger, before 13 years (2 times the risk), nulliparity, first full pregnancy after 30 years of age, not breastfeeding and menopause after 50 years of age (Angahar, 2017).
- Environmental and Lifestyle Factors - Tobacco abuse results in 24% higher risk of developing invasive breast cancer. Tobacco use prior to menarche increases breast cancer by 61% and the risk in 45%, when it is used for more than 11 years prior to parity. Postmenopausal women with type 2 Diabetes Mellitus have 17% higher risk, when compared to normal women. A meta analysis shows that 7% increase in the risk for every 10 grams of alcohol consumed per day. Obesity increases the risk of breast cancer. Ionising radiation exposure, poor cardiovascular health, high bone density, and exposure to insecticides like dichlorodiphenyl dichloroethylene (DDE) are also risk factors for breast cancer (Lahmann et al, 2004).
- Nutritional Factors - Diet with high amounts of fat, caffeine and red meat is a positive risk factor for breast cancer. Consumption of fruits and vegetables with phytoestrogens and high amounts of calcium/vitamin D reduces breast cancer risks (Angahar, 2017).
| Pathophysiology|| |
The current understanding of pathogenesis of breast cancer is that invasive cancers arise through a series of molecular alterations at the cell level resulting in uncontrolled growth of breast epithelial cells.
Gene expression in breast cancers
Of the two different types of estrogen receptors (ER) - alpha ( a ) and beta ( β ) (ER ot and ER ρ respectively), ERa protein is clearly linked to the development of breast cancer. Both ER subtypes carry a DNA binding domain. When estrogen enters the cell, it binds the ER and the complex migrates into the nucleus leading to the production of transcription proteins that induces changes in the cell. Large quantities of ER alpha receptors can stimulate cellular proliferation in the breast tissue. Estrogen has a property of inducing proliferation of cancers as well as that of the premalignant cells (promoter).
Role of Human Epidermal Growth Factor receptor 2(HER2)
HER2 is a protein whose overexpression is associated with rapid tumor growth, shortened survival, increased risk of recurrence after surgery, and poor response to conventional chemotherapeutic agents though its mechanism of carcinogenesis remains largely unknown (Yager, 2006). Overexpression of HER2 occurs in approximately 15-30% of breast cancers (Iqbal & Iqbal, 2014).
| Types of Breast Cancer|| |
The different types of breast cancer are presented in [Table 1] (Hinkle & Cheever, 2014).
| Clinical manifestations|| |
The most common symptom is a lump or mass (see [Figure 3]). This can be nontender, fixed rather than mobile and hard with irregular borders. The advanced signs include skin dimpling, nipple retraction (turning inward), nipple inversion, blood stained nipple discharge, venous prominence, skin ulcerations, edema, or peau d’orange (orange peel appearance caused by malignant cells blocking the lymph channels in the skin) (Hinkle & Cheever, 2014).
| Diagnostic tests|| |
There are various diagnostic tests done to detect breast cancer
- Mammography which is the gold standard for breast imaging (Shah, Rosso, & Nathanson, 2014) detects nonpalpable lesions, assists in diagnosing palpable masses and also detects microcalcifications which are calcium deposits within breast tissue (certain patterns of calcifications may indicate breast cancer) (Gulanick & Myers, 2014).
- Breast ultrasound is referred to as “the stethoscope of the breast specialist,” and is most often used for diagnosis of a mass that has already been located by palpation. It can usually identify masses as cystic or solid, and can recognize characteristics of solid masses that are strongly suggestive of malignancy (Dodge & Kegel, 2006).
- Breast biopsy is done to confirm malignancy. The following can be done:
Percutaneous biopsy (biopsy that obtains tissue by making a small puncture in the skin)
- Fine needle aspiration (FNA) is a procedure which removes some fluid or cells from a breast lesion with a fine needle.
- Core needle biopsy involves removal of actual tissue and not just cells.
- Stereotactic core biopsy is a procedure that uses a computer and imaging performed in atleast two planes to localize a target lesion.
- Ultrasound guided core biopsy
- Magnetic resonance imaging core biopsy
- Excisional biopsy involves the removal of the entire mass
- Incisional biopsy involves the removal of a portion of the mass
- Wire needle localization used to locate nonpalpable masses for biopsy using a wire and needle.
The other diagnostic tests are tumour tissue testing which shows the level of hormone receptors present in the tumour and classifies estrogen receptor (ER) or progesterone receptor (PR) as positive or negative. ER/PR positive indicates best prognosis. Genetic markers indicates positive or negative HER2/neu which is a gene associated with breast cancer. HER2/neu negative indicates best prognosis. Bone scan helps in ruling out bone metastasis. Magnetic Resonance Imaging (MRI) and Computed tomography (CT) scans can be used in evaluating tumours and distant metastasis (Gulanick & Myers, 2014).
| Staging of Breast Cancer|| |
Staging of the disease helps in guiding treatment decisions and also determines the prognosis of the disease. Disease identified at earlier stages allow early initiation of treatment. The staging system most often used for breast cancer is the TNM system, which is based on 7 key pieces of information (American Joint Committee on Cancer [AJCC], 2017):
- The extent (size) of the tumor (T): How large is the cancer? Has it grown into nearby areas?
- The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph nodes? If so, how many?
- The spread (metastasis) to distant sites (M): Has the cancer spread to distant organs such as the lungs or liver?
- Estrogen Receptor (ER) status: Does the cancer have the protein called an estrogen receptor?
- Progesterone Receptor (PR) status: Does the cancer have the protein called a progesterone receptor?
- HER2/neu (HER2) status: Does the cancer make too much of a protein called HER2?
- Grade of the cancer (G): How much do the cancer cells look like normal cells?
The most recent American Joint Committee on Cancer Breast (2018), has both clinical and pathologic staging systems for Breast Cancer.
- Stage 0 - Noninvasive carcinomas (LCIS or DCIS). Cancer cells have not invaded the surrounding breast tissue
- Stage I - The tumor is no more than 2 cm in size and cancer cells have not spread beyond the breast
- Stage II - The tumor has spread to the axillary lymph nodes and is less than 2 cm in size OR The tumor is greater than 5 cm in size without lymph node involvement, OR the tumor is between 2 and 5 cm and may or may not have spread to the nodes
- Stage III - The tumor is greater than 5 cm in size and has spread to the axillary lymph nodes
- Stage IV - The tumor cells have infiltrated to other parts of the body (metastatic cancer)
| Treatment|| |
There are several ways to treat breast cancer depending on its type and stage. Local therapies treat the tumour without affecting the rest of the body. The local therapies are surgery and radiation therapy. Systemic therapies treat the tumour using drugs. These are chemotherapy, hormone therapy, and targeted therapy (American Cancer Society, 2017).
Various types of surgery are done for breast cancer of which the most common is Modified Radical Mastectomy (MRM). It refers to the surgical removal of the entire breast and the axillary lymph nodes (simple mastectomy + axillary dissection). This is indicated for positive lymph nodes and advanced disease. When this procedure involves the removal of the pectoral muscles also, it is referred to as Radical Mastectomy. This is rarely done and may be performed for advanced disease. Simple Mastectomy which is the surgical removal of the entire breast that is indicated for large or multifocal tumours, women with very small breasts in whom local excision of tumour will be cosmetically unacceptable, ineligibility for radiation therapy, patient preference, and prophylaxis.
Breast conservation procedures include lumpectomy (excisional biopsy) which involves the removal of tumour and surrounding tissue. This is indicated for diagnosis of an abnormal mammographic finding or palpable breast lump if needle biopsy was not performed and may require further surgery. Quadrantectomy (partial mastectomy) involves the removal of a breast quadrant that includes the tumour area and possibly overlying skin. It is indicated for normal to large sized breasts and is usually done at the same time as axillary surgery.
The surgical removal of the axillary lymph nodes is referred to as axillary dissection which is performed along with mastectomy when lymph node is positive for tumour, for prognosis, staging, and local/regional disease control. The removal of only a few gatekeeper lymphnodes is referred to as sentinel lymphnode biopsy which is done along with mastectomy. This is performed to predict the status of lymph nodes and if status is negative for tumour, then axillary dissection is not performed.
Mastectomy may lead to side effects such as bleeding, infection, hematoma (collection of blood in the wound), numbness in the chest or upper arm, impaired mobility of arm or shoulder (Nettina, 2010).
The other side effects are as follows:
- Seroma collection of serous fluid : This may accumulate under the breast incision after mastectomy or breast conservation or in the axilla. Signs and symptoms may include swelling, heaviness, discomfort and sloshing of fluid. Seromas may develop temporarily after the drain is removed or if the drain is in place and becomes obstructed. If seroma is present, seroma aspiration will be done to remove the fluid.
- Lymphedema : It is a chronic swelling of an extremity due to interrupted lymphatic circulation (see [Figure 4]). This may occur if the axillary lymph nodes are removed and if functioning lymphatic channels are inadequate to ensure a return flow of lymph fluid to the general circulation. This is associated with a painful swelling of the arm as well as weakness, shoulder pain, and tingling sensations in the arm and shoulder.
- Post Mastectomy Pain Syndrome (PMPS) : This is a neuropathic pain in the chest wall, armpit and/or arm that doesn’t go away over time. Common symptoms include chest and upper arm pain, tingling down the arm, numbness, shooting or pricking pain, and unbearable itching that persist beyond the normal 3-months healing time. The most common theory for the onset of this syndrome is injury to intercostobrachial nerves, which are sensory nerves that exit the chest wall muscles and provide sensation to the shoulder and the upper arm.
Is one form of adjuvant therapy that can be used after surgery. Radiation therapy may be used for breast cancer as treatment to
- prevent local breast cancer recurrences after breast- conserving surgery
- prevent local and nodal recurrences after mastectomy
- relieve pain caused by local, regional or distant recurrence External beam radiation or brachytherapy (internal radiation) can be given ((Lewis et al., 2015)
Treatments include nonsteroidal anti-inflammatory drugs, antidepressants, topical lidocaine patches, local anaesthetics and antiseizure drugs (e.g., gapapentin). Other possible treatment modalities include imagery, biofeedback, physical therapy to prevent ‘frozen shoulder’ syndrome as a result of inadequate movement, and psychologic counseling.
Many breast cancers are responsive to chemotherapy (use of cytotoxic drugs to destroy cancer cells). Preoperative chemotherapy (neoadjuvant) is given to decrease tumour size with a goal of less extensive surgery. Postoperative chemotherapy (adjuvant) improves the survival. Examples of drug combinations are cyclophosphamide, methotrexate, and 5-fluorouracil; Adriamycin and cyclophosphamide.
ER/PR positive tumours respond to hormonal treatment with antiestrogens. The types of drug used are:
- Estrogen receptor blockers blocks estrogen receptors. e.g. Tamoxifen, Fulvestrant
- Aromatase inhibitors prevents production of estrogen by inhibiting aromatase which is an enzyme that is needed for estrogen synthesis e.g. Anastrozole, Letrozole
- Estrogen receptor modulator blocks the effect of estrogen in breast and promotes effect of estrogen in bone and thus prevents bone loss e.g. Raloxifene
Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2/neu protein expressed on the surface of breast cells. Herceptin slows the growth of cancer cells (Lewis et al., 2015).
| Prognosis|| |
The two most important prognostic factors are size and node involvement. The larger a tumor is, the greater the likelihood that there has been either lymphatic or vascular invasion and, therefore distant spread. Any lymphnode involvement indicates the propensity of the tumor to travel; multiple positive nodes are a strong indication for distant spread. Estrogen and progesterone receptors are the next most important prognostic factors. Breast cancers that are estrogen and/or progesterone receptor positive have a better prognosis (Nevidjon & Sowers, 2000).
The 5-year relative survival rates (relative survival rates are a more accurate way to estimate the effect of cancer on survival. These rates compare women with breast cancer to women in the overall population) is given by the American Cancer Society (2016) are as follows :
- Women with stage 0 or stage I breast cancer is close to 100%
- Women with stage II breast cancer is about 93 %
- Women with stage III breast cancer is about 72%
- Women with stage IV or metastatic breast cancer is about 22%
| Complication of Breast Cancer|| |
The main complication 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 bone, lung, brain, and liver (Lewis et al, 2015).
| Nursing Management|| |
The nursing management of a patient with breast cancer who underwent modified radical mastectomy is given as a case report using nursing process approach.
| Case Report|| |
Mrs. A, 47 years old female got admitted to the surgical unit with complaints of pain over the left breast and palpable lump for over a year. She had no nipple discharge or skin changes. There was no rapid increase in size of the lump. Her menstrual history revealed that she attained menarche at the age of 14 yrs. She had 2 children and had breast fed both of them. She had not taken oral contraceptive pills or hormone replacement therapy. She has no past history of breast, colonic, ovarian or uterine malignancies. She had underwent hysterectomy 7 years back for fibroids.
On inspection both the breasts appeared equal in size. The skin of the left breast had a biopsy scar at around 12 O clock position. There was mild nipple retraction. An ill-defined nodularity was palpable in the upper quadrant of the left breast at around 12 O clock position. Few lymph nodes were palpable in the ipsilateral axilla. Mammogram revealed highly suspicious mass in the left breast at 12 O clock position in the retroareolar region extending to the nipple. CT thorax showed an irregular lesion in the retroareolar region of the left breast, suggestive of malignancy. Trucut biopsy from left breast showed invasive ductal carcinoma, histological grade I.
She was diagnosed with Carcinoma left breast T2N2aM0, ER/PR+. She underwent 8 cycles of neoadjuvant chemotherapy. After this, she underwent left Modified Radical Mastectomy. In the preoperative period, she looked anxious and concerned about the proposed surgery.
| Nursing care|| |
1. Nursing diagnosis : Fear and anxiety related to surgery proposed and the potential consequences of the disease and its treatment
Expected Outcome : Fear and anxiety is reduced as evidenced by relaxed facial expression and verbalization of reduction in anxiety
- Assessed her anxiety
- Taught about relaxation technique such as deep breathing exercises
- Explained about the surgery, prognosis, preoperative and postoperative management
- Introduced to patients with similar condition who were doing well
- Clarified her doubts
- Provided counseling
- Ensured support from family members
- Administered Tab. Valium 5mg (anti-anxiety drug) before sending to the operating room
Evaluation: Fear and anxiety was minimized. She had a relaxed facial expression.
2. Nursing diagnosis : Deficient knowledge regarding surgery proposed related to ignorance
Expected outcome : Learning needs are met as evidenced by verbalization of understanding about preoperative and postoperative management
- Explained about the surgery proposed, anaesthesia, recovery room, postoperative management, pain management, and starvation
- Demonstrated postmastectomy exercises and postoperative exercises like deep breathing and coughing exercises, leg exercises
- Provided explanation in simple terms
Evaluation: She verbalized her understanding about the preoperative and postoperative management.
3. Nursing diagnosis : Risk for ineffective airway clearance related to pooling of secretions secondary to effects of general anaesthesia
Expected Outcome : Patent airway is maintained as evidenced by equal air entry, absence of abnormal breath sounds, normal saturation (90-100%) and respiratory rate (12-20/mt)
- Auscultated the chest to check for the air entry
- Provided steam inhalation and chest physiotherapy thrice a day
- Encouraged deep breathing and coughing exercises
Evaluation: Air entry was equal. Normal breath sounds were maintained. Respiratory rate was maintained within normal limits (16-24/mt) and saturation was above 95%.
4. Nursing diagnosis : Risk for ineffective breathing pattern related to relaxation of smooth muscles secondary to general anaesthesia
Expected outcome : Normal breathing pattern is maintained as evidenced by normal breath sounds
- Auscultated the chest and checked for breath sounds.
- Placed the patient in semi-fowler’s position to enhance lung expansion
- Administered 4 litres of oxygen via face mask
Evaluation: The breath sounds were normal. She had no complaints of breathing difficulty.
5. Nursing diagnosis : Risk for decreased cardiac output related to blood loss during surgery
Expected Outcome : Normal cardiac output is maintained as evidenced by absence of signs of hypovolemic shock
- Monitored the vital signs
- Checked for bleeding from the operated site
- Administered intravenous fluids as per order (Inj. 5% Dextrose 4 pints over 24 hours)
- Encouraged to start taking oral fluids once fully awake
- Maintained an intake-output chart to ensure fluid balance
Evaluation: The pulse rate and BP of Mrs. A was maintained within normal range. She did not develop any signs and symptoms of hypovolemic shock.
6. Nursing diagnosis : Acute pain related to the surgical incision
Expected Outcome : Pain is minimized as evidenced by verbalization of decrease in pain and decreased pain score
- Assessed the location and severity of pain. It was 8 on the pain scale
- Provided extra pillows on the affected side
- Monitored vital signs
- Administered Inj. Febrinil 1gm Q6h and Inj. Voveran 50 mg Q8h (analgesic)
- Provided diversional therapy like reading books/newspaper, listening to music, and talking with her relatives
- Reassured her
Evaluation: Mrs. A verbalized that her pain was reduced (pain score 3).
7. Nursing diagnosis : Risk for imbalanced nutrition related to nausea, vomiting and anorexia
Expected Outcome : Optimal nutrition is maintained as evidenced by normal intake of food
- Assessed nutritional status
- Administered intravenous fluids
- Administered antiemetics like Inj. Emes et 8mg Q8h IV
- Encouraged intake of fluids and then soft solids as tolerated
- Encouraged to take foods rich in vitamin C and protein rich diet to enhance wound healing and prevent infection
- Maintained a conducive environment
Evaluation: Mrs. A was able to take fluids after 6 hours of surgery and soft solids after 8 hours.
8. Nursing diagnosis : Risk for infection related to the surgical incision and presence of wound drains secondary to surgery
Expected Outcome : Infection is prevented as evidenced by normal vital signs
- Assessed the wound for colour, discharge and swelling
- Monitored vital signs
- Dressing was done in the surgical site and wound drain site following aseptic techniques.
- Instructed her about the care of wound drains and the emptying of wound drain after discharge
Evaluation: Mrs. A maintained normal vital signs. She did not develop any discharge from the operated site.
9. Nursing diagnosis : Body image disturbance related to loss of body part
Expected Outcome : Positive body image is enhanced as evidenced by acceptance of body changes and demonstration of positive coping strategies Interventions
- Assessed perception of self image
- Introduced to patients who have undergone similar surgeries
- Allowed to express her feelings about her appearance
- Provided explanation and reassured about the presence of phantom sensations in the chest wall, axilla and along the inner aspect of the upper arm
- Instructed about the availability of prosthesis (silicone or foam)
- Explained about the option of cosmetic breast reconstruction
Evaluation: Mrs. A had a positive perception towards her body image. She did not verbalize any negative feelings about her appearance. She seemed cheerful while talking to other patients.
10. Nursing diagnosis : Risk for complications related to the surgical procedure
Expected Outcome : Complications are prevented as evidenced by absence of the signs and symptoms
- Checked for swelling in the operated site
- Monitored vital signs
- Monitored the drains and dressings for bleeding and amount of drainage
- Monitored the surgical site for swelling
- Checked for fluid accumulation by pressing the area with fingers (fluid will move under the fingers if present) and assessed the need for seroma aspiration.
- Checked for proper functioning of the drains - checked for vacuum, air leaks and drain output at regular intervals
- Monitored the intake and output
- Checked for signs and symptoms of lymphedema
- Avoided checking BP on the affected arm (surgical side)
- Avoided inj ections or drawing blood on the surgical side
- Encouraged to perform postmastectomy exercises regularly and to avoid strenuous activities
- Encouraged the patient to avoid infection and injury in order to reduce the risk of developing lymphedema (as there is no cure) by doing the following:
- To elevate the arm above the heart several times a day and do gentle muscle pumping (making a fist and releasing)
- wear gloves while doing housework or gardening
- use nailcutters for cutting nails and thimble while sewing
- use insect repellents to prevent bug bites
- use razors carefully to avoid nicks and skin irritations
- protect skin from scratches, sores and burns
- practice good handwashing techniques
- maintain proper personal hygiene
- use sunscreen to prevent sunburns
- wear well-fitted bras; a wider shoulder strap is recommended
- avoid tight clothing and jewellery/watch on the affected arm
- avoid carrying heavy weights
Necrosis of surgical site
- Monitored the surgical site for colour, temperature
- Monitored vital signs
Evaluation: Mrs. A did not develop any signs of complications.
11. Nursing diagnosis : Deficient knowledge regarding home care related to ignorance
Expected Outcome : Learning needs are met as evidenced by verbalization of understanding of the health teachings
- Assessed her knowledge regarding home care
- Gave health teaching on the following topics
- Postoperative exercises
- Postmastectomy exercises (see [Figure 4])
- Prevention of lymphedema
- Prevention of infection
- Postoperative diet
- Availability of prosthesis (Breast prosthesis is an artificial breast form that can provide a psychological benefit and assist the woman in resuming proper posture because it helps balance the weight of the remaining breast)
- Care of wound drains
- Breast Self Examination - to perform monthly once (see [Figure 5])
- Medications and follow up
|Figure 5: Breast Self Examination (Source: Gulanick & Myers, 2014; Stoppler, 2016)|
Click here to view
Evaluation: Mrs. A was receptive to the health teachings and was able to demonstrate the exercises. Mrs. A had an uneventful postoperative period. She did not develop any complications.
| Conclusion|| |
Owing to the high incidence, mortality and morbidity of breast cancer, prevention and early detection of the disease should be of high priority among nurses. Nurses can also be patient advocates ensuring that they are provided the best and most safe treatment options. The scope of nurses as facilitators, educators, counselors, and practitioners is immense as efficient members of the health care team. Breast cancer awareness is an effort to raise awareness and reduce the stigma of breast cancer through education on symptoms and treatment. October is the breast cancer awareness month and pink ribbon symbolizes breast cancer awareness. As a member of the health care team, the nurse must be able to create awareness among the patients and their relatives about breast cancer by providing appropriate education.
Conflicts of Interest: The authors have declared no conflicts of interest.
| Continuing Education Series No: 33 Breast Cancer|| |
CE Test - 33 IJCNE
After reading the preceding article and taking this test, you should be able to :
- Define Breast Cancer
- Enumerate the risk factors of Breast Cancer
- E xplain the pathogenesis, staging, types and clinical manifestations of Breast Cancer
- Describe the management of Breast Cancer and its complication
- Discuss the nursing management of patients undergoing mastectomy
- The area of breast tissue that extends into the axilla is called as
- Tail of Spence
- Tail of Cooper
- The life time risk of a woman developing Breast Cancer is
- 1 in 6
- 1 in 8
- 1 in 10
- 1 in 12
- Mrs. X, 35 years old female is diagnosed to have Breast Cancer and is admitted for Radical mastectomy. Which of the following history given by Mrs. X can be identified as a risk factor for her disease?
- She attained menarche at the age of 14yrs
- Her first pregnancy was at the age of 27yrs
- Had breastfed her child for 1yr
- She was on oral contraceptives for 10yrs
- Which of the following contribute to the pathogenesis of Breast Cancer?
- Large quantities of estrogen beta receptors
- Small quantities of estrogen alpha receptors
- Over expression of HER2
- Proliferation of cancer due to progesterone
- Mrs. X was told that her carcinoma was in stage 3. This means that:
- The tumor is 2-5 cms in size
- The tumor size is > 5cms
- The tumor size is > 5cms and axillary lymph nodes are involved
- The tumor has infiltrated to other organs
- The most aggressive type of Breast Cancer is
- Tubular ductal carcinoma
- Inflammatory carcinoma
- Ductal carcinoma in situ
- Lobular carcinoma in situ
- The carcinoma that produces mucous is
- Infiltrating ductal carcinoma
- Colloid carcinoma
- Infiltrating lobular carcinoma
- Paget’s disease
- Advanced signs of Breast Cancer includes the following EXCEPT
- Peau d’orange
- Venous prominence
- Nipple inversion
- The inward turning of the nipple is called as
- The procedure which involves the removal of the entire mass is
- Excisional biopsy
- Incisional biopsy
- Core needle biopsy
- Sentinel lymph node biopsy
- Surgical removal of entire breast and axillary lymph nodes is
- Radical mastectomy
- Modified radical mastectomy
- Partial mastectomy
- Chemotherapy given before surgery is referred to as
- Adjuvant chemotherapy
- Neoadjuvant chemotherapy
- Combination chemotherapy
- Primary chemotherapy
- Internal radiation is also called as
- Hormonal therapy
- Targeted therapy
- The drug which affects estrogen synthesis is
- Swelling due to accumulation of lymphatic fluid is
- Neuropathic pain in chest wall and armpit is
- Postmastectomy pain syndrome
- Phantom pain syndrome
- Best prognosis in Breast Cancer is indicated by
- ER/PR positive
- HER2/neu positive
- Multiple positive nodes
- The practice that reduces the risk of developing lymphedema is
- Avoid use of gloves for gardening
- Avoidneedle pricks in the affected arm
- Lifting heavy weights
- Wear tight clothing
- Breast prosthesis helps in maintaining
- Muscle contracture
- Spinal curvature
- Monthly breast self-examination includes which of the following?
- Inspection and percussion
- Inspection and palpation
- Palpation and percussion
- Palpation and auscultation
CE Test No : 33 BREAST CANCER
Select the best answer and shade the circle against the suitable alphabet in the answer form provided.
Evaluation : Listed below are statements about the CNE on ‘Breast Cancer’ Please circle the number that best indicates your response.
Strongly Disagree Disagree Agree Strongly Agree
The stated objectives were met 1 2 3 4
The content was clearly presented 1 2 3 4
The content was related to the objectives 1 2 3 4
The test questions were clearly stated 1 2 3 4
PRESENT MAILING ADDRESS:
Cut out orphotocopy this form, fill and mail before June 30, 2018 to The Editor-in-Chief, IJCNE, College of Nursing, CMC, Vellore - 632 004, along with a Demand Draft for Rs. 100/- (Rupees hundred only), drawn in favour of CMC, Vellore Association. A certificate will be awarded to all the participants and a merit certificate to those who secure marks 80% and above. Participants who secure 100% will be awarded one issuefree subscription of IJCNE. Also, all those who score marks 80% and above will be awarded 2 credit hours (1 credit point).
| References|| |
American Joint Committee on Cancer Breast (2017). American Joint Committee on Cancer Cancer Staging Manual
. New York, NY: Springer.
Chlebowski, R.T, Anderson, G. L., Gass, M., Lane, D.S., Aragaki, A. K., Kuller, L. H.,…Prentice, R. L. (2010). Estrogen plus progestin and breast cancer incidence and mortality in postmenopausal women. Journal of the American Medical Association
. 304(15), 1684-92.
Dodge, D. G., & Kegel, J. L. (2006). Advances in Breast Cancer Screening and Diagnosis, The Journal of Lancaster General Hospital, 1(2), 47-51
Gulanick, M., & Myers, J. L. (2014). Nursing care plansdiagnoses, interventions and outcomes
. Philadelphia: Elsevier Mosby.
Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical nursing
. New Delhi: Wolters Kluwer.
Iqbal, N., & Iqbal, N. (2014). Human Epidermal Growth Factor Receptor 2 (HER2) in cancers: Overexpression and therapeutic implications. Molecular Biology International
. doi: 10.1155/2014/852748.
Lahmann, P. H., Hoffmann, K., Allen, N., VanGils, C. H., Khaw, K. T., Tehard, B., et.al. (2004). Body size and breast cancer risk: Findings from the European Prospective Investigation into Cancer And nutrition (EPIC). International Journal of Cancer. 111
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2015). Medical-surgical nursing assessment and management of clinical problems
. Haryana: Reed Elsevier India Private Limited. Lymphatic system
. (2004). Retrieved from http://slideplayer.com/slide/9984815/
Messersmith, L., Singer, J., & Ciesemier, G. (2015). Utilization of the breast cancer risk assessment tool in the identification and screening of women at increased risk of breast cancer. Journal of Women’s Healthcare, 4
, 259. doi:10.4172/2167-0420.1000259
Nelson, H. D., Zakher, B., Cantor, A., Fu, R., Griffin, J., O’Meara, E. S.,…Miglioretti, D. (2012). Risk factors for breast cancer for women age 40 to 49: A systematic review and meta-analysis. Annals of Internal Medicine
, 156(9), 635-648. doi: 10.1059/0003-4819-156-9201205010-00006
Nettina, S. M. (2010). Lippincott manual of nursing practice
. New Delhi: Wolters Kluwer.
Nevidjon, B. M., & Sowers, K. W. (2000). A nurse’s guide to cancer care
. Philadelphia: Lippincott Williams & Wilkins.
Shah, R., Rosso, K., & Nathanson, S. D. (2014). Pathogenesis, prevention, diagnosis and treatment of Breast Cancer. World Journal of Clinical Oncology
, 5(3), 283-298.
Stoppler, M. C. (2016). Lymphedema
. Retrieved from www.medicinenet.com.
Tortora, G. J., & Derrickson, B. (2011). Principles of anatomy & physiology
. New Jersey: John Wiley & Sons.
Yager, J.D., & Davidson, N. E. (2006). Estrogen carcinogenesis in breast cancer. The New England Journal of Medicine
. 354(3), 270-82.
Yarbro, C. H., Wujcik, D., & Gobel, B. H. (2011). Cancer Nursing-Principles and Practice
. Massachusetts: Jones and Barlett publishers.
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