Week 11 Breast Cancer 2024-2025 Student PDF

* FEMALE REPRODUCTIVE CANCERS Breast Cancer NURS 1028 Week 10...

* FEMALE REPRODUCTIVE CANCERS Breast Cancer NURS 1028 Week 10 Chapter 54 This Photo by Unknown Author is licensed under CC BY-NC-ND Note. "Please note that in an effort for more inclusive language, the content covered refers to individuals assigned female at birth (AFAB) even though we may use the term "female" when discussing these reproductive NURS 1028 / 2024-2025 1 cancers“.  *Risk Factors * Female and AFAB (99% of cases) * Increasing age – (i.e., over age 50) * Early menstrual period – (i.e., before age 12) * Late or no pregnancy – (i.e., first pregnancy after age 30) * Starting menopause after age 55 * Having dense breasts * Using combination hormone therapy * Taking oral contraceptives (birth control pills) * Personal history of breast cancer * those who have had breast cancer are more likely to get breast cancer a second time * Personal history of certain non-cancerous breast diseases - (i.e., benign breast disease) * People (e.g., females) with higher incomes * Working night shifts * Being overweight or obese after menopause (BMI>31.1) * Not being physically active * Alcohol intake 2 Refer to Table 54-2, p. 1336 NURS 1028 / 2024-2025  * Simple Modifiable Risk Factors and Cancer Smoking Connection A client’s risk was higher if she started smoking before age 17 – and the risk increase remained for at least twenty years after quitting Smoking was more strongly associated with breast cancer risk in those with a family history of breast cancer: their risk of the disease was raised by around 35% Smoking is associated with an increased incidence of hormone receptor positive breast cancer Physical Activity * Exercise has many biological effects on the body, some of which have been proposed to explain associations with specific cancers. These include: Lowering the levels of sex hormones, such as estrogen, and growth factors that have been associated with cancer development and progression (i.e., breast, colon) Alcohol * Body breaks down alcohol into a chemical called acetaldehyde * Acetaldehyde damages your DNA and prevents your body from repairing the damage * DNA is the cell’s “instruction manual” that controls a cell’s normal growth and function * When DNA is damaged, a cell can begin growing out of control and create a cancer tumor NURS 1028 / 2024-2025 3 * Genetic Factors *Risk Factors * Family member with ovarian cancer, was premenopausal, had bilateral breast cancer, and is a first-degree relative (i.e., mother, sister, daughter) * Having any first-degree relative with breast cancer increases a client's risk for breast cancer 1.5 to 3 times, depending on age * BRCA1 gene, located on chromosome 17, and the BRCA2 gene, located on chromosome 11, are tumour suppressor genes that, when functioning normally, inhibit tumour development * Those with inherited BRCA1 or BRCA2 mutations have up to an 85% lifetime chance of developing breast cancer * These clients are also at high risk for developing ovarian cancer * Risk Factors for Men and AMAB * Hyperestrogenism, a family history of breast cancer, and radiation exposure * A thorough examination of the breast should be a routine part of a physical examination for all men * People in BRCA-positive families may consider genetic testing * People with an abnormal BRCA gene also have an increased risk of developing prostate cancer NURS 1028 / 2024-2025 4  *Clinical Manifestations Nontender lump most  Inflammatory Breast often in the upper Cancer outer quadrant of the  Orange-peel skin (Peau d’orange) breast  Paget’s Breast Cancer Firm (fixed), hard  Abnormal nipple discharge embedded in (blood) surrounding tissue  A rash around the nipple area Dimpling of the skin  Nipple retraction Asymmetrical  Change in the position of the nipple Irregular shape (mass  Flaking or eruption near is not round) nipple  Burning, stinging, or prickly sensation NURS 1028 / 2024-2025 5  *Diagnostic Studies * Health history, including risk factors * Biopsy * Fine needle aspiration * Surgical * Breast MRI (if indicated) * Mammography This Photo by Unknown Author is licensed under CC BY-SA-NC * Physical examination, including breast and lymph nodes * Ultrasonography * Metastasis (if suspected): * Bone scan (assess for metastasis [e.g., bones]) * Chest radiograph * Complete blood cell count, platelet count, liver function tests * CT scan of chest, abdomen, pelvis (if indicated) NURS 1028 / 2024-2025 6  *Fine-Needle Aspiration * A needle is used to remove fluid * Discontinue any agents that can and/or tissue from the breast increase the risk of bleeding: lesion ASA * Best used for confirmation NSAIDs * Procedure takes a few minutes Vitamin E Supplements and may be done as an Herbal Supplements (i.e., outpatient Ginko Biloba and Garlic supplements) * Aspirated tissue is sent for Warfarin (Coumadin) histologic examination * Client may be instructed not to * Mild analgesics for pain at biopsy eat the night before the site procedure, depending on the type of biopsy * Most breast biopsy procedures are performed with the use of moderate sedation and local This Photo by Unknown Author is licensed under CC BY anaesthesia NURS 1028 / 2024-2025 7 * Ensure consent has been signed  * Breast Cancer *Mammography Screening * Canadian Cancer Society recommendations * Every 2 years between 50 and 69 years of age * X-Ray with compression; 2 views of breast, can show lumps less than 1cm is diameter (pea-sized); uses very low radiation (equivalent to 1hr in the sun); 90-95% accurate * Stage I = 5cm and 1 to 3 nodes * Stage III = >5cm and 4 to 9 nodes * Stage IV = Any size and any nodal involvement *Ultrasonography This Photo by Unknown Author is licensed under CC BY-SA-NC * Consistency of the mass; quick and non-invasive; differentiates between solid and liquid NURS 1028 / 2024-2025 8  * Breast Cancer Screening Update for Ontario *Update October 30, 2023: *Mammography * In Ontario starting in the fall of 2024, eligible women, non- binary, trans and two-spirit people between the ages of 40 and 74 can self refer for a mammogram every two years *Other Screening Tests in Ontario * People can already get regular mammograms and breast MRIs between the ages of 30 and 69 if they qualify as high risk, such as those with a family history of breast cancer or people who carry certain genes known to increase the risk of breast cancer NURS 1028 / 2024-2025 9  *Collaborative Care *Surgery * Breast-conserving (lumpectomy) with SNLD, ALND, or both * Modified radical mastectomy (may include reconstruction) *Radiation Therapy *Primary Radiotherapy *Adjuvant Radiotherapy *High-Dose Brachytherapy *Palliative Radiotherapy *Chemotherapy NURS 1028 / 2024-2025 10  *Breast Conserving *Lumpectomy Surgery *Breast-conserving surgery and radiation therapy is that the breast, including the nipple, is preserved *Axillary Node Dissection *Performed on the same side as the breast cancer *Typically involved the removal of 12 to 20 nodes *Lymphedema is the accumulation of lymph in soft tissue, causing obstructive pressure on the veins and venous return *Can occur as a result of the excision or irradiation of lymph nodes NURS 1028 / 2024-2025 11  *Lumpectomy Post- Procedure Nursing bleeding Interventions Monitor the effects of the anaesthesia and inspection the surgical dressing for signs of Once the sedation has resolved the nurse reviews the care of the biopsy site, pain management and activity restrictions Prior to discharge, the client must be able to tolerate fluids ambulate and void The client must have someone accompany them home Assess incision site The dressing covering can removed in 48 hours an the Steri-Strips, which are applied directly over the incision should stay in place for 7 to 10 days Use of a supportive bra is encouraged to limit movement of the breast and reduce discomfort Acetaminophen, mild analgesics for discomfort from biopsy Application of local heat or cold post-biopsy Most clients can return to their usual activities the day after the procedure but are encouraged to avoid impact activities for 1 week to promote healing of the biopsy site Allow client to express anxious feelings and provide support NURS 1028 / 2024-2025 12 *Surgical Therapy Mastectomy * Modified Radical Mastectomy * Removal of the breast tissue and associated axillary lymph nodes * Total or Simple Mastectomy * Removal of the entire breast and nipple-areola complex but does not include an axillary lymph node dissection * May be performed prophylactically in clients who are at high risk for breast cancer * Breast Conservation Treatment * In this procedure, most of the skin over the breast is left intact. Implants or tissue from other parts of the body are used at the time of surgery to reconstruct the breast. Many clients prefer skin-sparing mastectomy because it offers the advantage of less scar tissue and a reconstructed breast that seems more natural * Sentinel Lymph Node Biopsy (SLNB) * A sentinel lymph node is the first lymph node in a chain or group of lymph nodes that cancer is most likely to spread to. Used to find out if cancer has spread to lymph nodes NURS 1028 / 2024-2025 13 * Post Mastectomy Surgical Therapy * Breast Reconstruction * To improve a client’s self-image and regain a sense of normality in coping with the loss of a breast * 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 it * A tissue expander can be used to stretch the skin and muscle at the mastectomy site before implants are inserted * Tissue Flap Procedures * Use of autologous tissue to re-create a breast mound * Muscle, skin, fat blood supply is transposed from the abdomen and a block of skin and muscle from the client's back to the mastectomy site * Nipple–Areolar Reconstruction * Majority of clients who undergo breast reconstruction also receive nipple–areolar reconstruction * Gives the reconstructed breast a much more natural appearance * 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 * 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 NURS 1028 / 2024-2025 14  * Hormone Receptor Status * Breast cancer cells taken out during a biopsy or surgery are tested for certain proteins that are estrogen or progesterone receptors. Receptors are proteins in or on cells that can attach to certain substances in the blood. If breast cancer cells have these receptors (proteins), this means that when the hormones estrogen and progesterone attach to the receptors, they stimulate the cancer to grow Knowing the hormone receptor status of a cancer is important, because it helps determine the treatment options Breast cancer cells have either estrogen (ER) or progesterone (PR) receptors or Hormone Receptor- Positive Breast both. Cancer can be treated with hormone therapy drugs that lower estrogen levels or block estrogen receptors. Hormone receptor-positive cancers tend to grow more slowly than those that are hormone receptor-negative Women with hormone receptor-positive cancers tend to have a better outlook in the short-term, but these cancers can sometimes come back many years after treatment Hormone Receptor- Have no estrogen or progesterone receptors Negative Breast Treatment with hormone therapy drugs is not helpful for these cancers. These Cancer cancers tend to grow faster than hormone receptor-positive cancers If they come back after treatment, it’s often in the first few years more common in women who have not yet gone through menopause Triple- Do not have estrogen or progesterone receptors Negative Breast Tend to be more common in women < 40 years of age, who are Black, or who have Cancer a mutation in the BRCA1 gene Grow and spread faster than most other types of breast cancer. Do not have hormone receptors, hormone therapy is not helpful in treating these cancers Chemotherapy can still be useful Triple- Are ER-positive, PR-positive, and human epidermal growth factor receptor 2 (HER2)- Positive Cancers positive HER2 is a protein that helps breast cancer cells grow quickly NURS 1028 / 2024-2025 15 These cancers can be treated with hormone drugs as well as drugs that target HER2  * Hormone Receptor Status * Breast cancer cells may have one, both, or none of these receptors. ER-Positive Breast Cancer: Have estrogen receptors are called ER-positive (or ER+) cancers PR-Positive Breast Cancer: Have progesterone receptors are called PR-positive (or PR+) cancers Hormone Receptor-Positive Cancer: If the cancer cell has one or both of the receptors above, the term hormone-receptive positive (also called hormone- positive or HR+) breast cancer may be used Hormone Receptor-Negative Cancer: If the cancer cell does not have the estrogen or the progesterone receptor, it's called hormone-receptor negative (also called hormone-negative or HR-) * Keeping the hormones estrogen and progesterone from attaching to the receptors can help keep the cancer from growing and spreading NURS 1028 / 2024-2025 16  * Other Therapies * Adjuvant Therapy: Include local radiation therapy and systemic therapies such as chemotherapy and hormone therapy * Primary Radiation Therapy: Primary treatment, it is usually performed after local excision of the breast mass. is irradiated 5 days per week over the course of approximately 4 to 6 weeks * Fatigue, skin changes, and breast edema may be temporary adverse effects of external beam radiation therapy * High-Dose Brachytherapy (Internal Radiation): The most widely used method is balloon brachytherapy. MammoSite Radiation Therapy System, a balloon catheter is used to insert radioactive seeds into the breast after the tumour is removed. The radiation dose is focused on the area of the breast at highest risk for tumour recurrence. Performed over a 1- to 5-day period on an outpatient basis. Clients typically receive treatments twice a day for 5 days * Palliative Radiation Therapy: Used to stabilize symptomatic metastatic lesions in such sites as bone, soft tissue organs, the brain, and the chest and is successful in controlling recurrent or metastatic disease NURS 1028 / 2024-2025 17 * Systemic Therapy: Destroy tumour cells that may have spread to distant sites  *Other Therapies * Chemotherapy: Use of cytotoxic drugs to destroy cancer cells. Many breast cancers are responsive to chemotherapy. In some clients, chemotherapy is administered preoperatively. Preoperative (neoadjuvant) chemotherapy can decrease the size of the primary tumour, possibly enabling surgery to be less extensive * Adverse Effects: Gastro-intestinal tract, bone marrow, and hair follicles, resulting in nausea, anorexia, weight gain, bone marrow suppression and subsequent fatigue, and alopecia (hair loss) * Hormonal Therapy: Estrogen can promote the growth of breast cancer cells if the cells are estrogen receptor–positive. Hormonal therapy blocks the source of estrogen, thus promoting tumour regression * Estrogen Receptor Blockers: Tamoxifen, an antiestrogen drug, blocks the estrogen receptor sites of malignant cells and thus inhibits the growth-stimulating effects of estrogen. It is commonly used in early- stage and advanced breast cancer, to treat recurrent disease and prevent breast cancer in individuals at high risk for its development. Treatment with tamoxifen generally lasts 5 years * Adverse effects: Hot flashes, mood swings, vaginal discharge and dryness, and other effects commonly associated with decreased estrogen levels. It also increases NURS the risk for blood clots, cataracts, 1028 / 2024-2025 18 stroke, and endometrial cancer in postmenopausal people * Past Health History: *Assessment * Family history of breast cancer (especially mother or sister, young age at diagnosis) * History of abnormal mammogram findings or atypical findings in prior biopsy * Benign breast disorders with atypical changes * Previous unilateral breast cancer * Menstrual history (early menarche with late menopause) * Pregnancy history (nulliparity or first full-term pregnancy after age 30) * Previous endometrial, ovarian, or colon cancer * Hyperestrogenism and testicular atrophy (in men) * Dietary habits and history of alcohol use * Level of usual physical activity, weight, and BMI * Medications: * Use of hormones, especially as postmenopausal hormone therapy and in oral contraceptives; infertility treatments NURS 1028 / 2024-2025 19  *Assessment *Symptoms: *Palpable change found on self-examination *Obesity; unexplained severe weight loss (possible indicator of metastasis) *Changes in cognition; headache; bone pain (possible indicators of metastasis) *Unilateral nipple discharge (clear, milky, or bloody) *Change in breast contour, size, or symmetry *Psychological stress *Anxiety regarding threat to self-esteem NURS 1028 / 2024-2025 20  *Nursing Diagnosis *Decisional conflict related to insufficient information (treatment options and their effects) *Anxiety related to threat to current status, threat of death (diagnosis of cancer) *Disturbed body image related to alteration in self-perception *Example: Disturbed body image related to breast alteration from surgical scars as evidenced by client stating, “I am shocked what my chest area looks like, and I find myself actively avoiding to look in the mirror when I’m changing clothes to my upper body. I even go hide in the closet to change because there are no mirrors in there, so no temptation to even look”. NURS 1028 / 2024-2025 21  *Planning *The overall goals are that clients with breast cancer will: *Example: The client will verbalize acceptance of physical changes, express improved body image, and engage in activities that promote self-confidence and self-care within 3 to 6 months. *actively participate in the decision-making process related to treatment options *adhere to the therapeutic plan *manage the adverse effects of adjuvant therapy *access and benefit from the support provided by significant others and health NURS 1028 / 2024-2025 22 care providers  *Nursing Interventions * Review and reinforce information on treatment options * Prepare client regarding what to expect before, during, and after surgery * Inform client regarding surgical drain, arm and shoulder mobility, and range-of-motion exercises * Consent, NPO, pre-op and pain control medications and teach importance of turning and DB&C * Maintain open communications * Provide client with realistic expectations * Support coping related to pain and uncertain future * Involve or provide information for supportive services and resources * Note. Sensitivity to the individual's need for and type of information is essential. Some clients seek extensive, detailed information, whereas others avoid information * Support client’s decisions NURS 1028 / 2024-2025 23  *Nursing Interventions *Inform client regarding common postoperative sensations *Relieve pain and discomfort *Maintain privacy *Provide bra with breast form *Provide counselling and referral (e.g., physiotherapy, massage therapy) *Monitor for potential complications *Assess for infection-redness, foul-smelling, temperature, hematoma, surgical dressing *Assess drainage from incisional suction *Assess for tingling or numbness in affected arm NURS 1028 / 2024-2025 24  *Hand and Arm Care * Restoring arm function on the affected side after mastectomy and ALND is a key nursing goal * Prevention is vital; follow guidelines for the rest of life * No blood pressure, injections, or blood draws in the affected arm * Semi-Fowler's position with the arm on the affected side elevated on a pillow * Flexing and extending the fingers should begin in the recovery room, with progressive increases in activity encouraged * Perform exercises 3x a day for 20 minutes to increase circulation and muscle strength, prevent stiffness and contractures, and restore ROM * A mild analgesic 30 minutes or a warm shower may be helpful before exercise * Teach client to avoid use of deodorants and talcum powder until incision is completely healed * Initial limitation of lifting (over 5 to 10 pounds) and activity * Do not carry handbags (purses) on the arm with lymphedema NURS 1028 / 2024-2025 25  *Hand and Arm Care * When lymphedema is acute complete decongestive therapy may be recommended * Pneumatic compression sleeve, which intermittently applies mechanical massage to the arm and facilitates lymph drainage up toward the heart * Diuretics, isometric exercises, and elevation of the arm so that it is level with the heart may be recommended to reduce the fluid volume in the arm * Client may need to wear a fitted elastic pressure-gradient sleeve * during waking hours to maintain maximum volume reduction * preventively during air travel NURS 1028 / 2024-2025 26  *Psychological Care * Identify sources of support and strength, such as their partner, family, and spiritual or religious practices * Provide accurate and complete answers to their questions about the disease, treatment options, and reproductive, fertility, or lactation issues (if appropriate) * The Reach to Recovery program of the Canadian Cancer Society is a rehabilitation program for those who have undergone breast surgery. It is designed to help them meet their psychological, physical, and cosmetic needs. The volunteers, who have had breast cancer, can answer questions about expectations, surgery, and recovery * The Canadian Cancer Society and the Canadian Cancer Society Research Institute can provide excellent materials to assist nurses in meeting the special needs of those with breast cancer This Photo by Unknown Author is licensed under CC BY-SA NURS 1028 / 2024-2025 27  *after BREAST * after BREAST CANCER (ABC) is a registered charity that was founded in 2013 by Alicia Vianga, CANCER * (ABC) Care KIT! Program ABC Care KITS! include: a certified bra and breast 2x Temporary Breast Prostheses prosthesis fitter and owner of Premier Jour Fine Lingerie & 2x Drainage Pockets Swimwear, a Toronto-based 1x Front Closure Mastectomy intimate apparel boutique. Camisole * When Alicia was asked to review 1x Front Closure Mastectomy Bra the official Bra and Breast Prosthesis Guide for a major 1x Mastectomy Bra and Breast Toronto hospital, she identified a Prosthesis Fitting Guide serious gap in the health care 1x Seatbelt Pillow system. * 1x Handmade Knitted Blanket There was no program that provided breast prostheses or 1x Handmade Knitted Cap bras for cancer survivors in 1x Message of encouragement Toronto who had no insurance, or were financially challenged. from our Ambassadors who have completed breast cancer * The program provides clients with treatment and much more! limited financial needs with new prostheses and or new/gently used bras at no cost. * https://www.afterbreastcancer.ca/ * after BREAST CANCER - 1292 St. Clair Avenue West, Toronto ON M6E 1C1 NURS 1028 / 2024-2025 28 *Follow-Up and Survivorship Care * After surgery, client must be monitored for the rest of their life at regular intervals * Most have professional examinations every 6 months for 2 years and then annually thereafter * Recommended that these clients perform monthly examinations on both breasts or on the remaining breast and the surgical site * Most common site of local recurrence of breast cancer is at the surgical site * Undergo appropriate breast imaging at regular intervals (usually 6 months to 1 year), as determined by their risk for recurrence and breast cancer history * Encourage clients to talk about their feelings!!! NURS 1028 / 2024-2025 29  *References *Tyerman, J., Cobbett, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2022). Lewis’s medical- surgical nursing in Canada: Assessment and management of clinical problems (5th Canadian ed.). Elsevier Canada. NURS 1028 / 2024-2025 30 30