BREAST CANCER

 starts when cells in the breast begin to grow out of control.

 The tumor is malignant (cancer) if the cells can grow into (invade) surrounding tissues or spread
(metastasize) to distant areas of the body.
 the cancer forms in either the lobules or the ducts of the breast. Lobules are the glands that produce milk,
and ducts are the pathways that bring the milk from the glands to the nipple.

 Types of Breast Cancer:

 Ductal carcinoma in situ (DCIS) -noninvasive condition. With DCIS, the cancer cells are confined to the
ducts in the breast and haven’t invaded the surrounding breast tissue.
 Lobular carcinoma in situ (LCIS)- cancer that grows in the milk-producing glands of the breast. Like
DCIS, the cancer cells haven’t invaded the surrounding tissue.
 Invasive ductal carcinoma (IDC) - most common type of breast cancer. This type of breast cancer begins
in the breast’s milk ducts and then invades nearby tissue in the breast. Once the breast cancer has spread to
the tissue outside the milk ducts, it can begin to spread to other nearby organs and tissue.
 Invasive lobular carcinoma (ILC) first develops in the breast’s lobules and has invaded nearby tissue.

 Risk Factors:

MODIFIABLE FACTORS: NON MODIFIABLE FACTORS:

 Radiation to chest or face before age 30  Age : 55 yrs old & older
 Parent to child transmission  Gender – Female
 Overweight  Family hix of breast cancer
 Breastfeeding  Personal history of breast cancer
 Drinking alcohol & smoking  Pregnancy history (after age 30)
 Dense breasts  Menstrual hx (younger than age12)
 Lack of exercise

 SIGNS & SYMPTOMS:

 breast lump or tissue thickening that feels different than surrounding tissue and has developed
recently
 breast pain
 red, pitted skin over the entire breast
 swelling in all or part of the breast
 a nipple discharge other than breast milk
 bloody discharge from the nipple
 peeling, scaling, or flaking of skin on the nipple or breast
 a sudden, unexplained change in the shape or size of the breast
 inverted nipple
 changes to the appearance of the skin on then breasts
 a lump or swelling under the arm

 Stages of breast cancer:

 Stage 0 breast cancer- Cancer cells remain confined to the ducts in the breast and have not spread
into nearby tissue. (DICS)
 Stage 1 breast cancer
 Stage 1A: The primary tumor is 2 centimeters wide or less and the lymph nodes are not affected.
 Stage 1B: Cancer is found in nearby lymph nodes, and either there is no tumor in the breast, or the
tumor is smaller than 2 cm.
 Stage 2 breast cancer
 Stage 2A: The tumor is smaller than 2 cm and has spread to 1–3 nearby lymph nodes, or it’s between
2 and 5 cm and hasn’t spread to any lymph nodes.
 Stage 2B: The tumor is between 2 and 5 cm and has spread to 1–3 axillary (armpit) lymph nodes, or
it’s larger than 5 cm and hasn’t spread to any lymph nodes.
 Stage 3 breast cancer
 Stage 3A:
- The cancer has spread to 4–9 axillary lymph nodes or has enlarged the internal mammary lymph
nodes, and the primary tumor can be any size.
- Tumors are greater than 5 cm and the cancer has spread to 1–3 axillary lymph nodes or any
breastbone nodes.
 Stage 3B: A tumor has invaded the chest wall or skin and may or may not have invaded up to 9 lymph
nodes.
 Stage 3C: Cancer is found in 10 or more axillary lymph nodes, lymph nodes near the collarbone, or
internal mammary nodes.
 Stage 4 breast cancer - breast cancer can have a tumor of any size, and its cancer cells have spread to
nearby and distant lymph nodes as well as distant organs.

 COMPLICATIONS:

 destruction of the breast

 destruction of the chest wall surrounding of the breast
 mastitis
 nipple discharge
 chest pain
 most women will aches or pains from time to time in the treated breast even years after treatment
 hair loss after radiation therapy and chemotherapy

 Anatomy & Physiology:

 Adipose Tissue- female breast is mostly made up of a collection of fat cells called adipose tissue. This
tissue extends from the collarbone down to the underarm and across to the middle of the ribcage.

  PATHOPHYSOLOGY:

 DIAGNOSTIC PROCEDURE

 Mammogram

Definition is an X-ray image of your breasts used to screen for breast cancer
Normal  Calcium deposits (calcifications) in ducts and other tissues
Values/Findings  Masses or lumps
 Asymmetric areas on the mammogram
 Dense areas appearing in only one breast or one specific area on the mammogram

Significance X-ray imaging of your breasts designed to detect tumors and other abnormalities. Mammography can
be used either for screening or for diagnostic purposes in evaluating a breast lump:
 Screening mammography- is used to detect breast changes in women who have no signs or
symptoms or new breast abnormalities. The goal is to detect cancer before clinical signs are
noticeable.
 Diagnostic mammography- is used to investigate suspicious breast changes, such as a new
breast lump, breast pain, an unusual skin appearance, nipple thickening or nipple discharge.
It's also used to evaluate abnormal findings on a screening mammogram. A diagnostic
mammogram includes additional mammogram images.

Nsg. During:
Resposibility  Assist with patient positioning- Place patient in a standing or sitting position in front of the
X-ray machine, which is adjusted to the level of the breast. Place the patient’s arms out of the
range of the area to be imaged.
 Tell the patient that some discomfort may be felt- Pain/discomfort may be caused by the
pressure required to compress the breast tissue against the X-ray plate.
 Advise the patient to cooperate completely and follow directions- Instruct patient to
remain still throughout the procedure since movement produces unreliable results. Ask the
 patient to hold breath while the x-ray films are being taken.

After:
 Provide information about the availability of the results. Inform the patient a report of the
findings will be given to the requesting physician, who will discuss the results with the
patient.
 Reinforce the information given by the patient’s HCP. Assist the patient in arranging an
additional test, therapy, or referral to another HCP if an abnormality is found.

 Medical Management:

Generic & Trade XELODA (capecitabine)

Name
Classification ANTINEOPLASTIC; ANTIMETABOLITE, PYRIMIDINE
Mechanism of combination with docetaxel is indicated for the treatment of patients with metastatic breast
Action cancer after failure of prior anthracycline-containing chemotherapy
Indications Indicated to patient with breast and colorectal cancer
Contraindications patients with severe renal impairment, hypersensitive to caprecitabine
Side effects  severe nausea or vomiting (may be severe),
 stomach pain or upset,
 loss of appetite,
 constipation,
 tiredness,
 weakness,
 back/joint/muscle pain,
 headache,
 dizziness,
 trouble sleeping,
 skin darkening,
 skin rash,
 dry/itchy skin, or
 numbness or tingling in your hands or feet.

Nursing  Ensure 10 rights of giving medication

Responsibilities  Withhold drug and immediately report S&S of grade 2 or greater toxicity.
 Monitor for dehydration and replace fluids as needed.
 Monitor carefully patients with coronary artery disease for S&S of cardiotoxicity (e.g.,
increasing angina).
 Report immediately significant nausea, loss of appetite, diarrhea, soreness of tongue,
fever of 100.5° F or more, or signs of infection.

Generic & Trade Eribulin (Halaven)

Name
Classification Antineoplastics, Antimicrotubular

Mechanism of Microtubule inhibitor; inhibits growth phase of microtubules, leading to G2/M cell-cycle block,
Action disruption of mitotic spindles, and, ultimately, apoptotic cell death
Indications  Patients with metastatic breast cancer who have previously received at least 2
chemotherapeutic regimens for the treatment of metastatic disease.
Contraindications Hypersensitive to eribulin
Side effects  Low blood count
 Fatigue/weakness
  Hair loss
 Nausea
 Peripheral neuropathy(numbness and tingling of the hands and feet)
 Weight loss
 Loss of appetite
Nursing  Ensure 10 rights of giving medication
Responsibilities  Do not take aspirin, products containing aspirin unless doctor specifically permits this
 Do not receive any kind of immunization or vaccination without doctor’s approval
while taking Halaven.
 For both men and women: Use contraceptives, and do not conceive a child (get
pregnant) while taking Halaven. Barrier methods of contraception, such as condoms,
are recommended.

 Surgical Procedures:
 Mastectomy- removal of the breast
 Lumpectomy- remove cancer or other abnormal tissue from your breast.

 Nursing Diagnosis:
1. Acute pain

May be related to:

 Disease process (compression/destruction of nerve tissue, infiltration of nerves or their vascular

supply, obstruction of a nerve pathway, inflammation)
 Side effects of various cancer therapy agents

Desired Outcomes

 Report maximal pain relief/control with minimal interference with ADLs.

 Follow prescribed pharmacological regimen.
 Demonstrate use of relaxation skills and diversional activities as indicated for individual
situation.

INTERVENTION
Provide nonpharmacological comfort measures
(massage, repositioning, backrub) and diversional
activities (music, television)
Encourage use of stress management skills or
complementary therapies (relaxation techniques,
visualization, guided imagery, biofeedback, laughter,
music, aromatherapy, and therapeutic touch).
Inform patient and SO of the expected therapeutic
effects and discuss management of side effects
RATIOANALE
Promotes relaxation and helps refocus attention.
Enables patient to participate actively in nondrug
treatment of pain and enhances sense of control. Pain
produces stress and, in conjunction with muscle tension
and internal stressors, increases patient’s focus on self,
which in turn increases the level of pain.
This information helps establish realistic expectations,
confidence in own ability to handle what happens.
Provide cutaneous stimulation (heat or cold, massage). May decrease inflammation, muscle spasms, reducing
associated pain. Note: Heat may increase bleeding and
edema following acute injury, whereas cold may further
reduce perfusion to ischemic tissues.

2. Anticipatory Grieving

May be related to

 Anticipated loss of physiological well-being (e.g., loss of body part; change in body function);
change in lifestyle
 Perceived potential death of patient.

Desired Outcomes

 Identify and express feelings appropriately.

 Continue normal life activities, looking toward/planning for the future, one day at a time.
 Verbalize understanding of the dying process and feelings of being supported in grief work.

INTERVENTION
Provide open, nonjudgmental environment.
Use therapeutic communication skills of Active-
Listening, acknowledgment, and so on.
Encourage verbalization of thoughts or concerns and
accept expressions of sadness, anger, rejection.
Acknowledge normality of these feelings.
Be aware of mood swings, hostility, and other acting-out
behavior. Set limits on inappropriate behavior, redirect
negative thinking.
Be aware of debilitating depression. Ask patient direct
questions about state of mind.
Reinforce teaching regarding disease process and
treatments and provide information as appropriate about
dying. Be honest; do not give false hope while providing
emotional support.
Discuss ways patient and SO can plan together for the
future. Encourage setting of realistic goals.
RATIOANALE
Promotes and encourages realistic dialogue about
feelings and concerns.
Patient may feel supported in expression of feelings by
the understanding that deep and often conflicting
emotions are normal and experienced by others in this
difficult situation.
Indicators of ineffective coping and need for additional
interventions. Preventing destructive actions enables
patient to maintain control and sense of self-esteem.
cancer patients are at high risk for suicide. They are
especially vulnerable when recently diagnosed
and discharged from hospital.
Patient and SO benefit from factual information.
Individuals may ask direct questions about death, and
honest answers promote trust and provide reassurance
that correct information will be given.
Having a part in problem solving and planning can
provide a sense of control over anticipated events.

3. Situational Low Self-Esteem

May be related to

 Biophysical: disfiguring surgery, chemotherapy or radiotherapy side effects, e.g., loss of

hair, nausea/vomiting, weight loss, anorexia, impotence, sterility, overwhelming fatigue,
uncontrolled pain
  Psychosocial: threat of death; feelings of lack of control and doubt regarding acceptance
by others; fear and anxiety

Desired Outcomes

 Verbalize understanding of body changes, acceptance of self in situation.

 Begin to develop coping mechanisms to deal effectively with problems.
 Demonstrate adaptation to changes/events that have occurred as evidenced by setting
of realistic goals and active participation in work/play/personal relationships as
appropriate.

INTERVENTION
Discuss with patient and SO how the diagnosis and
treatment are affecting the patient’s personal life, home
and work activities.
Encourage discussion of concerns about effects of
cancer and treatments on role as homemaker, wage
earner, parent, and so forth.
Provide emotional support for patient and SO during
diagnostic tests and treatment phase.
Refer for professional counseling as indicated.
RATIOANALE
Aids in defining concerns to begin problem-solving
process.
May help reduce problems that interfere with acceptance
of treatment or stimulate progression of disease.
Although some patients adapt or adjust to cancer effects
or side effects of therapy, many need additional support
during this period.
May be necessary to regain and maintain a positive
psychosocial structure if patient and SO support systems
are deteriorating.

4. Imbalanced Nutrition: Less Than Body Requirements:

May be related to

 Hypermetabolic state associated with cancer

 Consequences of chemotherapy, radiation, surgery, e.g., anorexia, gastric irritation, taste
distortions, nausea
 Emotional distress, fatigue, poorly controlled pain

Desired Outcomes

 Demonstrate stable weight/progressive weight gain toward goal with normalization of

laboratory values and be free of signs of malnutrition.
 Verbalize understanding of individual interferences to adequate intake.
 Participate in specific interventions to stimulate appetite/increase dietary intake.

INTERVENTION RATIOANALE
Monitor daily food intake; have patient keep food diary Identifies nutritional strengths and deficiencies.
as indicated.
Encourage patient to eat high-calorie, nutrient-rich diet, Metabolic tissue needs are increased as well as fluids (to
with adequate fluid intake. Encourage use of
supplements and frequent or smaller meals spaced
throughout the day.
Adjust diet before and immediately after treatment
(clear, cool liquids, light or bland foods, candied ginger,
dry crackers, toast, carbonated drinks). Give liquids 1 hr
before or 1 hr after meals.
Refer for dietician
eliminate waste products). Supplements can play an
important role in maintaining adequate caloric and
protein intake.
The effectiveness of diet adjustment is very
individualized in relief of posttherapy nausea. Patients
must experiment to find best solution or combination.
Avoiding fluids during meals minimizes becoming
“full” too quickly.