2. DEFINITION
Breast cancer is an abnormal proliferation of breast cell that results a
lump in the breast, change in breast shape, dimpling of the skin etc.
Breast cancer occurs at any where in the breast, but most
commonly found in the upper outer quadrant, where most breast tissues
are located.
3. INCIDENCE
Breast cancer is the most common malignancy in Indian women
second only to the cervical cancer.
1 in 28 Indian women is likely to develop breast cancer during her
lifetime. It is more for urban women (1 in 22) than the rural group (1
in 60).
4. TYPES
NONINVASIVE CARCINOMA – An estimated 20% of all diagnosed breast cancers
are non-invasive.
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS)
INVASIVE CARCINOMA –
Infiltrating ductal carcinoma
Mucinous carcinoma
Medullary carcinoma
Tubular carcinoma
Infiltrating lobular carcinoma
Inflammatory carcinoma
Paget’s disease
5. DUCTAL CARCINOMA IN SITU
Occurs when cancer fill the ducts but haven’t yet spread through the
walls into fatty tissue.
6. LOBULAR CARCINOMA IN SITU
It develops in the cells of lobules the milk producing glands. It doesn’t spread
into nearby breast tissue, but can increases the risk of developing breast
cancer.
7. INFILTRATING DUCTAL CARCINOMA
Most common histologic type of breast cancer.
Found 80% of all cases.
Tumors arise from the duct system and invade
the surrounding tissue.
8. MEDULLARY CARCINOMA
5% cases
Tends to be diagnosed more often in women younger than 50 years.
The tumours grow in a capsule inside a duct.
9. MUCINOUS CARCINOMA
3% cases found.
Largely confined to the elderly population.
Tends to grow slowly over years.
Tumour cells are arranged in clusters and small islands of cells within large
lakes of mucin.
10. TUBULAR CARCINOMA
Incidence is approximate 2%
Most commonly diagnosed in the perimenopausal or early menopausal
population.
Tumour consist of well formed tubules.
Axillary metastases are rare.
Excellent prognosis.
11. INVASIVE LOBULAR CARCINOMA
Accounts for around 10% of cases.
Arises from the lobular epithelium of the breast.
12. INFLAMMATORY CARCINOMA
Very rare, accounts for about 1 – 3%.
Most aggressive type and difficult to treat because it spreads rapidly.
This is due to the malignant cells blocking the lymph channels in the skin.
13. PAGET’S DISEASE
Represents about 1 – 2% of breast cancer.
It stars in the milk ducts of nipple and can spread to the areola.
Symptoms include scaly, erythematous, pruritic lesion of the nipple.
14. CAUSES & RISK FACTORS
AGE
More than 80% of breast cancer cases occur in women over 50 years.
Uncommon before age 25years. Incidence increases to the time of
menopause and then slow down.
FAMILY HISTORY
Approx.10 % cases due to inherited genetic predisposition.
Risk increases 2 – 3 times in 1st degree relatives compared to other
women.
GENETIC FACTORS
Mutation of tumour suppressor gene BRCA1 BRCA2 play a role in 5 – 10 %
of this case.
15. CONT..
HISTORY OF OTHER CANCER
HORMONAL FACTORS
Increased levels of estrogen increases risk.
Early menarche ( before 12 years)
Late menopause (after 55 years)
Nulliparity
Late age at first child birth (after 30 years)
Hormonal therapy, use of long term OCP
16. CONT..
OTHERS
High fat intake.
Excess alcohol consumption
Exposure to ionizing radiation
Physical inactivity.
17. STAGING
The American Joint Committee on Cancer (AJCC) has designated staging by
TNM.
T = tumor size
N = lymph node involvement
M = metastasis
18.
19. CONT..
STAGE TUMOR SIZE
(T)
NODAL INVOLVMENT
(N)
METASTASIS
(M)
0 Carcinoma in situ No No
I ≤ 2 cm No No
II >2 cm but ≤ 5 cm No / 1 – 3 axillary lymph node No
III A No evidence of tumor ranging to > 5cm Yes, 4 – 9 axillary / internal
mammary lymph node
No
III B Any size with extension to chest wall
or skin.
Yes, 4 – 9 axillary / internal
mammary lymph node
No
III C Any size Yes, >10 axillary, internal
mammary, infraclavicular
nodes
No
IV Any size Any type of nodal involvement Yes
20. CLINICAL MANIFESTATIONS
Any unusual changes in the breast can be a symptom of breast cancer.
A lump or thickening in the breast.
Breast pain and tenderness.
Redness, scaliness or thickening of the nipple or beast skin.
Nipple pain and nipple turning inward.
Discharge from nipple.
Skin irritation and dimpling.
Enlarged axillary and supraclavicular lymph nodes.
21. DIAGNOSTIC STUDIES
History taking including risk factors.
Physical examination.
Imaging techniques
Breast ultrasound
Mammography
Breast MRI
Biopsy: When a lump can be felt and is suspicious for cancer on mammography.
FNAC
Incisional biopsy
Excisional biopsy
Ultrasound core biopsy
22.
23. MANAGEMENT
ADJUVANT THERAPY
Treatment that is given in addition to primary (initial) treatment.
It is an addition designed to help to reach the ultimate goal.
Adjuvant therapy for cancer usually refers to surgery followed by chemo or
radiotherapy to help to decrease the risk of cancer recurring.
24. SURGICAL MANAGEMENT
MASTECTOMY: An operation to remove the breast is called mastectomy. There
are five different types of mastectomy.
Simple or total mastectomy
Modified radical mastectomy
Radical mastectomy
Partial mastectomy
Nipple sparing mastectomy
Lymph node dissection
Cryotherapy
Breast reconstructive surgery
Prophylactic ovary removal
25. SIMPLE / TOTAL MASTECTOMY
The surgeon removes the entire breast.
Does not perform axillary lymph node
dissection.
No muscles are removed from beneath the
breast.
It is appropriate for women with multiple or
large areas of ductal carcinoma in situ (DCIS).
26. MODIFIED RADICAL MASTECTOMY
The surgeon removes the entire breast.
Axillary lymph node dissection is performed,
during which level I & II underarm lymph nodes
are removed.
No muscles are removed from beneath the
breast.
It is appropriate for women with invasive
breast cancer.
27. RADICAL MASTECTOMY
Entire breast should be removed.
Levels I, II & III of the underarm lymph nodes
are removed.
The surgeon also removes the chest wall
muscle under the breast.
It is recommended only when the breast
cancer has spread to the chest muscles under
the breast.
28. CONT..
PARTIAL MASTECTOMY - It is the removal of
cancerous part of the breast tissue and
some normal tissue around it.
NIPPLE SPARING MASTECTOMY – All of the
breast tissue is removed here, only the
nipple is left alone.
29.
30. CONT..
CRYOSURGERY - Uses extreme cold to
freeze and kill the cancer cells.
BREAST RECONSTRUCTIVE SURGERY –
Rebuilding of the breast after mastectomy
or sometimes lumpectomy.
TYPES
Prosthetic implant
Autologous tissue reconstructions
31.
32. MEDICAL MANAGEMENT
RADIATION THERAPY – most women receive radiation therapy after breast
sparing surgery. Sometimes it can be used as primary treatment. Radiation
destroys cancer cell that may remain in area.
TYPES
External radiation
Internal radiation (Brachytherapy)
33. CONT..
CHEMOTHERAPY –
Refers to use of cytotoxic drugs to destroy the cancer cell.
In some patient it is used preoperatively which decreases the size of the
primary tumor, possibly permitting less extensive surgery.
Most common combinations of chemotherapy are –
CMF – Cyclophosphamide, Methotrexate, 5 fluorouracil
CEF – Cyclophosphamide, Epirubicin, 5 fluorouracil
Treatments are given every 3 – 4 weeks for 6 – 9 months.
34. CONT..
HORMONAL THERAPY –
Recommended for all estrogen receptor positive patient.
Hormonal therapy blocks the source of estrogen thus promoting tumor
regression.
Anastrozole, tamoxifen etc most commonly used.
BIOTHERAPY –
Helps to strengthen the immune system to fight against the cancer.
Can be used alone or combined with chemotherapy.
Transtuzumab is a monoclonal antibody most commonly used.
36. NURSING DIAGNOSIS
Ineffective individual coping and compromised family coping related to
diagnosis of cancer and surgical changes in breast as evidenced by facial mask
of fear and frequent asking of questions.
Acute pain related to surgical incision as evidenced by verbalization of pain at
surgical site.
Fluid electrolyte imbalance related to NPM status of patient / less intake by
the patient or presence of surgical drainage system as evidenced by dry lip,
dry mouth.
37. CONT..
Impaired physical mobility related to weakness and muscular loss as
evidenced by limitation in movement of upper extremity on surgical site.
High risk for infection related to surgical incision, presence of drainage
system.
Risk for impaired skin integrity related to surgery or radiation therapy.
Disturbed body image related to mastectomy as evidenced by verbalization of
concern about appearance & feelings of loss of femineity.
38. POST MASTECTOMY EXERCISE
HAND WALL CLIMBING
Stand facing wall with toes 6 – 12 inches from
wall.
Bend elbows and place arms against wall at
shoulder level.
Gradually move both hands up the wall parallel to
each other until feel pain or pull in incision.
39. CONT..
ROPE TURNING
Tie rope to the door handle.
Hold rope in hand of operated side,
Back from door until arm is extended away from
body, parallel to floor.
Swing rope to make a circle as wide as possible.
40. CONT..
ROD OR BROOMSTICK LIFTING
Grasp a rod with both hands, held about 2 feet
apart.
Keeping the arm straight, raise the rod over the
head.
Bend elbows to lower the rod behind the head.
Reverse maneuver, raising the rod above the
head, then return to the starting position.
41. CONT..
PULLEY TUGGING
Toss a light rope over curtain rod.
Hold the ends of the rope in each hand.
Slowly raise operated arm as comfortable by pulling
down the rope on opposite side.
Reverse raise the unoperated arm by lowering the
operated side.
Instead of rope towel can be used as it is used to
clean the back of our body.
42. CONT..
ELBOW CIRCLES
While on sitting or standing position. Put your
right hand on right shoulder and left hand on
left shoulder.
Raise the elbows until you feel a stretch and
make circles with the elbows.
Start with small then make longer circles.
Change directions of circles and repeat 2 – 3
times.
