Copyright © 2008 Lippincott Williams & Wilkins. 1 Breast Disorders

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Copyright © 2008 Lippincott Williams & Wilkins.

Breast Disorders

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Breast Disorders• Overview of anatomy of the breast

• Cultural and psychosocial considerations

• Breast cancer is a major health problem

• In the U.S., more than 215,000 women and 1,450 men develop breast cancer annually, and more than 40,000 die

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Anatomy of the Breast

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Assessment

• Health history• Physical assessment

– Inspection– Palpation

• Upright and supine• Axillary and clavicular areas as well as breasts

– The male breast• Inspection, and palpation of axillae• Assess for gynecomastia

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Guidelines for Early Detection of Breast Cancer

• Women in their 20s and 30s: clinical breast exam at least every 3 years, then preferably annually after age 40

• Mammography annually beginning at age 40

• Women at increased risk may have earlier initial screening, shorter screening intervals, or additional screening procedures such as ultrasound and MRI

• Teach women in their 20s the benefits and limitations of breast self-examination (BSE)

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Breast Self-Examination• Provide instruction to women regarding BSE

• Instructions should be provided to men if there is a family history of breast cancer

• Encourage BSE but do not overemphasize it

• Instructional materials can be obtained from the American Cancer Society and The National Cancer Institute

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Lymph Nodes

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Teaching Breast Self-Examination

• Best performed days 5 to 7 days after first day of menses or once monthly for postmenopausal women

• Review the feel of normal breast tissue and ways or identify changes

• Routine BSE helps patients become familiar with their own “normal abnormalities”

• Demonstrate the examination technique• Encourage the patient to perform a BSE

demonstration on herself or on a breast model

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Breast Self-Examination• Stand in front of a

mirror

• Check both breasts for anything unusual

• Look for discharge from the nipple and puckering, dimpling, or scaling of the skin

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Breast Self-Examination (cont.)• Watch closely in the

mirror as you clasp your hands, bend your head, and press your hands forward

• Note any change in the contour or your breasts

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Breast Self-Examination (cont.)• Next, press your hands

firmly on your hips and bow slightly toward the mirror as you pull your shoulders and elbows forward

• Note any change in the contour of your breasts

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Breast Self-Examination (cont.)• Raise your left arm; using

2 or 3 fingers, feel your left breast carefully and thoroughly

• Beginning at the outer edge, press the flat part of your fingers in small circles, moving the circles slowly around the breast

• Gradually work toward the nipple

• Cover the whole breast

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Breast Self-Examination (cont.)• Feel for any lumps or

masses.• Repeat on the right breast;

step 4 should be repeated lying down

• Lie flat on your back with your left arm over you head and a pillow or folded towel under the left shoulder

• Use the same circular motion

• Repeat on the right breast

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Teaching Breast Self-Examination

• Part of the examination may be done in the shower with soapy hands to glide over the breast and focus on underlying tissue

• Note the importance of including the area between the breast and underarm, and the underarm itself

• Discuss reporting of any changes

• Describe the goals, methods of instruction, and methods of evaluation for a teaching plan for BSE

• List resources for information and materials

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Diagnostic Tests• Mammography

– Yearly starting at 40; earlier for high-risk women– Certified facility

• Galactography– Dye injected into ductal opening followed by

mammogram

• Ultrasonography– Helps to distinguish fluid-filled cysts from other lesions– Good for dense breasts

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Diagnostic tests

• Magnetic resonance imaging (MRI)– Highly sensitive– Most useful with proven breast cancer to assess

extent; also detects occult breast cancer

• Biopsies– Percutaneous: fine-needle aspiration and core

biopsies– Surgical biopsies

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Mammography

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Conditions affecting the nipple• Nipple discharge

– May be r/t many causes, including carcinoma, papilloma, pituatary adenoma, cystic breasts, medications (including OCP)

– May be normal with expression– Warrants investigation if green, malodorous, persistent,

spontaneous, bloody, unilateral• Evaluated via galactogram or biopsy

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Benign Conditions of the Breast

• Mastitis– Inflammation or infection of breast tissue-

usually breast feeding women– Dull to severe pain in affected area,

possilbe purulent discharge– Treatment is antibiotics and cold

compresses

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Benign conditions of the breast

• Cysts– Fluid filled sacs that develop as breast ducts

dilate; estrogen thought to play a role– Age 30-50– Cysts usually left alone once they are confirmed

nonmalignant

• Fibroadenomas– Firm, movable benign tumors– Nontender, sometimes removed to r/o malignancy

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Benign conditions of the breast

• Fibrocystic changes– Characterized by excessive fibrous tissue,

hyperplasia of the ductal epithelial lining, and cyst formation

• Results in pain and nerve irritation• Influenced by hormones

– Manifests as numerous palpable lumps - round, well delineated, movable; may be tender

– Lumps change size with hormone changes

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Breast cancer• Lifetime risk for women: 1 in 8; most diagnosed

after 50• Types

– Ductal carcinoma in situ– Invasive breast cancer

• Infiltrating ductal carcinoma (75%)• Infiltrating lobular carcinoma (5%)• Medullary carcinoma• Mucinous carcinoma• Tubular ductal carcinoma• Inflammatory carcinoma• Paget disease

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Risk Factors for Breast Cancer

• Female gender• Increasing age• Personal and family history including genetic mutations

– BRCA 1 and 2– 5-10%

• Hormonal factors (nullparity, 1st child>30, HT)• Exposure to radiation• History of benign proliferative breast disease• Obesity• High-fat diet (controversial)• Alcohol intake• ?Smoking

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Protective factors - breast cancer

• Regular exercise

• Breastfeeding

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Prevention in the high risk patient

• Long term surveillence

• Chemoprevention

• Prophylactic mastectomy

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Clinical manifestions of breast cancer

• Most often found in the upper outer quadrant

• Lesions are nontender, fixed, hard with irregular borders

• Advanced signs may include skin dimpling, nipple retraction, skin ulceration, peau d’orange QuickTime™ and a

decompressorare needed to see this picture.

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Prognosis for breast cancer

• Most dependent on tumor size and whether it has spread to the lymph nodes– The smaller the tumor, the better prognosis– Most common route of regional spread is axillary

lymph nodes; distant metastasis can affect any organ system

– 5 year survival by staging (0-4)• I - 98%• IIIA - 56%• IV - 16%

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Surgical Management—Breast Cancer

• Breast conservation treatment

– Removal of entire tumor

• Total mastectomy

– Removal of breasts, pectoral muscles, axillary lymph nodes, fat/adjacent tisue

• Modified radical mastectomy

– Remove breast and axillary nodes

• Sentinel node biopsy and axillary lymph node dissection

• Breast reconstruction surgery

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Breast Reconstruction With Tissue Expander

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Breast Reconstruction With TRAM

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Breast Reconstruction—Latissimus Dorsi Flap

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Adjuvant Nonsurgical Management of Breast Cancer

• Radiation therapy: external beam (weeks) , brachytherapy (days)

• Chemotherapy• Hormonal therapy

– Estrogen and progesterone receptor assay

– Selective estrogen receptor modulators (SERMs): tamoxifen

– Aromatase inhibitors: anastrozole, letrozole, and exemestane

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Nursing Process—Assessment of the Patient Undergoing Breast

Cancer Surgery• How is the patient responding to her diagnosis?

• What coping mechanisms does she find helpful?

• What psychological or emotional supports does she have and use?

• Is there a partner, family member, or friend available to assist in making treatment choices?

• What are her educational needs?

• Is she experiencing any discomfort?

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Nursing Process—Preoperative Diagnosis of the Patient

Undergoing Breast Cancer Surgery

• Deficient knowledge

• Anxiety

• Fear

• Risk for ineffective coping

• Decisional conflict

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Nursing Process—Postoperative Diagnosis of the Patient

Undergoing Breast Cancer Surgery• Pain

• Disturbed sensory perception

• Disturbed body image

• Self-care deficit

• Risk for sexual dysfunction

• Deficient knowledge

– Drain management

– Arm exercises

– Hand and arm care

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Collaborative Problems/Potential Complications

• Lymphedema (10-30%)

– Results if functioning lymphatic channels are inadequate to ensure a return flow of lymph fluid to general circulation

– Different from transient edema

• Hematoma/seroma formation

– Collection of blood or fluid inside the cavity

• Infection

– Risk is higher in patients with immunosuppression

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QuickTime™ and a decompressor

are needed to see this picture.

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Nursing Process—Planning the Care of the Patient Undergoing

Breast Cancer Surgery• Major goals may include:

– Increased knowledge about the disease and its treatment

– Reduction of preoperative and postoperative fear, anxiety, and emotional stress

– Improvement of decision-making ability and improvement of coping skills

– Improvement in sexual function

– Absence of complications

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Preoperative Interventions• Review and reinforce information on treatment options

• Prepare patient regarding what to expect before, during, and after surgery

• Inform patient regarding surgical drain, arm and shoulder mobility, and range-of-motion exercises

• Maintain open communications

• Provide patient with realistic expectations

• Support coping

• Involve or provide information for supportive services and resources

• Support patient decisions

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Postoperative Interventions• Monitoring and managing postoperative complications

– Lymphedema, hematoma, infection, as well as general complications related to surgery

• Inform patient regarding common postoperative sensations• Pain management• Promoting a positive body image

– Provide bra with breast form

• Support coping and adjustment• Provide counseling and referral • See NCP 52-1

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Hand and Arm Care• Potential for lymphedema formation after axilliary lymph node

dissection (ALND)

• Patient education

• Prevention is vital; follow guidelines for the rest of life

• No blood pressure, injections, or blood draws in the affected arm

• Perform exercises 3X a day for 20 minutes to increase circulation and muscle strength, prevent stiffness and contractures, and restore ROM

• A mild analgesic or a warm shower may be helpful prior to exercise

• Initial limitation of lifting (over 5 to 10 lbs) and activity

• Prevention of ANY injury and infection

• May require elastic sleeve

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Exercises After Breast SurgeryWall climbing

Rope turning

Rod liftingPulley tugging

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Drain Management

• May need home care referral to assist with drain management

• Drains are usually removed when drainage is less than 30 mL in a 24-hour period; usually occurs in 7 to 10 days

• Drain site and incision care

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Teaching self-care

• Report symptoms/signs - infection, swelling, hematoma,

• Drain management• Incision care

– Usually can shower and wash incision site after day 2

– May have to wait until drain is removed if present– Incision should heal after 4-6 weeks– ROM exercises until full ROM is restored (4-6 wks)

• Follow up care

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Quality of life and survivorship• Long term survivors have difficulty with issues

pertaining to sexuality and menopausal symptoms– Estrogen withdrawal from chemo-induced menopause

and hromonal treatments may lead to severe symptoms– Hormone therapy is contraindicated– Chemotherapeutic agents may cause impaired cognitive

functioning and cardiac side effects– Long term effects of radiation may include pneumonitis– Psychological sequelae

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Diseases of the Male Breast

• <1% of all breast cancers; average age 67 years

• Early detection is rare due to rarity of the disease

• Signs may include painless lump beneath the areola, nipple retraction, bloody discharge, or skin ulceration

• Total mastectomy is indicated, with possible adjuvant chemotherapy and radiation

Documents

Copyright © 2008 Lippincott Williams & Wilkins. 1 Breast Disorders