Breast cancer
Breast cancer: Excerpt from Handbook of Diseases
Breast cancer is the most common cancer affecting women and is the number two killer (after lung cancer) of women ages 35 to 54. It occurs in men, though only rarely. (See Breast cancer in men.) The overall breast cancer death rate for American women has fallen. Lymph node involvement is the most valuable prognostic predictor. With adjuvant therapy, 70% to 75% of women with negative nodes will survive 10 years or more, compared with 20% to 25% of women with positive nodes.
Although breast cancer may develop anytime after puberty, it’s most common after age 50.
Causes
The cause of breast cancer is unknown, but its high incidence in women implicates estrogen. Certain predisposing factors are clear; women at high risk include those who:
❑ have a family history of breast cancer
❑ have long menses; began menses early or menopause late
❑ have never been pregnant
❑ were first pregnant after age 31
❑ have had unilateral breast cancer
❑ have had endometrial or ovarian cancer
❑ have been exposed to low-level ionizing radiation.
Many other predisposing factors have been investigated, including estrogen therapy, antihypertensives, high-fat diet, obesity, and fibrocystic disease of the breasts.
Women at lower risk include those who:
❑ were pregnant before age 20
❑ have had multiple pregnancies
❑ are Indian or Asian.
Pathophysiology
Breast cancer is more common in the left breast than in the right and more common in the upper outer quadrant. Growth rates vary. Theoretically, slow-growing breast cancer may take up to 8 years to become palpable at 1 cm in size. It spreads by way of the lymphatic system and the bloodstream, through the right side of the heart to the lungs and, eventually, to the other breast, the chest wall, liver, bone, and brain.
Many refer to the estimated growth rate of breast cancer as doubling time, or the time it takes the malignant cells to double in number. Survival time for breast cancer is based on tumor size and spread; the number of involved nodes is the single most important factor in predicting survival time.
Classified by histologic appearance and location of the lesion, breast cancer may be:
❑ adenocarcinoma — arising from the epithelium
❑ intraductal — developing within the ducts (includes Paget’s disease)
❑ infiltrating — occurring in parenchymatous tissue of the breast
❑ inflammatory (rare) — reflecting rapid tumor growth, in which the overlying skin becomes edematous, inflamed, and indurated
❑ lobular carcinoma in situ — reflecting tumor growth involving lobes of glandular tissue
❑ medullary or circumscribed — a large tumor with a rapid growth rate.
Signs and symptoms
Warning signals of breast cancer include:
❑ a lump or mass in the breast (a hard, stony mass is usually malignant)
❑ a change in symmetry or size of the breast
❑ a change in breast skin (thickening, scaly skin around the nipple, dimpling, edema [peau d’orange], or ulceration)
❑ a change in skin temperature (a warm, hot, or pink area; suspect cancer in a non-breast-feeding woman past childbearing age until proven otherwise)
❑ unusual drainage or discharge (a spontaneous discharge of any kind in a non-breast-feeding woman warrants thorough investigation; so does any discharge produced by breast manipulation [greenish black, white, creamy, serous, or bloody]). If a breast-feeding infant rejects one breast, this may suggest possible breast cancer.
❑ a change in the nipple, such as itching, burning, erosion, or retraction
❑ pain (not usually a symptom of breast cancer unless the tumor is advanced, but it should be investigated)
❑ bone metastasis, pathologic bone fractures, and hypercalcemia
❑ edema of the arm.
Diagnosis
Diagnostic measures for breast cancer include the following.
Breast self-examination
Although not proven to lower mortality rates, breast self-examination may detect palpable breast lumps, allowing the woman to contact her physician for early evaluation.
Mammography and biopsies
Other diagnostic measures include mammography, a needle biopsy, and a surgical biopsy. Mammography is indicated for any woman whose physical examination might suggest breast cancer. It should be done as a baseline on women ages 35 to 39, every 1 to 2 years for women ages 40 to 49, and annually for women older than age 50, women who have a family history of breast cancer, and women who have had unilateral breast cancer, to check for new disease. However, the value of mammography is questionable for women younger than age 35 (because of the density of the breasts), except those who are strongly suspected of having breast cancer.
False-negative results can occur in as many as 30% of all tests. Consequently, with a suspicious mass, a normal mammogram result should be disregarded, and a fine-needle aspiration or surgical biopsy should be done. Ultrasonography, which can distinguish a fluid-filled cyst from a tumor, can also be used instead of an invasive surgical biopsy.
Other tests
Bone scan, computed tomography scan, measurement of alkaline phosphatase levels, liver function studies, and a liver biopsy can detect distant metastasis. A hormonal receptor assay done on the tumor can determine if the tumor is estrogen- or progesterone-dependent. (This test guides decisions to use therapy that blocks the action of the estrogen hormone that supports tumor growth.)
Treatment
Much controversy exists over breast cancer treatments. In choosing therapy, the patient and physician should consider the stage of the disease, the woman’s age and menopausal status, and the disfiguring effects of the surgery. Treatment for breast cancer may include one or any combination of the following.
Surgery
With breast cancer, surgery involves either lumpectomy or mastectomy. A lumpectomy may be done on an outpatient basis and may be the only surgery needed, especially if the tumor is small and there’s no evidence of axillary node involvement. Radiation therapy is often combined with this surgery.
A two-stage procedure, in which the surgeon removes the lump, confirms that it’s malignant, and discusses treatment options with the patient, is desirable because it allows the patient to participate in her treatment plan. Sometimes, if the tumor is diagnosed as malignant, such planning can be done before surgery. In lumpectomy and dissection of the axillary lymph nodes, the tumor and the axillary lymph nodes are removed, leaving the breast intact.
A simple mastectomy removes the breast but not the lymph nodes or pectoral muscles. A modified radical mastectomy removes the breast and the axillary lymph nodes. A radical mastectomy, the performance of which has declined, removes the breast, the pectoralis major and minor, and the axillary lymph nodes.
After a mastectomy, reconstructive surgery can create a breast mound if the patient desires it and doesn’t have evidence of advanced disease.
Chemotherapy, tamoxifen, and peripheral
stem cell therapy
Various cytotoxic drug combinations are used as either adjuvant or primary therapy, depending on several factors, including staging and estrogen receptor status. The most commonly used antineoplastics are cyclophosphamide, fluorouracil, methotrexate, doxorubicin, vincristine, paclitaxel, and prednisone. A common drug combination used in both premenopausal and postmenopausal women is cyclophosphamide, methotrexate, and fluorouracil.
Tamoxifen, an estrogen antagonist, is the adjuvant treatment of choice for postmenopausal patients with positive estrogen receptor status.
Peripheral stem cell therapy may be used for patients with advanced breast cancer.
Primary radiation therapy
Used before or after tumor removal, primary radiation therapy is effective for small tumors in early stages with no evidence of distant metastasis; it’s also used to prevent or treat local recurrence. Presurgical radiation to the breast in patients with inflammatory breast cancer helps make tumors more surgically manageable.
Other drug therapy
Breast cancer patients may also receive estrogen, progesterone, androgen, or antiandrogen aminoglutethimide therapy. The success of these drug therapies with growing evidence that breast cancer is a systemic, not local, disease has led to a decline in ablative surgery.
Special considerations
To provide good care for a breast cancer patient, begin with a history; assess the patient’s feelings about her illness, and determine what she knows about it and what she expects. Be sure you know what kind of surgery is scheduled so you can prepare the patient. If a mastectomy is scheduled, in addition to the usual preoperative preparation (for example, skin preparations and allowing nothing by mouth), also perform the following:
❑ Teach the patient how to deep-breathe and cough to prevent pulmonary complications and how to rotate her ankles to prevent thromboembolism.
❑ Tell the patient she can ease her pain by lying on the affected side or by placing a hand or pillow on the incision. Show her where the incision will be. Inform her that she’ll receive pain medication and that she needn’t fear addiction.
❑ Explain to the patient that after mastectomy, an incisional drain or suction device (Hemovac) will be used to remove accumulated serous or sanguineous fluid and to keep the tension off the suture line, promoting healing.
For postoperative care, perform the following:
❑ Inspect the dressing anteriorly and posteriorly. Be alert for bleeding.
❑ Measure and record the amount and note the color of drainage. Expect drainage to be bloody during the first 4 hours and afterward to become serous.
❑ Check circulatory status (blood pressure, pulse rate, respirations, and bleeding).
❑ Monitor intake and output for at least 48 hours after general anesthesia.
❑ Encourage coughing and turn the patient every 2 hours to prevent comlications. (Positioning a small pillow under the patient’s arm provides comfort.)
❑ Encourage the patient to get out of bed as soon as possible (even as soon as the anesthesia wears off or the first evening after surgery).
❑ Prevent lymphedema of the arm, which may be an early complication of any breast cancer treatment that involves lymph node dissection. Help the patient prevent lymphedema by instructing her to exercise her hand and arm regularly and to avoid activities that might cause infection in this hand or arm (infection increases the chance of developing lymphedema). Such prevention is important because lymphedema can’t be treated effectively.
❑ Inspect the incision. Encourage the patient and her partner to look at her incision as soon as feasible, perhaps when the first dressing is removed.
❑ Advise the patient to ask her physician about reconstructive surgery or to call the local or state medical society for the names of plastic reconstructive surgeons who regularly perform surgery to create breast mounds. In many cases, reconstructive surgery may be planned before the mastectomy.
❑ Instruct the patient about breast prostheses. The American Cancer Society’s Reach to Recovery program can provide instruction, emotional support and counseling, and a list of area stores that sell prostheses.
❑ Provide psychological and emotional support. Many patients fear cancer and possible disfigurement and worry about loss of sexual function. Explain that breast surgery doesn’t interfere with sexual function and that the patient may resume sexual activity as soon as she desires after surgery.
Clinical tip Explain to the patient that she may experience “phantom breast syndrome” (a phenomenon in which a tingling or a pins-and-needles sensation is felt in the area of the amputated breast tissue) or depression following mastectomy. Listen to the patient’s concerns, offer support, and refer her to an appropriate organization, such as the American Cancer Society’s Reach to Recovery, which offers caring and sharing groups to help breast cancer patients in the facility and at home.
Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
More About Breast Cancer
More Medical Textbooks Online about Breast Cancer
Review other book chapters online related to Breast Cancer:
Medical Books Excerpts
- Peau d'orange
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Nipple Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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