Breast cancer
Breast cancer: Excerpt from Professional Guide to Diseases (Eighth Edition)
Breast cancer occurs more commonly in the left breast than the right and more commonly in the outer upper quadrant. Growth rates vary. Theoretically, slow-growing breast cancer may take up to 8 years to become palpable at 1 cm. 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.
The estimated growth rate of breast cancer is referred to 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.
Breast cancer is classified by histologic appearance and location of the lesion, as follows:
❑adenocarcinoma — arising from the epithelium
❑intraductal — developing within the ducts (includes Paget's disease)
❑infiltrating — occurring in parenchyma 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 — large tumor with rapid growth rate.
These histologic classifications should be coupled with a staging or nodal status classification system for a clearer understanding of the extent of the cancer. The most commonly used system for staging cancer, both before and after surgery, is the TNM staging (tumor size, nodal involvement, metastatic progress) system. (See Staging breast cancer.)
Causes and incidence
The cause of breast cancer isn't known, 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, particularly first-degree relatives (mother, sister, and maternal aunt).
Other women at high risk include those who:
❑have long menstrual cycles or began menses early (before age 12) or menopause late (after age 55)
❑have taken hormonal contraceptives
❑used hormone replacement therapy for more than 5 years
❑who took diethylstilbestrol to prevent miscarriage
❑have never been pregnant
❑were first pregnant after age 30
❑have had unilateral breast cancer
❑have had ovarian cancer — particularly at a young age
❑were exposed to low-level ionizing radiation.
Recently, scientists have discovered the BRCA1 and BRCA2 genes. Mutations in these genes are thought to be responsible for less than 10% of breast cancers. However, these discoveries have made genetic predisposition testing an option for women at high risk for breast cancer.
Women at lower risk include those who:
❑were pregnant before age 20
❑have had multiple pregnancies
❑are Native American or Asian.
Most breast cancer deaths occur in women age 50 and older (84% of cases), and 77% of new breast cancer cases occur in this age-group. However, it may develop any time after puberty. It occurs in men, but rarely; male cases of breast cancer account for less than 1% of all cases.
The 5-year survival rate for localized breast cancer has improved because of earlier diagnosis and the variety of treatments now available. According to the most recent data, mortality rates continue to decline in White women and, for the first time, are also declining in younger Black women. 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.
Signs and symptoms
Warning signals of possible breast cancer include:
❑a lump or mass in the breast (a hard, stony mass is usually malignant)
❑ change in symmetry or size of the breast
❑ change in skin, thickening, scaly skin around the nipple, dimpling, edema (peau d'orange), or ulceration
❑ change in skin temperature (a warm, hot, or pink area; suspect cancer in a nonlactating woman older than childbearing age until proven otherwise)
❑ unusual drainage or discharge (a spontaneous discharge of any kind in a nonbreast-feeding, nonlactating woman warrants thorough investigation; so does any discharge produced by breast manipulation (greenish black, white, creamy, serous, or bloody.) (If a breast-fed infant rejects one breast, this may suggest possible breast cancer.)
❑ 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
The most reliable method of detecting breast cancer is the clinical breast examination, followed by immediate evaluation of any abnormality. Other diagnostic measures include mammography, ultrasound, needle biopsy, and surgical biopsy. Mammography is indicated for any woman whose physical examination suggests breast cancer. It should be done as a baseline on women between ages 35 and 39 and annually on all women older than age 40, on those who have a family history of breast cancer, and on those who have had unilateral breast cancer (to check for new disease).
ELDER TIP Unfortunately, many older women don't receive regular mammograms, even when recommended by health care professionals, either because they fear radiation, discovering cancer, or discomfort during the procedure or because they're embarrassed about exposing their breasts.
The value of mammography is questionable for women under age 35 (because of the density of the breasts), except for those women 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 negative mammogram 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.
Bone scan, brain scan, computed tomography scan, measurement of alkaline phosphatase levels, liver function studies, and liver biopsy can detect distant metastases. 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 take into consideration the stage of the disease, the woman's age and menopausal status, and the disfiguring effects of the surgery. Treatment of breast cancer may include one or any combination of the following:
❑Surgery involves either mastectomy or lumpectomy. 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. In many cases, radiation therapy is combined with this surgery.
A two-stage procedure, in which the surgeon removes the lump and confirms that it's malignant and then discusses treatment options with the patient, is desirable because it allows the patient to participate in her plan of treatment. Sometimes, if the tumor is diagnosed as clinically 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. Modified radical mastectomy removes the breast and the axillary lymph nodes. Radical mastectomy, the performance of which has declined, removes the breast, pectoralis major and minor, and the axillary lymph nodes.
The spread of breast cancer to regional lymph nodes is considered a vital prognostic indicator. Sentinel lymph-node biopsy, a reliable and minimally invasive procedure, is used to identify and sample the sentinel lymph node closest to the breast tumor. During the patient's surgery, the axillary node is injected with dye to help with identification and then sent to the pathologist to assess for cancer spread. If the node is negative, the patient can be spared an axillary node dissection, which carries its own risks and the potential for long-term complications .
Reconstructive breast surgery can be performed at the same time as mastectomy or it can be planned for a later date. Several options are available for breast reconstruction, including the insertion of breast implants or a transverse rectus abdominis musculocutaneous flap.
❑Chemotherapy, involving various cytotoxic drug combinations, is used as either adjuvant or primary therapy, depending on several factors, including the TNM staging and estrogen receptor status. The most commonly used antineoplastic drugs are cyclophosphamide, fluorouracil, methotrexate, doxorubicin, vincristine, and paclitaxel. A common drug combination used in both premenopausal and postmenopausal women is cyclophosphamide, doxorubicin, and paclitaxel.
Tamoxifen, an estrogen antagonist, is the adjuvant treatment of choice for postmenopausal patients with positive estrogen receptor status. It's also been found to reduce the risk of breast cancer in women at high risk.
❑ Peripheral stem cell therapy is an option, but it's rarely used for advanced breast cancer.
❑ Primary radiation therapy before or after tumor removal 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 inflammatory breast cancer helps make tumors more surgically manageable.
❑ Estrogen, progesterone, androgen, or antiandrogen aminoglutethimide therapy may also be given to breast cancer patients. The success of these drug therapies — along 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 patient with breast cancer, begin with a history, assess the patient's feelings about her illness, and determine what she knows about it and what she expects. Preoperatively, make sure you know what kind of surgery is scheduled, so you can prepare her properly. If a mastectomy is scheduled, in addition to the usual preoperative preparation (for example, skin preparations and not allowing the patient anything by mouth), provide the following information:
❑Teach her how to deep-breathe and cough to prevent pulmonary complications and how to rotate her ankles to help prevent thromboembolism.
❑Tell her she can ease her pain by lying on the affected side or by placing a hand or pillow on the incision. Preoperatively, show her where the incision will be. Inform her that she'll receive pain medication and that she need not fear addiction. Remember, adequate pain relief encourages coughing and turning and promotes general well-being. Positioning a small pillow anteriorly under the patient's arm provides comfort.
❑Encourage her to get out of bed as soon as possible (even as soon as the anesthesia wears off or the first evening after surgery).
❑Explain that, after mastectomy, an incisional drain or suction device will be used to remove accumulated serous or sanguineous fluid, thereby promoting healing.
Postoperative care:
❑Inspect the dressing anteriorly and posteriorly, reporting bleeding promptly.
❑Measure and record the amount of drainage; also note the color. Expect drainage to be bloody during the first 4 hours and afterward to become serous.
❑Check circulatory status (blood pressure, pulse, respirations, and bleeding).
❑Monitor intake and output for at least 48 hours after general anesthesia.
❑Prevent lymphedema of the arm, which may be an eventual complication of any breast cancer treatment that involves lymph node manipulation. Help the patient prevent lymphedema by instructing her to exercise her hand and arm regularly and to avoid activities that might cause infection or impairment in this hand or arm, which increases the chance of developing lymphedema. (See Postoperative arm and hand care.)
❑Inform the patient to not let anyone draw blood, start an I.V., give an injection, or take a blood pressure on the affected side because these activities will also increase the chances of developing lymphedema.
❑Inspect the incision. Encourage the patient and her partner to look at her incision as soon as possible, 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 group can provide instruction, emotional support and counseling, and a list of area stores that sell prostheses.
❑Give psychological and emotional support. Most 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.
❑Also 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 hospital and at home.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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