Breast Cancer

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  1. Etiology
    • Heredity or genetically related susceptibility
    • Hormonal regulation of the breast related to the development of breast cancer
    • Sex hormones (estrogen and progesterone) may act as tumor promoters
  2. Risk factors
    • Being a woman (99% breast cancers occur in women)
    • Increasing Age
    • Women under 25 low risk
    • Increases gradually until the age of 60
    • Increases dramatically after 60
    • Early menarche, late menopause
    • Full term pregnancy after age 30
    • Nuliparity
    • Increased Alcohol consumption
    • Decreased Physical Activity
  3. Modifiable Risk Factors
    • Weight gain during adulthood
    • Sedentary lifestyle
    • Dietary fat intake
    • Obesity
    • Alcohol intake
    • Environmental factors
    • Risk factors appear to be cumulative and interacting. Therefore the presence of other risk factors may greatly increase the overall risk, especially for those with a positive family history.
  4. Family history
    • Especially if the involved family member
    • Ovarian cancer
    • Premenopausal
    • Bilateral breast cancer
    • First degree relative (1.5-3 times)
  5. Use of combined hormonal replacement therapy
    • increases the risk
    • Larger more advanced case when diagnosed
    • Use of estrogen alone does not appear to increase the risk
  6. BRCA1 gene
    • chromosome 17 tumor suppressor gene inhibits tumor development when functioning normally
    • Women who have BRCA mutations (40-80% lifetime chance of developing breast cancer)
  7. BRCA2 gene
    Chromosome 11 similar risk of breast cancer
  8. Women with BRCA1 or BRCA2 mutations
    • Prophylactic bilateral oophorectomy (can decrease the risk of breast and ovarian cancer)
    • Prophylactic bilateral mastectomy(may reduce risk of breast cancer by 90%)
  9. Oophorectomy
    Remove the hormones that cause cancer
  10. Hereditary non-BRCA
    Breast cancer have a high risk of develpoing a 2nd primary cancer in the unaffected (contralateral) breast.
  11. Predisposing Risks in Men
    • States of hyperestrogenism
    • Family history of breast cancer
    • Radiation exposure
    • All men must check breast routinely
  12. Symptoms of breast cancer in men
    • Lumps
    • Any kind of nipple discharge
    • Redness
    • Inversion of the nipple
    • Loose/dangling skin on the breast
  13. Pathophysiology
    • Various types (histologic characteristics and growth patterns)
    • Epithelial lining of ducts (ductalcarcinoma)
    • Epithelium of the lobules (lobularcarcinoma)
    • In situ (within the duct)
    • Invasive (arising from the duct and invading through the wall of the duct)
    • Metastatic (bone, liver, lung, brain)
  14. Cancer growth
    slow to rapid
  15. Factors that affect prognosis
    • Tumor size
    • Axillary node involvement
    • Tumor differentiation
    • Estrogen and progesterone receptor status
    • HER-2 status (receptor that helps regulate cell growth)
    • Overexpressed in many patients with breast cancer
  16. Axillary node involvement
    The more nodes involved the worse the prognosis
  17. Typically occurs in what location
    Upper outer section of the breast because it contains the most glandular tissue
  18. Pagets Disease
    • (rare breast malignancy)
    • Can be confused with infection or dermatitis
    • - bc it is characterized by persistent lesions of the nipple and areola with or without a palpable mass
  19. Signs & Symptoms of Pagets Disease
    • Itching
    • Burning
    • Bloody discharge
    • Superficial erosion
    • Ulceration
  20. Treatment of Pagets Disease
    • Simple mastectomy
    • Modified radical mastectomy
  21. Inflammatory Breast Cancer
    • (most malignant form)
    • Aggressive and fast growing
    • High risk for metastasis
    • Peau d’orange
  22. Peau d’orange
    • orange peel like
    • due to the plugging of the dermal lymphatic
    • warm
    • red
  23. Treatment for Inflammatory Breast Cancer
    • Neoadjuvant chemotherapy (Before chemo)
    • Radiation
    • Surgery
    • Hormone therapy
    • Biologic therapy
  24. Breast Cancer
    • lump
    • mammographic abnormality
    • Hard
    • Irregularly shaped
    • Poorly delineated
    • Nonmobile
    • Nontender
  25. Abnormalities of the nipple due to cancer
    • Small percentage cause nipple discharge (clear or bloody)
    • nipple retraction
    • infiltration
    • induration
    • dimpling of the overlying skin (large cancers)
  26. Main complication is
    • Recurrence
    • local (skin and chest wall)
    • regional (lymph nodes)
    • Metastatic disease involves growth of colonies of cancerous breast cells
    • Primarily occurs through the lymphatics (axilla)

    Also the cancer can spread to other parts of the body without invading the auxillary nodes even when the primary breast tumor is small.
  27. Axillary lymph node status
    • (NB prognostic factor)
    • Axillary lymph node dissection
    • (4+ greatest risk of recurrence)
    • Lymphatic mapping
    • Sentinel lymph node dissection
    • (lymph nodes drain from the tumor site)
  28. Sentinel lymph node dissection
    • a blue dye is injected and the Dr. watches for which lymph nodes the dye goes to. Dr. removes blue nodes.
    • increased accuracy
  29. Estrogen and progesterone receptor status
    • (useful for treatment decisions)
    • protien in the body that are present on normal breast cells.
    • can bind to estrogen and progesterone, binding the cells with abnormal growth of cancer cells.
  30. Receptor – positive tumors
    • Histologic evidence of being well differentiated
    • Frequently have diploid DNA(determination of DNA content-Prognostic indicator)
    • Lower proliferative indices
    • Lower chance of recurrence
    • Frequently hormone dependent and responsive to hormonal therapy
  31. Receptor- negative tumors
    • Poorly differentiated histologically
    • Have a high incidence of aneuploidy (abnormally high or low DNA content)
    • High proliferative indices
    • Frequently recur
    • Usually unresponsive to hormonal therapy

    - Tend to be larger with a poorer prognosis
  32. Prognostic Indicator
    Percentage of tumor cells in the S phase ofthe cell cycle analysis of cell cycle phases
  33. HER-2
    • protien that in incoded over one of the genes
    • over expression of this receptor
    • (25-30 percent of metastatic breast cancers produce excessive)
    • high numbers associated with unusually aggressive tumor growth
    • assists in the selection and sequence of chemotherapy
  34. Staging
    • I-IV
    • Tumor size (T)
    • Nodal Involvement (N)
    • Presence of metastasis (M)
  35. Most common options for resectable breast cancer
    (tumors smaller than 4-5 cm)
    • Breast conservation therapy surgery with radiation therapy
    • Modified radical mastectomy with or without breast reconstruction
  36. SLND replaced ALND
    • (if no malignant cells found in their sentinel nodes)
    • decreases the lymphodema for the pt
    • Examination of lymph nodes
    • provide prognostic information
    • determine further treatment
    • (chemotherapy, hormone therapy or both)
  37. Lumpectomy
    • Removal of entire tumor
    • with a margin of normal surrounding tissue
    • Radiation therapy to the entire breast
    • Chemotherapy may be administered before radiation
  38. Contraindications to breast conservation therapy
    • Small breast size to small comparative to tumor
    • Masses and calcifications that are multifical (within the same quadrant)
    • Masses are multicentric (in more than one quadrant)
    • Diffuse calcifications in more than one quadrant
    • Central location of tumor near nipple
    • Contraindications to irradiation
  39. Breast Conservation Therapy
    • Goal of the combined treatment maximize benefits of both cancer treatment and cosmetic outcome while minimizing risks
    • - preserves the breast and nipple
  40. Breast Conservation Therapy
    Increased cost of surgery and radiationpossible side effects of radiation
  41. Modified Radical mastectomy
    • Removal of the breast and axillary lymph nodes
    • Option of breast reconstruction (immediately or delayed)
  42. Follow-up
    • Rest of her life at regular intervals
    • Every 6 months for 2 years than annually
    • Monthly BSE on both breast
    • breast and surgical site
    • Breast imaging done at regular intervals (6 months to 1 year)
  43. Lymphedema
    • Accumulation of lymph in the soft tissues (when the axillary nodes cannot return lymph fluid to the central circulation, fluid accumulates in the arm, causing obstructive pressure on veins and veinous return)
    • happens after excision or irradiation of the lymph nodes
    • - can always be prevented but can not be controlled
  44. Lymphedema S&S
    • pain
    • heaviness impaired motor function in the affected arm
    • numbness and paresthesia of the fingers
  45. Postmastectomy Pain Syndrome (MastectomyAxillary node dissection)
    • chest and upper arm pain
    • tingling down arms
    • numbness
    • shooting or pricing pain
    • unbearable itching
    • Most common theory Injury to the intercostobrachial nerves
  46. Treatment for postmastectomy pain syndrome
    • Nonsteroidal antiinflammatory drugs (NSAIDS, ibeprophen)
    • Antidepressants (chronic pain [tryceclopin])
    • Topical lidocaine patches
    • Antiseizure drugs (neurontin - peripheral pain)
    • Imagery
    • Biofeedback
    • Physical therapy (prevent frozen shoulder syndrome)
    • Psychologic counseling
  47. Adjuvant Therapy
    • Local radiation therapy
    • Chemotherapy
    • Hormonal therapies
    • Biologic therapies
  48. Treatment therapy of cancer depends on...
    • Stage of the disease (# of involved nodes and tumor size)
    • Cancer cell characteristics
    • Presence or absence of (estrogen, progesterone and HER-2 receptors)
    • Menstrual status
    • Health (general)
    • Age
  49. Primary Radiation Therapy
    • (5 days per week over the course of 5 to 6 weeks)
    • (a “boost” 8 more treatments)
  50. High-Dose Brachytherapy
    • (internal radiation)
    • Multicatheter implant
    • Balloon catheter (insert radioactive seeds)
    • 1-5 day period
  51. Palliative Radiation
    • in late stage metastic cancer
    • helps to control pain
  52. Hormonal Therapy
    • 1. blocks snd destroys the estrogen receptor
    • 2. supress estrogen synthesis through inhibiting aromatase (an enzyme needed for endogenous estrogen synthesis)
    • May be used as an adjuvant to primary treatment or in pts with recurrent or metastic cancer.
    • Tomoxicin can be given to those who are at risk of getting cancer.
  53. Biologic and Targeted Therapy
    • antibody to HER-2 (tumors that overexpress HER-2)
    • - attaches to antigen, it is taken into the cells and kills it.
  54. Culturally Competent CareCultural values strongly influence how women respond tocope with Breast cancer and treatment
    • Cultural values strongly influence how women
    • respond to
    • cope with
    • Breast cancer and treatment
  55. Mammoplasty
    • (cosmetic and reconstruct)
    • Breast reconstruction
    • - simultaneously
    • - afterward
  56. Mammoplasty Advantage of immediate reconstruction
    • one surgery
    • one anesthesia
    • one recovery period before the development of scar tissue or adhesions
  57. Indications for breast reconstruction therapy
    • Improve self image
    • Regain a sense of normalcy
    • Assist in coping with the loss of a breast
  58. Types of Reconstruction
    • Breast Implants and Tissue Expansion
    • Musculocutaneous Flap Procedure (tran flap - take some abdominal muscle to reconstruct the breast)
    • Nipple-Areolar Reconstruction
  59. Health History
    • – Benign breast disease, menstrual history, pregnancy history, cancers, BSE
    • – Use of hormones
    • – Exposure to radiation
    • – Family history
    • – Alcohol use
    • – Obesity, anorexia, dietary habits
    • – Headache; back, arm, or bone pain
    • – Nipple discharge, change in size or symmetry of breast
    • – Chronic psychologic stress, anxiety threatening self-esteem
  60. Objective Data
    • – Axillary and supraclavicular lymphadenopathy
    • – Firm nodules at mastectomy site, peripheral edema
    • – Hepatomegaly (enlarged liver), jaundice, ascites
    • Hard, irregular, nonmobile breast lump; nipple inversion or retraction
    • Positive mammography or ultrasonography results
    • Positive results of biopsy
  61. Planning
    • Actively participate in decision-making process related to treatment options
    • Fully comply with therapeutic plan
    • Manage side effects of adjuvant therapy
    • Supported to access and benifit from the support provided by significant others and HCP
  62. Acute Intervention
    • – Assess body language, motor activity, and affect during periods of high stress and indecision
    • – Provide patient with sufficient information on planned surgery
  63. Preoperative teaching
    • • Turn, cough, breathe deep
    • • Post-op exercises
    • • Pain management plan
    • • Explanation of recovery period
  64. Postop excercises to help prevent lymphedema
    • – Use of semi-Fowler’s position with arm on affected side elevated on a pillow post-op
    • – Flexing and extending fingers and/or arm exercises beginning in recovery room
    • – Administration of analgesics to minimize post-op pain and allow for exercise
    • – Procedures should not be done on affected side
    • - NO BP
    • - Protect from infection! Lymph drainage is altered.
  65. Psychologic care for breast cancer pts
    • • Assist in developing positive but realistic attitude
    • • Help identify sources of support
    • • Encourage verbalization of anger and fears
  66. Ambulatory and Home Care
    • – Emphasize importance of BSE and annual mammography
    • – Refer to mental health provider for support and coping needs
  67. Evaluate Goals
    • – Indication of beginning of resolution of negative feelings toward self
    • – Acceptance of altered body image
    • – Able to change dressings with minimal assistance
    • – Practice monthly BSE
  68. Immediately report symptoms after surgery
    • • Fever
    • • Inflammation at surgical site
    • • Erythema
    • • Constipation
    • • Unusual swelling
  69. Report changes after discharge
    • • New back pain
    • • Weakness
    • • SOB
    • • Confusion
    • Stress importance of wearing well-fitting prosthesis
  70. Goals
    • • Absence of or tolerable level of pain
    • • Satisfaction with pain control
    • • Verbalization of fear
    • • Support from others
    • • Early recognition of recurrent or metastic disease
    • • Return to usual arm and shoulder function
    • • Monitor for signs of lymphedema
    • • Report deviations from normal parameters
Card Set
Breast Cancer
Breast Cancer (Test 5)
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