 OVERVIEW

As in all forms of cancer, breast cancer is made of abnormal cells that have grown
uncontrollably. Those cells may also travel to places in our body where they aren’t normally found.
When that happens, the cancer is called metastatic. Breast cancer usually begins in a small,
confined area in the or glands, which produce milk (lobular carcinoma) or the ducts (ductal
carcinoma), which carry it to the nipple. Men can get breast cancer, too, but they account for less
than 1% of all breast cancer cases. Among women, breast cancer is the second most common
cancer diagnosed after skin cancer and the second leading cause of cancer deaths after lung
cancer.On average, 1 in 8 women will develop breast cancer in her lifetime. About two-thirds of
women with breast cancer are 55 or older. Most of the rest are between 35 and 54.
Advances in screening and treatment for breast cancer have improved survival rates
dramatically since 1989. According to the American Cancer Society (ACS), there are more
than 3.1 million breast cancer survivors in the United States. The chance of any woman dying
from breast cancer is around 1 in 38 (2.6%). The ACS estimate that 268,600 women will receive
a diagnosis of invasive breast cancer, and 62,930 people will receive a diagnosis of noninvasive
cancer in 2019. In the same year, the ACS report that 41,760 women will die as a result of breast
cancer. However, due to advances in treatment, death rates from breast cancer have been
decreasing since 1989. Awareness of the symptoms and the need for screening are important
ways of reducing the risk. In rare instances, breast cancer can also affect men.

 EPIDEMIOLOGY

Worldwide

 According to WHO, it is the most common cancer in women both in the developed
and less developed world.
 It is estimated that worldwide over 508 000 women died in 2011 due to breast cancer
(Global Health Estimates, WHO 2013).
 Each year, 40,000 women die of breast cancer
 It is the second-leading cause of cancer deaths among women after lung cancer.
 The lifetime risk of dying of breast cancer is approximately 3.4%.
Philippines
 According to statistics from the World Health Organization, in 2014, 18,327 new cases of
breast cancer were newly enlarged in the Philippines, the mortality rate ranked first
with 7728 dead cases.
 Top causes of death among women in the Philippines (according to Philippine Statistics
Authority PSA and DOH- Feb. 2018)
 Philippines had the highest prevalence of breast cancer among 197 countries (February
2017, Philippine Obstetrical and Gynecological Society)
 Three out of 100 Filipino women will develop breast cancer in their lifetime.
MANIFESTATION

History
1. Just being a women
 Just being a woman is the biggest risk factor for developing breast cancer.
 Bbiggest reasons for the difference in breast cancer rates between men and women are:

 Women's breast development takes 3 to 4 years and is usually complete by age 14.
It's uncommon for men's breasts to fully form -- most of the male breasts you see
are fat, not formed glands.
 Once fully formed, breast cells are very immature and highly active until a woman's
first full-term pregnancy. While they are immature, a women's breast cells are very
responsive to estrogen and other hormones, including hormone disrupters in the
environment.
 Men's breast cells are inactive and most men have extremely low levels of estrogen.

2. Family History

 Women with close relatives who've been diagnosed with breast cancer have a higher risk of
developing the disease.

 If you've had one first-degree female relative (sister, mother, daughter) diagnosed with breast
cancer, your risk is doubled. If two first-degree relatives have been diagnosed, your risk is 5
times higher than average.

 If your brother or father have been diagnosed with breast cancer, your risk is higher, though
researchers aren't sure how much higher.

 a strong family history of breast cancer is linked to having an abnormal gene associated with
a high risk of breast cancer, such as the BRCA1 or BRCA2 gene.

3. Genetics

 About 5% to 10% of breast cancers are thought to be hereditary, caused by abnormal genes
passed from parent to child.
 Some DNA changes are harmless, but others can cause disease or other health issues. DNA
changes that negatively affect health are called mutations.
 You are substantially more likely to have a genetic mutation linked to breast cancer if:
 You have blood relatives (grandmothers, mother, sisters, aunts) on either your
mother's or father's side of the family who had breast cancer diagnosed before age
50.
  There is both breast and ovarian cancer on the same side of the family or in a single
individual.
 You have a relative(s) with triple-negative breast cancer.
 There are other cancers in your family in addition to breast, such as prostate,
melanoma, pancreatic, stomach, uterine, thyroid, colon, and/or sarcoma.
 Women in your family have had cancer in both breasts.
 You are of Ashkenazi Jewish (Eastern European) heritage.
 You are African American and have been diagnosed with breast cancer at age 35 or
younger.
 A man in your family has had breast cancer.
 There is a known abnormal breast cancer gene in your family.

4. Personal History of breast cancer

 If you've been diagnosed with breast cancer, you're 3 to 4 times more likely to develop a new
cancer in the other breast or a different part of the same breast. This risk is different from the
risk of the original cancer coming back (called risk of recurrence).
5. Race/Ethnicity
 White women are slightly more likely to develop breast cancer than African American,
Hispanic, and Asian women.
 But African American women are more likely to develop more aggressive, more advanced-
stage breast cancer that is diagnosed at a young age.
 African American women are also more likely to die from breast cancer.
6. Being overweight
 Overweight women have a higher risk of being diagnosed with breast cancer compared to
women who maintain a healthy weight. Women who started menstruating (having periods)
younger than age 12 have a higher risk of breast cancer later in life especially after
menopause.
 Being overweight also can increase the risk of the breast cancer coming back (recurrence)
in women who have had the disease.
7. Pregnancy History
 Women who haven't had a full-term pregnancy or have their first child after age 30 have a
higher risk of breast cancer compared to women who gave birth before age 30.
 Your first full-term pregnancy makes the breast cells fully mature and grow in a more regular
way. This is the main reason why pregnancy helps protect against breast cancer.
8. Breastfeeding History
 Breastfeeding can lower breast cancer risk, especially if a woman breastfeeds for longer than
1 year.
 Reasons why breastfeeding protects breast health:
  making milk 24/7 limits breast cells' ability to misbehave
 most women have fewer menstrual cycles when they're breastfeeding (added
to the 9 missed periods during pregnancy) resulting in lower estrogen levels
 many women tend to eat more nutritious foods and follow healthier lifestyles
(limit smoking and alcohol use) while breastfeeding

9. Menstrual History
 Women who started menstruating younger than age 12 have a higher risk of breast cancer
later in life.
 The same is true for women who go through menopause when they're older than 55.
 The earlier your breasts form, the sooner they're ready to interact with hormones inside and
outside your body, as well as with chemicals in products that are hormone disruptors. This
longer interaction with hormones and hormone disruptors can increase risk.
 The longer a woman menstruates, the higher her lifetime exposure to the hormones estrogen
and progesterone. All of these factors are associated with a higher risk of breast cancer later
in life.

10. Using hormone replacement therapy (HRT): Estrogen and Progesterone & Estrogen
only
 Current or recent past users of hormonal replacement therapy (HRT) have a higher risk of
being diagnosed with breast cancer.
 Breast cancer risk increases the most during the first 2 to 3 years of taking combination HRT.

11. Drinking alcohol

 Alcohol can increase levels of estrogen and other hormones associated with hormone-
receptor-positive breast cancer.
 Alcohol also may increase breast cancer risk by damaging DNA in cells.
 Compared to women who don't drink at all, women who have three alcoholic drinks per week
have a 15% higher risk of breast cancer
 Teen and tween girls aged 9 to 15 who drink three to five drinks a week have three times the
risk of developing benign breast lumps.

12. Lack of exercise

 Research shows a link between exercising regularly at a moderate or intense level for 4 to 7
hours per week and a lower risk of breast cancer.
 Fat cells make estrogen and extra fat cells make extra estrogen. When breast cells are
exposed to extra estrogen over time, the risk of developing breast cancer is higher.

13. Smoking
 It causes a number of diseases and is linked to a higher risk of breast cancer in younger,
premenopausal women.
 Smoking also can increase complications from breast cancer treatment, including:

 damage to the lungs from radiation therapy

 difficulty healing after surgery and breast reconstruction
 higher risk of blood clots when taking hormonal therapy medicines

14. Unhealthy Diet

 Girls who eat a high-fat diet during puberty, even if they don't become overweight or obese,
may have a higher risk of developing breast cancer later in life.

15. Dense Breast

 Dense breasts have less fatty tissue and more non-fatty tissue compared to breasts that
aren't dense.
 Dense breasts have more gland tissue that makes and drains milk and supportive tissue (also
called stroma) that surrounds the gland. Breast density can be inherited, so if your mother
has dense breasts, it's likely you will, too.
 Research has shown that dense breasts:

 can be twice as likely to develop cancer as nondense breasts

 can make it harder for mammograms to detect breast cancer; breast cancers (which
look white like breast gland tissue) are easier to see on a mammogram when they're
surrounded by fatty tissue (which looks dark)

16. Exposure to chemicals on sunscreen and cosmetics

 While chemicals can protect us from the sun's harmful ultraviolet rays, research strongly
suggests that at certain exposure levels, some of the chemicals in some sunscreen products
may cause cancer in people.
 Many of these chemicals are considered hormone disruptors. Hormone disruptors can affect
how estrogen and other hormones act in the body, by blocking them or mimicking them, which
throws off the body's hormonal balance.
 17. Low Vitamin D levels
 Vitamin D helps the body absorb calcium, which is essential for good bone health.
 Most vitamin D is made when an inactive form of the nutrient is activated in your skin when
it's exposed to sunlight.
 Research suggests that women with low levels of vitamin D have a higher risk of breast
cancer.
 Vitamin D may play a role in controlling normal breast cell growth and may be able to stop
breast cancer cells from growing.

18. Light exposure at night

 The results of several studies suggest that women who work at night -- factory workers,
doctors, nurses, and police officers, for example -- have a higher risk of breast cancer
compared to women who work during the day.

 Other research suggests that women who live in areas with high levels of external light at
night (street lights, for example) have a higher risk of breast cancer.

 Researchers think that this increase in risk is linked to melatonin levels. Melatonin is a
hormone that plays a role in regulating the body's sleep cycle. Melatonin production peaks at
night and is lower during the day when your eyes register light exposure. When women work
at night or if they're exposed to external light at night, their melatonin levels tend to stay low.
 PATHOPHYSIOLOGY

NON MODIFIABLE RISK MODIFIABLE RSIK

FACTORS: FACTORS:

AGE LIFESTYLE
GENDER DIET
GENETICS RADIATION EXPOSURE
FAMILY HISTORY HORMONE TREATMENT

ETIOLOGY
Cells molecular alteration

Cells of glandular tissue has Linked to mutation in ERRB2, increase epidermal

receptors for hormones tumor suppressor genes growth factor
(estrogen and progesterone) (BRCA1, BRCA2, TP53)

These hormones stimulate Slow cell division Promotes cell growth

alveolar cells division

apoptosis

Cell division
Affected cells (epithelial cells)
begins to grow and replicate out of
control
 Genetic mutation

Tumor (in situ carcinoma) formed

Ductal carcinoma Lobular carcinoma (cluster of tumor

(grows in the wall of cells within the lobules)
the ducts)

It doesn’t cross
If left untreated, it crosses
membrane but causes
the basement membranes the alveoli to enlarge
(Invasive ductal carcinoma)

Signs and symptoms Mechanism

1. Lumps

2. Nipple discharges
3. Dimpling caused by interference with lymphatic
drainage
4. Breast or nipple pain
5. Nipple retraction or inversion Retraction signs may appear only with
position changes or with breast
palpation associated with fibrosis
6. Redness
7. Changes in skin’s texture
8. Lymph nodes changes
9. Swelling
Physical Exam

If the patient has not noticed a lump, then signs and symptoms indicating the possible
presence of breast cancer may include the following:
 Change in breast size or shape
 Skin dimpling or skin changes (eg, thickening, swelling, or redness)
 Recent nipple inversion or skin change or other nipple abnormalities (eg, ulceration, retraction,
or spontaneous bloody discharge)
 Nipple discharge, particularly if bloodstained
 Axillary lump

To detect subtle changes in breast contour and skin tethering, the examination must
include an assessment of the breasts with the patient upright with arms raised. The following
findings should raise concern:
 Lump or contour change
 Skin tethering
 Nipple inversion
 Dilated veins
 Ulceration
 Edema

The nature of palpable lumps is often difficult to determine clinically, but the following
features should raise concern:
 Hardness
 Irregularity
 Focal nodularity
 Asymmetry with the other breast
 Fixation to skin or muscle (assess fixation to muscle by moving the lump in the line of the
pectoral muscle fibers with the patient bracing her arms against her hips)

A complete examination includes assessment of the axillae and supraclavicular fossae,

examination of the chest and sites of skeletal pain, and abdominal and neurologic examinations.
The clinician should be alert to symptoms of metastatic spread, such as the following:

 Breathing difficulties
 Bone pain
 Symptoms of hypercalcemia
 Abdominal distention
 Jaundice
 Localizing neurologic signs
 Altered cognitive function
 Headache

DIAGNOSIS

Laboratories and Tests

Goals:

 Identify genetic risk in high-risk women

 Detect and diagnose breast cancer in its earliest stages
 Determine how far it has spread
 Evaluate the cancer's characteristics in order to guide treatment
 Monitor the effectiveness of treatment and monitor the person over time to detect
and address any cancer recurrences

1. BRCA1/BRCA2 ( BReast CAncer gene1/BReast CAncer gene2

- Genetic mutations, if present, suggest a lifetime risk around 70%. Women who are at
high risk because of a personal or strong family history of early onset breast cancer or ovarian
cancer can find out if they have a BRCA gene mutation. A mutation in either gene indicates that
the person is at significantly higher lifetime risk (between 69-72%) for developing the disease.

- Test sample (blood)

2. HER2- A test for the overexpression of HER2 proteins or the amplification of the gene that
codes for the protein; tumors that are positive may respond well to a medication that targets HER2,
such as Herceptin.

- is an oncogene associated with cell growth. Normal epithelial cells contain two copies
of the HER2 gene and produce low levels of the HER2 protein on the surface of their cells.

- In about 20-30% of invasive breast cancers, the HER2 gene is amplified and its protein
is over-expressed. These tumors are susceptible to treatment that specifically binds to this over-
expressed protein (targeted therapy). Women with amplified HER2 gene respond well to these
drugs and have a good prognosis.

- Test sample (tissue)

3. ESTROGEN/ PROGESTERONE RECEPTOR (ER/PR status)- Increased levels suggest a

good response to hormonal therapy.

- It is important for predicting the course of the disease and helping to guide treatment.
 - Breast cancer cells that have estrogen and/or progesterone receptors can bind
estrogen and progesterone. These female hormones promote cell growth in ER- and PR-positive
cancers.

- The higher the percentage of cancer cells that are positive, as well as the greater the
intensity (the number of receptors per cell), the better the prognosis. This is because hormone-
dependent cancers frequently respond well to hormonal therapy that blocks estrogen or lowers
estrogen levels.

- Test sample (tissue)

4. CA 15-3- These tests measure a specific cancer antigen. Elevated blood levels may indicate
recurrence of cancer after initial treatment.

- this is a protein that is produced by normal breast cells.

- there’s increase in production with women with breast CA

- They are not used as screens for breast cancer but can be used to follow it in some
women once it has been diagnosed.

- Test sample (blood)

5. BREAST CANCER GENE EXPRESSION TEST- Genetic tests used to predict prognosis by
estimating risk of recurrence, and spread (metastasis) of the cancer, as well as to guide treatment.

- Test sample (tissue)

*Breast cancer cells that are negative for HER2 amplification and negative for estrogen and
progesterone receptors are called "triple-negative." This type of breast cancer occurs more often
in younger women and in women of African or Hispanic descent. Women with BRCA mutations
may be predisposed to triple-negative breast cancer.

*Triple-negative breast cancers tend to grow and spread more quickly than other types and have
a worse prognosis. Because the cells do not have amplified HER2, they will not respond to
targeted treatment.

Diagnosis: cytology and surgical pathology

When a radiologist detects a suspicious area, such as hardened tissue (calcifications) or a non-
palpable mass on a mammogram, or if a lump has been found during a clinical breast exam, a
healthcare practitioner will frequently order one of the following:

 Fine needle aspiration (FNA)—a thin needle and a syringe are used to remove a sample
of cells from a suspicious area of the breast
 Core needle biopsy—a larger bore needle is used to remove a solid "core" of breast tissue;
one or more core samples may be removed.
 Surgical biopsy—a physician cuts out all or part of the breast lump

Radiography
1. Mammogram: It is a type of xray that doctors commonly use during an
initial breast CA screening. It detects lumps or abnormalities.
2. UTZ: This uses sound waves to differentiate between a solid mass and
a fluid-filled cyst.
3. Breast Magnetic Resonance Imaging (MRI): It uses magnets and
radio waves to take pictures of the breast. MRI is used along with mammograms
to screen women who are at high risk for getting breast cancer.

Special Procedure

1. Surgery/Surgical Resection- Big Trauma, high risk, easy to have

complications, not suitable for advanced breast cancer patient. For some of the breast
cancer patients, mastectomy will affect their quality of life.
a. Mastectomy- A simple mastectomy involves removing the lobules,
ducts, fatty tissue, nipple, areola, and some skin. In some types, a
surgeon will also remove the lymph nodes and muscle in the chest wall.
b. Lumpectomy- This involves removing the tumor and a small amount
of healthy tissue around it. It can also help prevent the spread of the
cancer.
c. Reconstruction- Following mastectomy, a surgeon can reconstruct
the breast to look more natural. This can help a person cope with the
psychological effects of breast removal. They may use a breast implant
or tissue from another part of the body.
d. Axillary lymph node dissection- If a doctor finds cancer cells in the
sentinel nodes, they may recommend removing several lymph nodes
in the armpit. This can prevent the cancer from spreading

2. Biopsy- This shows whether the cells are cancerous. If they are, a biopsy
indicates which type of cancer has developed, including whether or not the cancer is
hormone sensitive.
a. Sentinel node biopsy- If breast cancer reaches the sentinel lymph
nodes, which are the first nodes to which a cancer can spread, it can
spread into other parts of the body through the lymphatic system. If the
doctor does not find cancer in the sentinel nodes, then it is usually not
necessary to remove the remaining nodes.
Radiation and Chemotherapy- Chemotherapy kills normal cells while killing cancer cells,
resulting in damage to the immune system, and have toxic side effects such as: hair loss, vomiting,
etc. It is not suitable for advanced breast cancer patients.

MANAGEMENT

NURSING MANAGEMENT

Nursing Action Mechanism

General Nursing Interventions:
1. Provide atmosphere of
acceptance, frequent
patient contact, and
encouragement in illness
adjustment.
2. Encourage grooming
activities.
3. Arrange attractive Promotes relaxation for the patient.
environment.
4. If the patient is receiving For the pt to be aware of what will
radiation or chemotherapy, happen to her esp. S/sx of the side
explain and assist with effects.
potential side effects.
Pre-operative Nursing Interventions:
1. Provide education and Provides knowledge base for the
preparation about surgical nurse to enable reinforcement of
treatments. needed information and helps identify
patient with high anxiety.
2. Reduce fear and anxiety and More understanding of what is
improve coping ability. happening increases feelings of
control and lessens anxiety.
3. Promote decision making ability.
Post-operative Nursing Interventions:
1. Relieve pain and discomfort. Facilitates rest for the patient.
2. Manage post-operative Promotes relaxation for the patient.
sensations.
3. Promote positive body image.
4. Promote positive adjustment and Makes the pt focus on activities she’s
coping. interested and happy instead of her
altered body part.
5. Monitor and manage potential
complications.
Nursing Interventions upon discharge:
1. Exercise to tolerance.
2. Sleep with arm elevated.
3. Elevate arm several times
daily.
4. Avoid injections, vaccinations,
IV, and taking blood pressure
in affected arm.
5. Teach patient adaptive
behavior like using of
adaptive equipment that
conceals altered body
Early post-op exercises are usually
started in the first 24hr to prevent
stiffness.
Promotes venous return, lessening
possibility of lymphedema.
Increases circulation, helps minimize
edema.
Helps the patient gain back her
confidence by concealing altered body
part.

MEDICAL MANAGEMENT

DRUGS FOR BREAST CANCER

DRUG/DRUG MECHANISM OF INDICATION PATIENT
CLASS ACTION CONTRAINDICATION TEACHING

Tamoxifen citrate Tamoxifen attaches Indication: treatment Do gynecological

(Antiestrogen) to the hormone of metastatic breast exam at least
receptor in the cancer in men and annually.
cancer cell, blocking women. Axillary node-
estrogen from positive breast cancer
attaching to the in postmenopausal
receptor. This slows women after surgery +
or stops the growth irradiation. Axillary
of the tumor by node-negative breast
preventing the cancer in women after
cancer cells from surgery + irradiation.
getting the hormones Reduction in risk of
they need to grow. invasive breast cancer
in women with ductal
carcinoma in situ
(DCIS) after surgery +
irradiation. Reduction
in breast cancer
incidence in high-risk
women.
 Contraindication
For risk reduction:
concomitant coumarin
anticoagulants, history
of deep vein
thrombosis or
pulmonary embolism,
planned pregnancy.
Pregnancy (Category
D). Nursing mothers.

Pertuzumab Pertuzumab inhibits Indication

the formation of both It is used: Drink at least two to
heterodimers and - In patients with three quarts of fluid
homodimers in the metastatic every 24 hours,
presence of an disease that unless you are
HER2 ligand; more has not been instructed otherwise.
specifically, it inhibits treated with
the potent HER2- hormone Wash your hands
HER3 interaction in therapy or often.
the presence of chemotherapy. Avoid sun exposure.
heregulin (HRG), - As Wear SPF 15 (or
which activates the neoadjuvant higher) sun block
PI3k/Akt signaling therapy in and protective
pathway. It also patients with clothing.
induces ADCC locally
(antibody-dependent advanced, Use an electric razor
Cellular Cytotoxicity). inflammatory, and a soft toothbrush
or early stage to minimize bleeding.
breast cancer.
- As adjuvant
therapy in
patients with
early stage
breast cancer
who have a
high risk that
the cancer will
recur.

Contraindications:
Cardiac arrhythmias,
cardiac disease, heart
failure, hypertension,
myocardial infarction,
radiation therapy and
ventricular
dysfunction.

Alpelisib Indication:
 Phosphatidyl-3- To treat breast cancer Severe
kinase-α (PI3Kα) is that is hormone hypersensitivity:
responsible for cell receptor positive and Permanently
proliferation in HER2 negative and discontinue the drug.
response to growth has a mutation in the Promptly initiate
factor-tyrosine PIK3CA gene. It is appropriate
kinase pathway used with fulvestrant treatment.
activation. In some to treat
cancers PI3Kα’s postmenopausal
p110α catalytic women, and men,
subunit is mutated whose breast cancer
making it is advanced or
hyperactive. Alpesilib metastatic and has
inhibits the (PI3K), gotten worse during or
with the highest after treatment with
specificity for PI3Kα. hormone therapy.

Contraindication:
Contraindicated in
patients with severe
hypersensitivity to it or
any of its components.

Atezolizumab It is a humanized IgG Indication: Try to avoid crowds

antibody that binds Is indicated for people with colds,
PD-L1, preventing its treatment of patients and report fever or
interaction with PD- with locally advanced any other signs of
L1 and B7-1. or metastatic urothelial infection immediately
Preventing the carcinoma who: to your healthcare
interaction of PD-L1 - Are not eligible provider.
and PD-1 removes for cisplatin-
inhibition of immune containing Maintain good
responses such as chemotherapy, nutrition.
the anti-tumor and whose
immune response tumors express Get plenty of rest.
but not antibody PD-L1, as
dependent cellular determined by
cytotoxicity. an FDA-
approved test,
or
- Are not eligible
for any
platinum-
containing
chemotherapy
regardless of
PD-L1 status,
or
- Have disease
progression
 during or
following any
platinum-
containing
chemotherapy,
or within 12
months of
neoadjuvant or
adjuvant
chemotherapy.

Contraindication:
NONE

Neratinib meleate Neratinib irreversibly Indication: Do not share this

binds to the Treats breast cancer medication to others.
intercellular signaling that is early stage and
domain of HER1, HER2 positive. It is If you miss a dose,
HER2, HER3, and used as extended skip the missed
epithelial growth adjuvant therapy in dose. Take your next
factor receptor, and patients who have dose at the regular
inhibits already been treated time. Do not double
phosphorylation and with trastuzumab after the dose to catch up.
several HER surgery.
downstream
signaling pathways. Contraindication:
The result is NONE
decreased
proliferation and
increased cell death.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Deficient After 8hrs of INDEPENDENT: 1. Validates After 8hrs of

knowledge nursing current level of nursing
“I have a regarding intervention, 1. Review with understanding intervention,
lump in my illness, the patient patient , identifies the patient was
breast.” What prognosis, will understanding learning needs able to
should I do?” treatment, self- verbalize of specific and provides verbalize
as verbalized care and accurate diagnosis, knowledge accurate
by the discharge information treatment base from information
patient. needs. about alternatives and which patient about
diagnosis, future can make diagnosis,
prognosis expectations. informed prognosis, and
OBJECTIVE: and decisions. potential
potential 2. Provide clear complications
- Change in complicatio accurate, 2. Helps with at own level of
breast ns at own information and adjustment to readiness.
size or level of a factual but the diagnosis
shape readiness. sensitive of cancer by
manner. providing
- Skin Answers needed
dimpling specifically but information
or skin do not provide along with
changes unessential time to absorb
details. it.

- Axillary 3. Provide 3. Patient has

lump anticipatory the right to
guidance with know and
patient participate in
regarding decision
treatment making.
protocol, Accurate and
expected concise
results, possible information
side effects. Be helps dispel
honest with the fears and
patient. anxiety, helps
clarify
4. Review with expected
patient the routine, and
importance of enables
maintaining patient to
optimal maintain some
nutritional degree of
status. control.

5. Encourage diet 4. Promotes

variations and wellbeing,
experimentation facilitates
 in meal recovery and
planning and its critical in
food enabling
preparations. patient to
tolerate
6. Recommend treatments.
increase fluid
intake and fiber 5. Creativity may
in diet as well enhance flavor
as routine and intake,
exercise. esp. when
protein foods
7. Instruct patient taste bitter.
to assess oral
mucous 6. Improves
membranes consistency of
routinely, noting stool and
erythema and stimulates
ulceration. peristalsis.

7. Early
recognition of
problems,
early
intervention,
minimizing
complications
that may
impair oral
intake and
provide
routine
avenue from
systemic
infection.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Disturbed After a month 1. Assess 1. To identify After a month

body image of nursing perception of existing of nursing
“I feel so helpless, I R/T loss of intervention, change in problem intervention
thought it was just a body part patient structure or and plan client’s
simple rash that I’ve secondary psychological function of certain psychological
seen on my left to curative condition will body part. therapeutic condition
breast, if only it was Surgery in improve actions. improved
detected and treated CA or evident by 2. Assess evident by the
earlier, I would not mastectomy. the 5 stage perceive 2. To help 5 stage of grief
have undergo of grief from impact of the patient from
surgery” as bargaining change on sustain his bargaining and
verbalized by the and activities of physical depression to
patient. depression daily living, and social acceptance.
towards social needs
acceptance. behavior, while she SUBJECTIVE:
personal is I feel much
OBJECTIVE: relationships, unstable. better now, I
and thought about
- Evident occupational 3. To allow it and it’s not
missing activities. the patient the end of my
body part to express life and there’s
of the left 3. Encourage herself and still a hope for
breast verbalization of release me.
positive or tension on
- Grimace negative feelings.
and crying feelings about
actual or 4. To
- Poor perceive facilitate
appetite change. good
and nurse-
uncoopera 4. Maintain patient
tive in therapeutic interaction
ADL communication and also
and gain
- Apathy demonstrate clients
positive caring trust to
- Social in routine cooperate.
isolation activities.
5. To help
- Concealin 5. Teach patient the client
g of the adaptive gain back
loss body behavior like her
part using of confidence
adaptive by
equipment that concealing
conceals altered
altered body body part.
 part (breast 6. To make
pads) the client
focus on
6. Help patient activities
identify ways she’s
of hoping and interested
diversional and happy
activities. instead of
her altered
body part.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Acute pain Within 8 hours of INDEPENDENT: After 8 hours

R/T nursing of nursing
I have undergone postoperativ interventions 1. Establish 1. To gain trust interventions,
mastectomy e incision at patient will rapport and promote patient
on my left left breast manifested a cooperation manifested a
breast last secondary to decrease in pain 2. Perform 2. To assess decrease in
August 7. The mastectomy scale from 8/10 to pain etiology and pain to 5/10.
incision site as 5/10. assessment contributing
has been manifested factors. Patient
painful as by pain 3. Accept 3. Pain is a verbalized
verbalized by scale of - Verbalize patient’s subjective that the pain
the patient. 8/10. understanding of description of experience is caused by
the cause of pain. pain and cannot be her surgery.
- Identify ways to felt by others.
alleviate pain. 4. Monitor 4. Usually Patient
OBJECTIVE: - Participate in care vital signs altered in verbalized
and acute pain that pain is
- Pain scale of pharmacological 5. Instruct 5. Timely alleviating
8/10 at the regimen patient to report intervention is when she is
site of - Demonstrate use of pain as soon as more likely to relaxed.
operation, 0 relaxation techniques topossible. be successful
being the reduce pain. in alleviating
lowest and 10 pain.
being the
highest.
- Sharp,
intermittent
pain radiating
from
postsurgical
site to left arm
- Slight
redness and
warmth on
the incision.
 DISCHARGE PLAN

Instructions after Mastectomy:

1. Pain Management
 People experience different types and amount of pain or discomfort after surgery. The goal of
pain management is to assess your own level of discomfort and to take medication as needed.
You will have better results controlling your pain if you take pain medication before your pain is
severe.
 You will be given a prescription for Vicodin for the management of moderate pain. It is
recommended to take medication for pain when pain is experienced on a regular schedule.
Ibuprofen (Advil or Motrin) or Tylenol can be added to or replace the Vicodin.
 Please notify health practitioner of any drug allergies, reactions or medical problems that would
prevent you from taking these drugs. Vicodin is a narcotic and should not be taken with
alcoholic drinks. Do not use narcotics while driving.
 Narcotics also can cause or worsen constipation, so increase your fluid intake, eat high fiber
foods — such as prunes and bran — and make sure that you get up and out of bed to take
small walks.
 An icepack may be helpful to decrease discomfort and swelling, particularly to the armpit after
a lymph node dissection. A small pillow positioned in the armpit also may decrease discomfort.

2. Incision and Dressing care

Incision, or scar, has both stitches and steri-strips, which are small white strips of tape, and is
covered by a gauze dressing and tape or a plastic dressing.
 Do not remove the dressing, steri-strips or stitches. We will remove the dressing in seven to 10
days. We also will remove the sutures in one to two weeks unless they absorb on their own. If
the dressing or steri-strips fall off, do not attempt to replace them.
 You may shower one day after the drain(s) is out and if you have a plastic dressing.
 If you have gauze and paper tape, you may remove it two days after surgery and shower after
that. Use a towel to dry your incision thoroughly after showering. Be careful not to touch or
remove the steri-strips or sutures.
 Bruising and some swelling are common in women after surgery.
 A low-grade fever that is under 100 degrees Fahrenheit is normal the day after surgery.
 You will have a Jackson-Pratt (JP) drain after your surgery. This drain is a plastic tube from
under the skin to outside your body with a bulb attached to it. Empty the drain two to three times
per day or when the bulb is full. Write down the amount drained on a sheet of paper. Your nurse
will teach you how to empty your drain. An information sheet on JP drains is included in your
binder.
 3. Activity
 Avoid strenuous activity, heavy lifting and vigorous exercise until the stitches are removed.
 Walking is a normal activity that can be restarted right away.
 You cannot do housework or driving until the drain is out. You may restart driving when you are
no longer on narcotics and you feel safe turning the wheel and stopping quickly.
 Following a lymph node dissection, don't avoid using your arm, but don't exercise it until your
first post-operative visit.
 You will be given exercises to regain movement and flexibility. You may be referred to physical
therapy for additional rehabilitation if it is needed.
 Most people return to work within three to six weeks. Return to work varies with your type of
work, your overall health and personal preferences. Discuss returning to work with us.

4. Diet
 You may resume your regular diet as soon as you can take fluids after recovering from
anesthesia.
 Drink 8 to 10 glasses of water and non-caffeinated beverages per day, plenty of fruits and
vegetables as well as lower fat foods.
 Consult a nutritionist in the Breast Care Center for your recommended diet

5. Follow-up care
 The pathology results from your surgery should be available within one week after your surgery.
 Follow-up appointments are generally made before surgery with your physician and a nurse.
Your sutures will be removed in approximately 10 to 14 days. Call the Breast Care Center if
you do not have or remember your appointment.
 Your dressing will be changed or removed at your post-operative visit.

Instructions after Chemotherapy:

After chemotherapy, you may have mouth sores, an upset stomach, and diarrhea. You will
probably get tired easily. Your appetite may be poor, but you should be able to drink and eat.
1. Mouth Care
 Brush your teeth and gums 2 to 3 times a day for 2 to 3 minutes each time. Use a toothbrush with
soft bristles.
 Let your toothbrush air dry between brushings.

 Use a toothpaste with fluoride.

 Floss gently once a day.

 Rinse your mouth 4 times a day with a salt and baking soda solution. (Mix one half teaspoon, or
2.5 grams, of salt and one half teaspoon, or 2.5 grams, of baking soda in 8 ounces or 240 mL of
water.)

 Your doctor may prescribe a mouth rinse. DO NOT use mouth rinses with alcohol in them.

 Use your regular lip care products to keep your lips from drying and cracking. Tell your doctor if
you develop new mouth sores or pain.

 DO NOT eat foods and drinks that have a lot of sugar in them. Chew sugarless gums or suck on
sugar-free popsicles or sugar-free hard candies.

 Take care of your dentures, braces, or other dental products.

2. Preventing Infections

 DO NOT eat or drink anything that may be undercooked or spoiled.

 Make sure your water is safe.

 Know how to cook and store foods safely.

 Be careful when you eat out. DO NOT eat raw vegetables, meat, fish, or anything else you are
not sure is safe

 Wash your hands with soap and water often.

 Keep your house clean. Stay away from crowds. Ask visitors who have a cold to wear a mask, or
not to visit. Don't do yard work or handle flowers and plants.

 Be careful with pets and animals.

3. Other Self-care

 If you have a central venous line or PICC (peripherally inserted central catheter) line, know how
to take care of it.

 If your health care provider tells you your platelet count is still low, learn how to prevent bleeding
during cancer treatment.

 Stay active by walking. Slowly increase how far you go based on how much energy you have.

 Eat enough protein and calories to keep your weight up.

 Ask your provider about liquid food supplements that can help you get enough calories and
nutrients.

 Be careful when you are in the sun. Wear a hat with a wide brim. Use sunscreen with SPF 30 or
higher on any exposed skin.

 DO NOT smoke.

When to call your doctor:

 Signs of infection, such as fever, chills, or sweats

 Diarrhea that does not go away or is bloody

 Severe nausea and vomiting

 Inability to eat or drink

 Extreme weakness

 Redness, swelling, or drainage from any place where you have an IV line inserted

 A new skin rash or blisters

 Jaundice (your skin or the white part of your eyes looks yellow)

 Pain in your abdomen

 A very bad headache or one that does not go away

 A cough that is getting worse

 Trouble breathing when you are at rest or when you are doing simple tasks

 Burning when you urinate

RESEARCH INTEGRATION

According to American Cancer Society (ACS)

Reducing breast cancer risk

Researchers continue to look for medicines that might help lower breast cancer risk, especially
women who are at high risk.

 Hormone therapy drugs are typically used to help treat breast cancer, but some might also
help prevent it. Tamoxifen and raloxifene have been used for many years to prevent breast
cancer. More recent studies with another class of drugs called aromatase inhibitors
(exemestane and anastrozole) have shown that these drugs are also very effective in
preventing breast cancer
 Other clinical trials are looking at non-hormonal drugs for breast cancer reduction. Drugs
of interest include drugs for osteoporosis and bone metastases, COX-2 inhibitors, non-
steroidal anti-inflammatory drugs, and statins (used to lower cholesterol).

New lab tests

Tests for circulating tumor cells (CTCs)

Researchers have found that in many women with breast cancer, cells may break away from the
tumor and enter the blood. These circulating tumor cells (CTCs) can be detected with sensitive
lab tests. Although these tests can help predict which patients may have breast cancer that has
spread beyond the breast (metastatic disease), it isn’t clear if the use of these tests can tell
whether the cancer will come back after treatment (recur) or help patients live longer. Some
studies are looking at if these CTCs can be removed and then tested in the lab to determine which
specific anticancer drugs will work on the tumor.

New imaging tests

Scintimammography (molecular breast imaging)

In this test, a slightly radioactive drug called a tracer is injected into a vein. The tracer attaches
to breast cancer cells and is detected by a special camera.

This technique is still being studied to see if it will be useful in finding breast cancers. Some
doctors believe it may be helpful in looking at suspicious areas found by regular mammograms,
but its exact role is still unclear. Current research is aimed at improving the technology and
evaluating its use in specific situations such as in the dense breasts of younger women.

Breast cancer treatment

Oncoplastic surgery

Breast-conserving surgery (lumpectomy or partial mastectomy) can often be used for early-stage
breast cancers. But for some women, it can result in breasts of different sizes and/or shapes. For
larger tumors, it might not even be possible, and a mastectomy might be needed instead. Some
doctors are addressing this problem by combining cancer surgery and plastic surgery techniques,
known as oncoplastic surgery. This typically involves reshaping the breast at the time of the
initial surgery, such as doing a partial breast reconstruction after breast-conserving surgery or a
full reconstruction after mastectomy. Oncoplastic surgery may mean operating on the other breast
as well to make the breasts more alike.

Triple-negative breast cancer

Since triple-negative breast cancers cannot be treated with hormone therapy or targeted therapy
such as HER2 drugs, the treatment options are limited to chemotherapy. Other potential targets
for new breast cancer drugs have been identified in recent years. Drugs based on these targets,
such as kinase inhibitors and immunotherapy, are now being studied to treat triple-negative breast
cancers, either by themselves, in combination, or with chemotherapy.

Targeted therapy drugs

Targeted therapies are a group of drugs that specifically target gene changes in cancer cells that
help the cells grow or spread. New targeted therapies are being studied for use against breast
cancer, including PARP inhibitors. These drugs are most likely to be helpful against cancers
caused by BRCA gene mutations, and have shown some promise in treating some types of breast
cancers. Olaparib (Lynparza) is now being used to treat women with BRCAmutations who have
metastatic, HER2-negative breast cancer and who have already gotten chemotherapy. Other
PARP inhibitors are also being studied.
Supportive care

There are trials looking at different medicines to try and improve memory and brain symptoms
after chemotherapy. Other studies are evaluating if certain cardiac drugs, known as beta-blockers,
can prevent the heart damage sometimes caused by the common breast cancer chemotherapy
drugs, doxorubicin and epirubicin.