Liceo de Cagayan University

Graduate Studies

Master in Nursing

Submitted By

Noemie R. Baculio, RN

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Learning Objectives:

At the end of the discussion, we will be able to:

1. Review about the anatomy and physiology of the breast

2. Distinguish cancer from healthy cells
3. Learn about breast cancer’s epidemiology
4. Understand the pathophysiology
5. Gain knowledge on the signs and symptoms
6. Have an understanding on the risk factors and prevention
7. Know the medical management
8. Learn about the nursing management

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 I. ANATOMY AND PHYSIOLOGY OF THE BREAST

B R EA ST C OM P OS I T I ON
The breast is a mass of glandular, fatty, and fibrous tissues positioned over the pectoral muscles of
the chest wall and attached to the chest wall by fibrous strands called Cooper’s ligaments. A
layer of fatty tissue surrounds the breast glands and extends throughout the breast. The fatty tissue
gives the breast a soft consistency.

The glandular tissues of the breast house the lobules (milk producing glands at the ends of the
lobes) and the ducts (milk passages). Toward the nipple, each duct widens to form a sac (ampulla).
During lactation, the bulbs on the ends of the lobules produce milk. Once milk is produced, it is
transferred through the ducts to the nipple.

The breast is composed of:

 milk glands (lobules) that produce milk

 ducts that transport milk from the milk glands (lobules) to the nipple
 nipple
 areola (pink or brown pigmented region surrounding the nipple)
 connective (fibrous) tissue that surrounds the lobules and ducts
 fat

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 Arteries carry oxygen rich blood from the heart to the chest wall and the breasts and veins take de-
oxygenated blood back to the heart. The axillary artery extends from the armpit and supplies the
outer half of the breast with blood; the internal mammary artery extends down from neck and
supplies the inner portion of the breast.

I N IT I AL B R E A ST D E VE L O PM EN T
Human breast tissue begins to develop in the sixth week of fetal life. Breast tissue initially develops
along the lines of the armpits and extends to the groin (this is called the milk ridge). By the ninth
week of fetal life, it regresses (goes back) to the chest area, leaving two breast buds on the upper
half of the chest. In females, columns of cells grow inward from each breast bud, becoming separate
sweat glands with ducts leading to the nipple. Both male and female infants have very small breasts
and actually experience some nipple discharge during the first few days after birth.

Female breasts do not begin growing until puberty—the period in life when the body undergoes a
variety of changes to prepare for reproduction. Puberty usually begins for women around age 10 or
11. After pubic hair begins to grow, the breasts will begin responding to hormonal changes in the
body. Specifically, the production of two hormones, estrogen and progesterone, signal the
development of the glandular breast tissue. This initial growth of the breast may be somewhat painful
for some girls. During this time, fat and fibrous breast tissue becomes more elastic. The breast ducts
begin to grow and this growth continues until menstruation begins (typically one to two years after
breast development has begun). Menstruation prepares the breasts and ovaries for potential
pregnancy.

Before puberty Early puberty Late puberty

the breast is flat except for the areola becomes a glandular tissue and fat
the nipple that sticks out prominent bud; breasts increase in the breast, and
from the chest begin to fill out areola becomes flat

CANCER CELLS

Cancer cells are cells that divide relentlessly, forming solid tumors or flooding the blood with abnormal
cells. Cell division is a normal process used by the body for growth and repair. A parent cell divides to form
two daughter cells, and these daughter cells are used to build new tissue, or to replace cells that have died
because of aging or damage. Healthy cells stop dividing when there is no longer a need for more daughter
cells, but cancer cells continue to produce copies. They are also able to spread from one part of the body to
another in a process known as metastasis.[1]

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There are different categories of cancer cell, defined according to the cell type from which they originate. [2]

 Carcinoma, the majority of cancer cells are epithelial in origin, beginning in the membranous tissues
that line the surfaces of the body.
 Leukaemia, originate in the tissues responsible for producing new blood cells, most commonly in
the bone marrow.
 Lymphoma and myeloma, derived from cells of the immune system.
 Sarcoma, originating in connective tissue, including fat, muscle and bone.
 Central nervous system, derived from cells of the body and spinal cord.
 Mesothelioma, originating in the mesothelium; the lining of body cavities.

Cancer cells have distinguishing histological features visible under the microscope. The nucleus is often
large and irregular, and the cytoplasm may also display abnormalities.[3]

Nucleus
The shape, size, protein composition, and texture of the nucleus are often altered in malignant cells. The
nucleus may acquire grooves, folds or indentations, chromatin may aggregate or disperse, and
the nucleolus can become enlarged. In normal cells, the nucleus is often round or ellipsoid in shape, but in
cancer cells the outline is often irregular. Different combinations of abnormalities are characteristic of
different cancer types, to the extent that nuclear appearance can be used as a marker in cancer
diagnostics and staging.[4]

Cancer Cells vs. Normal Cells

Below are some of the major differences between normal cells and cancer cells, which in turn account for
how malignant tumors grow and respond differently to their surroundings than benign tumors.

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  Growth—Normal cells stop growing (reproducing) when enough cells are present. For example, if
cells are being produced to repair a cut in the skin, new cells are no longer produced when there
are enough cells present to fill the hole; when the repair work is done. In contrast, cancer cells
don’t stop growing when there are enough cells present. This continued growth often results in a
tumor (a cluster of cancer cells) being formed. Each gene in the body carries a blueprint that codes
for a different protein. Some of these proteins are growth factors, chemicals that tell cells to grow
and divide. If the gene that codes for one of these proteins is stuck in the “on” position by a
mutation (an oncogene)—the growth factor proteins continue to be produced. In response, the cells
continue to grow.
 Communication—Cancer cells don’t interact with other cells as normal cells do. Normal cells
respond to signals sent from other nearby cells that say, essentially, “you’ve reached your
boundary.” When normal cells “hear” these signals they stop growing. Cancer cells do not respond
to these signals.

 Cell repair and cell death—Normal cells are either repaired or die (undergo apoptosis) when they
are damaged or get old. Cancer cells are either not repaired or do not undergo apoptosis. For
example, one protein called p53 has the job of checking to see if a cell is too damaged to
repair and if so, advise the cell to kill itself. If this protein p53 is abnormal or inactive (for example,
from a mutation in the p53 gene,) then old or damaged cells are allowed to reproduce. The p53
gene is one type of tumor suppressor gene that code for proteins that suppress the growth of cells.
 Stickiness—Normal cells secrete substances that make them stick together in a group. Cancer
cells fail to make these substances, and can “float away” to locations nearby, or through the
bloodstream or system of lymph channels to distant regions in the body.
 Ability to Metastasize (Spread)—Normal cells stay in the area of the body where they belong. For
example, lung cells remain in the lungs. Cancer cells, because they lack the adhesion
molecules that cause stickiness, are able to travel via the bloodstream and lymphatic system to
other regions of the body—they have the ability to metastasize. Once they arrive in a new region
(such as lymph nodes, the lungs, the liver, or the bones) they begin to grow, often forming tumors
far removed from the original tumor.

 Appearance—Under a microscope, normal cells and cancer cells may look quite different. In
contrast to normal cells, cancer cells often exhibit much more variability in cell size—some are
larger than normal and some are smaller than normal. In addition, cancer cells often have an
abnormal shape, both of the cell, and of the nucleus (the “brain” of the cell.) The nucleus appears
both larger and darker than normal cells. The reason for the darkness is that the nucleus of cancer
cells contains excess DNA. Up close, cancer cells often have an abnormal number of
chromosomes that are arranged in a disorganized fashion.
 The rate of growth—Normal cells reproduce themselves and then stop when enough cells are
present. Cancer cells reproduce rapidly before the cells have had a chance to mature.
 Maturation—Normal cells mature. Cancer cells, because they grow rapidly and divide before cells
are fully mature, remain immature. Doctors use the term undifferentiated to describe immature
cells (in contrast to differentiated to describe more mature cells.) Another way to explain this is to
view cancer cells as cells that don’t “grow up” and specialize into adult cells. The degree of
maturation of cells corresponds to the "grade" of cancer. Cancers are graded on a scale from 1 to
3 with 3 being the most aggressive.

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  Evading the immune system—When normal cells become damaged, the immune system (via
cells called lymphocytes) identifies and removes them. Cancer cells are able to evade (trick) the
immune system long enough to grow into a tumor by either by escaping detection or by secreting
chemicals that inactivate immune cells that come to the scene. Some of the newer immunotherapy
medicationsaddress this aspect of cancer cells.
 Functioning—Normal cells perform the function they are meant to perform, whereas cancer cells
may not be functional. For example, normal white blood cells help fight off infections. In leukemia,
the number of white blood cells may be very high, but since the cancerous white blood cells are not
functioning as they should, people can be more at risk for infection even with an elevated white
blood cell count. The same can be true of substances produced. For example, normal thyroid cells
produce thyroid hormone. Cancerous thyroid cells (thyroid cancer) may not produce thyroid
hormone. In this case, the body may lack enough thyroid hormone (hypothyroidism) despite an
increased amount of thyroid tissue.

 Blood supply—Angiogenesis is the process by which cells attract blood vessels to grow and feed
the tissue. Normal cells undergo a process called angiogenesis only as part of normal growth and
development and when new tissue is needed to repair damaged tissue. Cancer cells undergo
angiogenesis even when growth is not necessary. One type of cancer treatment involves the use of
angiogenesis inhibitors—medications that block angiogenesis in the body in an effort to keep
tumors from growing.

More Differences Between Cancer Cells and Normal Cells

 Evading growth suppressors—Normal cells are controlled by growth (tumor) suppressors. There
are three main types of tumor suppressor genes that code for proteins that suppress growth. One
type tells cells to slow down and stop dividing. One type is responsible for fixing changes in
damaged cells. The third type is in charge of the apoptosis noted above. Mutations that result in
any of these tumor suppressor genes being inactivated allow cancer cells to grow unchecked.
 Invasiveness—Normal cells listen to signals from neighboring cells and stop growing when they
encroach on nearby tissues (something called contact inhibition.) Cancer cells ignore these cells
and invade nearby tissues. Benign (non-cancerous) tumors have a fibrous capsule. They may push
up against nearby tissues but they do not invade/intermingle with other tissues. Cancer cells, in
contrast, don’t respect boundaries and invade tissues. This results in the fingerlike projections that
are often noted on radiologic scans of cancerous tumors. The word cancer, in fact, comes from the
latin word for crab used to describe the crablike invasion of cancers into nearby tissues.

 Energy Source—Normal cells get most of their energy (in the form of a molecule called ATP)
through a process called the Krebs cycle, and only a small amount of their energy through a
different process called glycolysis. Whereas normal cells produce most of their energy in the
presence of oxygen, cancer cells produce most of their energy in the absence of oxygen. This is
the reasoning behind hyperbaric oxygen treatments that have been used experimentally (with
disappointing results thus far) in some people with cancer.
 Mortality/Immortality—Normal cells are mortal, that is, they have a lifespan. Cells aren’t designed
to live forever, and just like the humans they are present in, cells grow old. Researchers are
beginning to look at something called telomeres, structures that hold DNA together at the end of
the chromosomes, for their role in cancer. One of the limitations to growth in normal cells is the

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 length of the telomeres. Every time a cell divides, the telomeres get shorter. When the telomeres
become too short, a cell can no longer divide and the cell dies. Cancer cells have figured out a way
to renew telomeres so that they can continue to divide. An enzyme called telomerase works to
lengthen the telomeres so that the cell can divide indefinitely—essentially becoming immortal.

 Ability to "hide"—Many people wonder why cancer can recur years, and sometimes decades
after it appears to be gone (especially with tumors such as estrogen receptor-positive breast
cancers.) There are several theories why cancers may recur. In general, it's thought that there is a
hierarchy of cancer cells, with some cells (cancer stem cells) having the ability to resist treatment
and lie dormant. This is an active area of research, and extremely important.
 Genomic instability—Normal cells have normal DNA and a normal number of chromosomes.
Cancer cells often have an abnormal number of chromosomes and the DNA becomes increasingly
abnormal as it develops a multitude of mutations. Some of these are driver mutations, meaning
they drive the transformation of the cell to be cancerous. Many of the mutations are passenger
mutations, meaning they don’t have a direct function for the cancer cell. For some cancers,
determining which driver mutations are present (molecular profiling or gene testing) allows
physicians to use targeted medications which specifically target the growth of the cancer. The
development of targeted therapies such as EGFR inhibitors for cancers with EGFR mutations is
one of the more rapidly growing and progressing areas of cancer treatment.

Breast Cancer

Breast cancer is an uncontrolled growth of breast cells. To better understand breast cancer, it helps to
understand how any cancer can develop.

Breast cancer is the most common invasive cancer in women, and the second main cause of cancer death
in women, after lung cancer.

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 Advances in screening and treatment have improved survival rates dramatically since 1989. There are
around 3.1 million breast cancersurvivors in the United States (U.S.). The chance of any woman dying from
breast cancer is around 1 in 37, or 2.7 percent.

In 2017, around 252, 710 new diagnoses of breast cancer are expected in women, and around 40,610
women are likely to die from the disease.

Awareness of the symptoms and the need for screening are important ways of reducing the risk.

Breast cancer can affect men too, but this article will focus on breast cancer in women.

Fast facts on breast cancer:

Here are some key points about breast cancer. More detail is in the main article.

 Breast cancer is the most common cancer among women.

 Symptoms include a lump or thickening of the breast, and changes to the skin or the nipple.

 Risk factors can be genetic, but some lifestyle factors, such as alcohol intake, make it more likely to
happen.

 A range of treatments is available, including surgery, radiation therapy, and chemotherapy.

 Many breast lumps are not cancerous, but any woman who is concerned about a lump or change should
see a doctor.

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 II. RISK FACTORS

A breast cancer risk factor is anything that makes it more likely you'll get breast cancer. But having one or
even several breast cancer risk factors doesn't necessarily mean you'll develop breast cancer. Many
women who develop breast cancer have no known risk factors other than simply being women.

Factors that are associated with an increased risk of breast cancer include:

 Being female. Women are much more likely than men are to develop breast cancer.

 Increasing age. Your risk of breast cancer increases as you age.

 A personal history of breast conditions. If you've had a breast biopsy that found lobular carcinoma
in situ (LCIS) or atypical hyperplasia of the breast, you have an increased risk of breast cancer.

 A personal history of breast cancer. If you've had breast cancer in one breast, you have an
increased risk of developing cancer in the other breast.

 A family history of breast cancer. If your mother, sister or daughter was diagnosed with breast
cancer, particularly at a young age, your risk of breast cancer is increased. Still, the majority of people
diagnosed with breast cancer have no family history of the disease.

 Inherited genes that increase cancer risk. Certain gene mutations that increase the risk of breast
cancer can be passed from parents to children. The most well-known gene mutations are referred to
as BRCA1 and BRCA2. These genes can greatly increase your risk of breast cancer and other
cancers, but they don't make cancer inevitable.

 Radiation exposure. If you received radiation treatments to your chest as a child or young adult, your
risk of breast cancer is increased.

 Obesity. Being obese increases your risk of breast cancer or for it to come back. (recurrence)

 Race / Ethnicity. White women are slightly more likely to develop breast cancer than African
American, Hispanic and Asian women.

 Beginning your period at a younger age. Beginning your period before age 12 increases your risk
of breast cancer.

 Beginning menopause at an older age. If you began menopause older than 55, you're more likely to
develop breast cancer.

 Having your first child at an older age. Women who give birth to their first child after age 30 may
have an increased risk of breast cancer.

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 Having never been pregnant. Women who have never been pregnant have a greater risk of breast
cancer than do women who have had one or more pregnancies.

 Postmenopausal hormone therapy. Women who take hormone therapy medications that combine
estrogen and progesterone to treat the signs and symptoms of menopause have an increased risk of
breast cancer. The risk of breast cancer decreases when women stop taking these medications.

 Drinking alcohol. Drinking alcohol increases the risk of breast cancer.

EMERGING RISK FACTORS

 Low Vitamin D Level. Vitamin D play a role in controlling normal best cell growth and may be
able to stop breast cancer cells from growing.
 Light exposure at night. Several studies suggest that women who work at night – factory
workers, doctors, nurses- have a higher risk of breast cancer. Other research suggests that those
women living in areas with high levels of external light at night (street lights) have higher risk of
breast cancer.
 Eating unhealthy food.
 Exposure to cosmetic chemicals. Parabens and phthalates.

IV. Symptoms

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 The first symptoms of breast cancer are usually an area of thickened tissue in the breast, or a lump in the
breast or in an armpit.

An early diagnosis of breast cancer increases the chance of recovery.

Other symptoms include:

 a pain in the armpits or breast that does not change with the monthly cycle

 pitting or redness of the skin of the breast, like the skin of an orange

 a rash around or on one of the nipples

 a discharge from a nipple, possibly containing blood

 a sunken or inverted nipple

 a change in the size or shape of the breast

 peeling, flaking, or scaling of the skin on the breast or nipple

Most lumps are not cancerous, but women should have them checked by a health care professional.

Types of breast cancer

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Types of Breast Cancer

There are many types of breast cancer. The most common types are ductal carcinoma in situ, invasive
ductal carcinoma, and invasive lobular carcinoma.

The type of breast cancer is determined by the specific cells in the breast that are affected. Most breast
cancers are carcinomas. Carcinomas are tumors that start in the epithelial cells that line organs and
tissues throughout the body. Sometimes, an even more specific term is used. For example, most breast
cancers are a type of carcinoma called adenocarcinoma, which starts in cells that make up glands
(glandular tissue). Breast adenocarcinomas start in the ducts (the milk ducts) or the lobules (milk-producing
glands).

There are other, less common, types of breast cancers, too, such as sarcomas, phyllodes, Paget
disease, and angiosarcomas which start in the cells of the muscle, fat, or connective tissue.

Sometimes a single breast tumor can be a combination of different types. And in some very rare types of
breast cancer, the cancer cells may not form a lump or tumor at all.

When a biopsy is done to find out the specific type of breast cancer, the pathologist will also check if the
cancer has spread into the surrounding tissues. The following terms are used to describe the extent of the
cancer:

 In situ breast cancers have not spread.

 Invasive or infiltrating cancers have spread (invaded) into the surrounding breast tissue.

Common kinds of breast cancer

The most common kinds of breast cancer are carcinomas, and are named based on where they form and
how far they have spread.

These general kinds of breast cancer below can be further described with the terms outlined above.

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In situ cancers

Ductal carcinoma in situ (DCIS; also known as intraductal carcinoma) is a non-invasive or pre-invasive
breast cancer.

Lobular carcinoma in situ (LCIS) may also be called lobular neoplasia. This breast change is not a
cancer, though the name can be confusing. In LCIS, cells that look like cancer cells are growing in the
lobules of the milk-producing glands of the breast, but they don’t grow through the wall of the lobules.

Invasive (infiltrating) breast cancer

Breast cancers that have spread into surrounding breast tissue are known as invasive breast cancer. There
are many different kinds of invasive breast cancer, but the most common are called invasive ductal
carcinoma and invasive lobular carcinoma.

Less common types of breast cancer

Inflammatory breast cancer

Inflammatory breast cancer is an uncommon type of invasive breast cancer. It accounts for about 1% to 5%
of all breast cancers.

Paget disease of the nipple

Paget disease of the nipple starts in the breast ducts and spreads to the skin of the nipple and then to the
areola(the dark circle around the nipple). It is rare, accounting for only about 1-3% of all cases of breast
cancer.

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Phyllodes tumor

Phyllodes tumors are rare breast tumors. They develop in the connective tissue (stroma) of the breast, in
contrast to carcinomas, which develop in the ducts or lobules. Most are benign, but there are others that
are malignant (cancer).

Angiosarcoma

Sarcomas of the breast are rare making up less than 1% of all breast cancers. Angiosarcoma starts in cells
that line blood vessels or lymph vessels. It can involve the breast tissue or the skin of the breast. Some
may be related to prior radiation therapy in that area.

V. Prevention
Breast cancer risk reduction for women with an average risk

Making changes in your daily life may help reduce your risk of breast cancer. Try to:

 Ask your doctor about breast cancer screening. Discuss with your doctor when to begin breast
cancer screening exams and tests, such as clinical breast exams and mammograms.

Talk to your doctor about the benefits and risks of screening. Together, you can decide what breast
cancer screening strategies are right for you.

 Become familiar with your breasts through breast self-exam for breast awareness. Women

may choose to become familiar with their breasts by occasionally inspecting their breasts during a
breast self-exam for breast awareness. If there is a new change, lumps or other unusual signs in your
breasts, talk to your doctor promptly.

Breast awareness can't prevent breast cancer, but it may help you to better understand the normal
changes that your breasts undergo and identify any unusual signs and symptoms.

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 The best time to do a monthly self-breast exam is about 3 to 5 days after your period starts. Do it at
the same time every month. Your breasts are not as tender or lumpy at this time in your monthly cycle.
If you have gone through menopause, do your exam on the same day every month.

 Drink alcohol in moderation, if at all. Limit the amount of alcohol you drink to no more than one
drink a day, if you choose to drink.

 Exercise most days of the week. Aim for at least 30 minutes of exercise on most days of the week. If
you haven't been active lately, ask your doctor whether it's OK and start slowly.

 Limit postmenopausal hormone therapy. Combination hormone therapy may increase the risk of
breast cancer. Talk with your doctor about the benefits and risks of hormone therapy.

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 Some women experience bothersome signs and symptoms during menopause and, for these women,
the increased risk of breast cancer may be acceptable in order to relieve menopause signs and
symptoms.

To reduce the risk of breast cancer, use the lowest dose of hormone therapy possible for the shortest
amount of time.

 Maintain a healthy weight. If your weight is healthy, work to maintain that weight. If you need to lose
weight, ask your doctor about healthy strategies to accomplish this. Reduce the number of calories
you eat each day and slowly increase the amount of exercise.

 Choose a healthy diet. Women who eat a Mediterranean diet supplemented with extra-virgin olive oil
and mixed nuts may have a reduced risk of breast cancer. The Mediterranean diet focuses mostly on
plant-based foods, such as fruits and vegetables, whole grains, legumes, and nuts. People who follow
the Mediterranean diet choose healthy fats, such as olive oil, over butter and fish instead of red meat.
Breast cancer risk reduction for women with a high risk

If your doctor has assessed your family history and determined that you have other factors, such as a
precancerous breast condition, that increase your risk of breast cancer, you may discuss options to reduce
your risk, such as:

 Preventive medications (chemoprevention). Estrogen-blocking medications, such as selective

estrogen receptor modulators and aromatase inhibitors, reduce the risk of breast cancer in women
with a high risk of the disease.

These medications carry a risk of side effects, so doctors reserve these medications for women who
have a very high risk of breast cancer. Discuss the benefits and risks with your doctor.

 Preventive surgery. Women with a very high risk of breast cancer may choose to have their healthy
breasts surgically removed (prophylactic mastectomy). They may also choose to have their healthy
ovaries removed (prophylactic oophorectomy) to reduce the risk of both breast cancer and ovarian
cancer.

VI. Diagnosis

Diagnosing breast cancer

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 

Core needle biopsy

Breast MRI

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Tests and procedures used to diagnose breast cancer include:

 Breast exam. Your doctor will check both of your breasts and lymph nodes in your armpit, feeling
for any lumps or other abnormalities.

 Mammogram. A mammogram is an X-ray of the breast. Mammograms are commonly used to

screen for breast cancer. If an abnormality is detected on a screening mammogram, your doctor
may recommend a diagnostic mammogram to further evaluate that abnormality.

 Breast ultrasound. Ultrasound uses sound waves to produce images of structures deep within the
body. Ultrasound may be used to determine whether a new breast lump is a solid mass or a fluid-
filled cyst.

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  Removing a sample of breast cells for testing (biopsy). A biopsy is the only definitive way to
make a diagnosis of breast cancer. During a biopsy, your doctor uses a specialized needle
device guided by X-ray or another imaging test to extract a core of tissue from the suspicious
area. Often, a small metal marker is left at the site within your breast so the area can be easily
identified on future imaging tests.

Biopsy samples are sent to a laboratory for analysis where experts determine whether the cells
are cancerous. A biopsy sample is also analyzed to determine the type of cells involved in the
breast cancer, the aggressiveness (grade) of the cancer, and whether the cancer cells have
hormone receptors or other receptors that may influence your treatment options.

 Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio waves to
create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye.
Unlike other types of imaging tests, an MRI doesn't use radiation to create the images.

Other tests and procedures may be used depending on your situation.

Research shows that people who are treated for breast cancer at medical centers that treat many cases of
breast cancer have better outcomes than do people treated at medical centers that treat breast cancer less
frequently. With campuses in Arizona, Florida and Minnesota, Mayo Clinic's multidisciplinary teams
diagnose and treat breast cancer, including rare types, for more than 9,500 patients each year.

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Staging breast cancer

Once your doctor has diagnosed your breast cancer, he or she works to establish the extent (stage) of your
cancer. Your cancer's stage helps determine your prognosis and the best treatment options.

Complete information about your cancer's stage may not be available until after you undergo breast cancer
surgery.

Tests and procedures used to stage breast cancer may include:

 Blood tests, such as a complete blood count

 Mammogram of the other breast to look for signs of cancer

 Breast MRI

 Bone scan

 Computerized tomography (CT) scan

 Positron emission tomography (PET) scan

Not all women will need all of these tests and procedures. Your doctor selects the appropriate tests based
on your specific circumstances and taking into account new symptoms you may be experiencing.

Breast cancer stages range from 0 to IV with 0 indicating cancer that is noninvasive or contained within the
milk ducts. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread
to other areas of the body.

Breast cancer staging also takes into account your cancer's grade; the presence of tumor markers, such as
receptors for estrogen, progesterone and HER2; and proliferation factors.

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Grade is a “score” that tells you how different the cancer cells’ appearance and growth patterns are from
those of normal, healthy breast cells. Your pathology report will rate the cancer on a scale from 1 to 3:

 Grade 1 or low grade (sometimes also called well differentiated): Grade 1 cancer cells look a little bit
different from normal cells, and they grow in slow, well-organized patterns. Not that many cells are
dividing to make new cancer cells.

 Grade 2 or intermediate/moderate grade (moderately differentiated): Grade 2 cancer cells do not

look like normal cells and are growing and dividing a little faster than normal.

 Grade 3 or high grade (poorly differentiated): Grade 3 cells look very different from normal cells.
They grow quickly in disorganized, irregular patterns, with many dividing to make new cancer cells.

Stage

The stage of a breast cancer is determined by the cancer’s characteristics, such as how large it is and
whether or not it has hormone receptors. The stage of the cancer helps you and your doctor:

 figure out your prognosis, the likely outcome of the disease

 decide on the best treatment options for you

 determine if certain clinical trials may be a good option for you

Breast cancer stage is usually expressed as a number on a scale of 0 through IV — with stage 0 describing
non-invasive cancers that remain within their original location and stage IV describing invasive cancers that
have spread outside the breast to other parts of the body.

How a breast cancer’s stage is determined

Your pathology report will include information that is used to calculate the stage of the breast cancer — that
is, whether it is limited to one area in the breast, or it has spread to healthy tissues inside the breast or to
other parts of the body. Your doctor will begin to determine this during surgery to remove the cancer and
look at one or more of the underarm lymph nodes, which is where breast cancer tends to travel first. He or
she also may order additional blood tests or imaging tests if there is reason to believe the cancer might
have spread beyond the breast.

Stage 0

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Stage 0 is used to describe non-invasive breast cancers, such as DCIS (ductal carcinoma in situ). In stage
0, there is no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the
breast in which they started, or getting through to or invading neighboring normal tissue.

Stage I
Stage I describes invasive breast cancer (cancer cells are breaking through to or invading normal
surrounding breast tissue) Stage I is divided into subcategories known as IA and IB.

In general, stage IA describes invasive breast cancer in which:

 the tumor measures up to 2 centimeters (cm) and

 the cancer has not spread outside the breast; no lymph nodes are involved

In general, stage IB describes invasive breast cancer in which:

 there is no tumor in the breast; instead, small groups of cancer cells — larger than 0.2 millimeter
(mm) but not larger than 2 mm — are found in the lymph nodes or

 there is a tumor in the breast that is no larger than 2 cm, and there are small groups of cancer cells
— larger than 0.2 mm but not larger than 2 mm — in the lymph nodes

Still, if the cancer is estrogen-receptor-positive or progesterone-receptor-positive, it is likely to be classified

as stage IA.

Microscopic invasion is possible in stage I breast cancer. In microscopic invasion, the cancer cells have just
started to invade the tissue outside the lining of the duct or lobule, but the invading cancer cells can't
measure more than 1 mm.

Stage II
Stage II is divided into subcategories known as IIA and IIB.

In general, stage IIA describes invasive breast cancer in which:

 no tumor can be found in the breast, but cancer (larger than 2 millimeters [mm]) is found in 1 to 3
axillary lymph nodes (the lymph nodes under the arm) or in the lymph nodes near the breast bone
(found during a sentinel node biopsy) or

 the tumor measures 2 centimeters (cm) or smaller and has spread to the axillary lymph nodes or

23
  the tumor is larger than 2 cm but not larger than 5 cm and has not spread to the axillary lymph nodes

Still, if the cancer tumor measures between 2 and 5 cm and:

 has not spread to the lymph nodes or parts of the body away from the breast

 is HER2-negative

it will likely be classified as stage I.

Similarly, if the cancer tumor measures between 2 and 5 cm and:

 has not spread to the lymph nodes

 is HER2-negative

 is estrogen-receptor-positive

 is progesterone-receptor-negative

 has an Oncotype DX Recurrence Score of 9

it will likely be classified as stage IA.

In general, stage IIB describes invasive breast cancer in which:

 the tumor is larger than 2 cm but no larger than 5 centimeters; small groups of breast cancer cells —
larger than 0.2 mm but not larger than 2 mm — are found in the lymph nodes or

 the tumor is larger than 2 cm but no larger than 5 cm; cancer has spread to 1 to 3 axillary lymph
nodes or to lymph nodes near the breastbone (found during a sentinel node biopsy) or

 the tumor is larger than 5 cm but has not spread to the axillary lymph nodes

Still, if the cancer tumor measures between 2 and 5 cm and:

 cancer is found in 1 to 3 axillary lymph nodes

 is HER2-positive

 estrogen-receptor-positive

 progesterone-receptor-positive

24
it will likely be classified as stage I.

Stage III
Stage III is divided into subcategories known as IIIA, IIIB, and IIIC.

In general, stage IIIA describes invasive breast cancer in which either:

 no tumor is found in the breast or the tumor may be any size; cancer is found in 4 to 9 axillary lymph
nodes or in the lymph nodes near the breastbone (found during imaging tests or a physical exam) or

 the tumor is larger than 5 centimeters (cm); small groups of breast cancer cells (larger than 0.2
millimeter [mm] but not larger than 2 mm) are found in the lymph nodes or

 the tumor is larger than 5 cm; cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes
near the breastbone (found during a sentinel lymph node biopsy)

Still, if the cancer tumor measures more than 5 cm across and:

 is grade 2

 cancer is found in 4 to 9 axillary lymph nodes

 is estrogen-receptor-positive

 is progesterone-receptor-positive

 is HER2-positive

it will likely be classified as stage IB.

In general, stage IIIB describes invasive breast cancer in which:

 the tumor may be any size and has spread to the chest wall and/or skin of the breast and caused
swelling or an ulcer and

 may have spread to up to 9 axillary lymph nodes or

 may have spread to lymph nodes near the breastbone

Still, if the cancer tumor measures more than 5 cm across and:

 is grade 3

25
  cancer is found in 4 to 9 axillary lymph nodes

 is estrogen-receptor-positive

 is progesterone-receptor-positive

 is HER2-positive

it will likely be classified as stage IIA.

Inflammatory breast cancer is considered at least stage IIIB. Typical features of inflammatory breast cancer
include:

 reddening of a large portion of the breast skin

 the breast feels warm and may be swollen

 cancer cells have spread to the lymph nodes and may be found in the skin

In general, stage IIIC describes invasive breast cancer in which:

 there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have
spread to the chest wall and/or the skin of the breast and

 the cancer has spread to 10 or more axillary lymph nodes or

 the cancer has spread to lymph nodes above or below the collarbone or

 the cancer has spread to axillary lymph nodes or to lymph nodes near the breastbone

Still, if the above-mentioned cancer tumor measures any size and:

 is grade 2

 is estrogen-receptor-positive

 is progesterone-receptor-positive

 is HER2-positive or negative

it will likely be classified as stage IIIA.

Learn about what treatments you can generally expect for stage IIIA, IIIB, and IIIC in the Options by Cancer
Stage: Stage IIIA, IIIB, and IIIC page in Planning Your Treatment.

26
Stage IV
Stage IV describes invasive breast cancer that has spread beyond the breast and nearby lymph nodes to
other organs of the body, such as the lungs, distant lymph nodes, skin, bones, liver, or brain.

You may hear the words “advanced” and “metastatic” used to describe stage IV breast cancer. Cancer may
be stage IV at first diagnosis, called “de novo” by doctors, or it can be a recurrence of a previous breast
cancer that has spread to other parts of the body.

Note:

Be careful not to confuse grade with stage, which is usually expressed as a number from 0 to 4 (often using
Roman numerals I, II, III, IV). Stage is based on the size of the cancer and how far it has (or hasn’t) spread
beyond its original location within the breast.

Having a low-grade cancer is an encouraging sign. But keep in mind that higher-grade cancers may be
more vulnerable than low-grade cancers to treatments such as chemotherapy and radiation therapy, which
work by targeting fast-dividing cells.

VII. Treatment

Breast cancer surgery

Mastectomy

27
 

Sentinel node biopsy

Radiation therapy

28
Operations used to treat breast cancer include:

 Removing the breast cancer (lumpectomy).During a lumpectomy, which may be referred to as

breast-conserving surgery or wide local excision, the surgeon removes the tumor and a small
margin of surrounding healthy tissue.

A lumpectomy may be recommended for removing smaller tumors. Some people with larger
tumors may undergo chemotherapy before surgery to shrink a tumor and make it possible to
remove completely with a lumpectomy procedure.

 Removing the entire breast (mastectomy). A mastectomy is an operation to remove all of your
breast tissue. Most mastectomy procedures remove all of the breast tissue — the lobules, ducts,
fatty tissue and some skin, including the nipple and areola (total or simple mastectomy).

Newer surgical techniques may be an option in selected cases in order to improve the
appearance of the breast. Skin-sparing mastectomy and nipple-sparing mastectomy are
increasingly common operations for breast cancer.

 Removing a limited number of lymph nodes (sentinel node biopsy). To determine whether
cancer has spread to your lymph nodes, your surgeon will discuss with you the role of removing
the lymph nodes that are the first to receive the lymph drainage from your tumor.

If no cancer is found in those lymph nodes, the chance of finding cancer in any of the remaining
lymph nodes is small and no other nodes need to be removed.

 Removing several lymph nodes (axillary lymph node dissection). If cancer is found in the
sentinel lymph nodes, your surgeon will discuss with you the role of removing additional lymph
nodes in your armpit.

 Removing both breasts. Some women with cancer in one breast may choose to have their other
(healthy) breast removed (contralateral prophylactic mastectomy) if they have a very increased
risk of cancer in the other breast because of a genetic predisposition or strong family history.

Most women with breast cancer in one breast will never develop cancer in the other breast.
Discuss your breast cancer risk with your doctor, along with the benefits and risks of this
procedure.

29
Complications of breast cancer surgery depend on the procedures you choose. Breast cancer surgery
carries a risk of pain, bleeding, infection and arm swelling (lymphedema).

You may choose to have breast reconstruction after surgery. Discuss your options and preferences with
your surgeon.

Consider a referral to a plastic surgeon before your breast cancer surgery. Your options may include
reconstruction with a breast implant (silicone or water) or reconstruction using your own tissue. These
operations can be performed at the time of your mastectomy or at a later date.

Radiation therapy

Radiation therapy uses high-powered beams of energy, such as X-rays and protons, to kill cancer cells.
Radiation therapy is typically done using a large machine that aims the energy beams at your body
(external beam radiation). But radiation can also be done by placing radioactive material inside your body
(brachytherapy).

External beam radiation of the whole breast is commonly used after a lumpectomy. Breast brachytherapy
may be an option after a lumpectomy if you have a low risk of cancer recurrence.

Doctors may also recommend radiation therapy to the chest wall after a mastectomy for larger breast
cancers or cancers that have spread to the lymph nodes.

Breast cancer radiation can last from three days to six weeks, depending on the treatment. A doctor who
uses radiation to treat cancer (radiation oncologist) determines which treatment is best for you based on
your situation, your cancer type and the location of your tumor.

Side effects of radiation therapy include fatigue and a red, sunburn-like rash where the radiation is aimed.
Breast tissue may also appear swollen or more firm. Rarely, more-serious problems may occur, such as
damage to the heart or lungs or, very rarely, second cancers in the treated area.

30
Chemotherapy

Chemotherapy uses drugs to destroy fast-growing cells, such as cancer cells. If your cancer has a high risk
of returning or spreading to another part of your body, your doctor may recommend chemotherapy after
surgery to decrease the chance that the cancer will recur.

Chemotherapy is sometimes given before surgery in women with larger breast tumors. The goal is to shrink
a tumor to a size that makes it easier to remove with surgery.

Chemotherapy is also used in women whose cancer has already spread to other parts of the body.
Chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer
is causing.

Chemotherapy side effects depend on the drugs you receive. Common side effects include hair loss,
nausea, vomiting, fatigue and an increased risk of developing an infection. Rare side effects can include
premature menopause, infertility (if premenopausal), damage to the heart and kidneys, nerve damage, and,
very rarely, blood cell cancer.

Hormone therapy

Hormone therapy — perhaps more properly termed hormone-blocking therapy — is often used to treat
breast cancers that are sensitive to hormones. Doctors sometimes refer to these cancers as estrogen
receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers.

Hormone therapy can be used before or after surgery or other treatments to decrease the chance of your
cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.

Treatments that can be used in hormone therapy include:

31
  Medications that block hormones from attaching to cancer cells (selective estrogen receptor
modulators)

 Medications that stop the body from making estrogen after menopause (aromatase inhibitors)

 Surgery or medications to stop hormone production in the ovaries

Hormone therapy side effects depend on your specific treatment, but may include hot flashes, night sweats
and vaginal dryness. More serious side effects include a risk of bone thinning and blood clots.

Targeted therapy drugs

Targeted drug treatments attack specific abnormalities within cancer cells. As an example, several targeted
therapy drugs focus on a protein that some breast cancer cells overproduce called human epidermal
growth factor receptor 2 (HER2). The protein helps breast cancer cells grow and survive. By targeting cells
that make too much HER2, the drugs can damage cancer cells while sparing healthy cells.

Targeted therapy drugs that focus on other abnormalities within cancer cells are available. And targeted
therapy is an active area of cancer research.

Your cancer cells may be tested to see whether you might benefit from targeted therapy drugs. Some
medications are used after surgery to reduce the risk that the cancer will return. Others are used in cases
of advanced breast cancer to slow the growth of the tumor.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of
a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an
extra layer of support that complements your ongoing care. Palliative care can be used while undergoing
other aggressive treatments, such as surgery, chemotherapy or radiation therapy.

32
When palliative care is used along with all of the other appropriate treatments, people with cancer may feel
better and live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative
care teams aim to improve the quality of life for people with cancer and their families. This form of care is
offered alongside curative or other treatments you may be receiving.

VIII. Nursing management

Anticipatory Grieving

Grieving: A normal complex process that includes emotional, physical, spiritual, social, and intellectual
responses and behaviors by which individuals, families, and communities incorporate an actual,
anticipated, or perceived loss into their daily lives.

May be related to

- Anticipated loss of physiological wellbeing (e.g., loss of body part, change in body function, change
in lifestyle
- Perceived potential death of patient

Possibly evidenced by:

- Changes in eating habits, alteration in sleep patterns, activity levels, libido and communication
patterns
- Denial of potential loss, anger

Desired outcomes

- Identify and express feelings appropriately

- Continue normal life acitivits, looking toward/planning for the future, one day at a time.
- Verbalize understanding of the dying process and feelings of being supported in grief work.

Nursing Interventions Rationale

Expect initial shock and disbelief following Few patients are fully prepared for the reality of the

33
 Nursing Interventions Rationale

diagnosis of cancer and traumatizing changes that can occur.

procedures (disfiguring surgery, colostomy,
amputation).

Knowledge about the grieving process reinforces

Assess patient and SO for stage of grief
the normality of feelings and reactions being
currently being experienced. Explain process
experienced and can help patient deal more
as appropriate.
effectively with them.

Provide open, nonjudgmental environment. Use

Promotes and encourages realistic dialogue about
therapeutic communication skills of Active-
feelings and concerns.
Listening, acknowledgment, and so on.

Encourage verbalization of thoughts or Patient may feel supported in expression of feelings

concerns and accept expressions of sadness, by the understanding that deep and often conflicting
anger, rejection. Acknowledge normality of emotions are normal and experienced by others in
these feelings. this difficult situation.

Indicators of ineffective coping and need for

Be aware of mood swings, hostility, and other
additional interventions. Preventing destructive
acting-out behavior. Set limits on inappropriate
actions enables patient to maintain control and
behavior, redirect negative thinking.
sense of self-esteem.

Studies show that many cancer patients are at high

Be aware of debilitating depression. Ask patient risk for suicide. They are especially vulnerable
direct questions about state of mind. when recently diagnosed and discharged from
hospital.

Visit frequently and provide physical contact as

appropriate, or provide frequent phone support
Helps reduce feelings of isolation and
as appropriate for setting. Arrange for care
abandonment.
provider and support person to stay with patient
as needed.

Reinforce teaching regarding disease process Patient and SO benefit from factual information.
and treatments and provide information as Individuals may ask direct questions about death,
appropriate about dying. Be honest; do not give and honest answers promote trust and provide
false hope while providing emotional support. reassurance that correct information will be given.

Review past life experiences, role changes, Opportunity to identify skills that may help
and coping skills. Talk about things that interest individuals cope with grief of current situation more
the patient. effectively.

34
 Nursing Interventions Rationale

Interpersonal conflicts or angry behavior may be

Note evidence of conflict; expressions of anger;
patient’s way of expressing and dealing with
and statements of despair, guilt, hopelessness,
feelings of despair or spiritual distress and could be
“nothing to live for.”
indicative of suicidal ideation.

Determine way that patient and SO understand

and respond to death such as cultural
These factors affect how each individual deals with
expectations, learned behaviors, experience
the possibility of death and influences how they
with death (close family members, friends),
may respond and interact.
beliefs about life after death, faith in Higher
Power (God).

Possibility of remission and slow progression of

Identify positive aspects of the situation. disease and new therapies can offer hope for the
future.

Discuss ways patient and SO can plan together

Having a part in problem solving and planning can
for the future. Encourage setting of realistic
provide a sense of control over anticipated events.
goals.

Provides support in meeting physical and emotional

Refer to visiting nurse, home health agency as
needs of patient and SO, and can supplement the
needed, or hospice program, if appropriate.
care family and friends are able to give.

Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage
or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with
anticipated or predictable end and a duration of <6 months.

May be related to

 Disease process (compression/destruction of nerve tissue, infiltration of nerves or their vascular

supply, obstruction of a nerve pathway, inflammation)
 Side effects of various cancer therapy agents

Possibly evidenced by

35
  Reports of pain
 Self-focusing/narrowed focus
 Alteration in muscle tone; facial mask of pain
 Distraction/guarding behaviors
 Autonomic responses, restlessness (acute pain)

Desired Outcomes

 Report maximal pain relief/control with minimal interference with ADLs.

 Follow prescribed pharmacological regimen.
 Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions Rationale

Information provides baseline data to evaluate

Determine pain history (location of pain,
effectiveness of interventions. Pain of more than 6 mo
frequency, duration, and intensity using
duration constitutes chronic pain, which may affect
numeric rating scale (0–10 scale), or
therapeutic choices. Recurrent episodes of acute pain can
verbal rating scale (“no pain” to
occur within chronic pain, requiring increased level of
“excruciating pain”) and relief measures
intervention. Note: The pain experience is an individualized
used. Believe patient’s report.
one composed of both physical and emotional responses.

Pain may occur near the end of the dose interval, indicating
Determine timing or precipitants of
need for higher dose or shorter dose interval. Pain may be
“breakthrough” pain when using around-
precipitated by identifiable triggers, or occur spontaneously,
the-clock agents, whether oral, IV, or
requiring use of short half-life agents for rescue or
patch medications.
supplemental doses.

Evaluate and be aware of painful effects

A wide range of discomforts are common (incisional pain,
of particular therapies (surgery, radiation,
burning skin, low back pain, headaches), depending on the
chemotherapy, biotherapy). Provide
procedure and agent being used. Pain is also associated
information to patient and SO about what
with invasive procedures to diagnose or treat cancer.
to expect.

Provide nonpharmacological comfort

measures (massage, repositioning,
Promotes relaxation and helps refocus attention.
backrub) and diversional activities
(music, television)

Encourage use of stressmanagement

Enables patient to participate actively in nondrug treatment
skills or complementary therapies
of pain and enhances sense of control. Pain produces
(relaxation techniques, visualization,
stress and, in conjunction with muscle tension and internal
guided imagery, biofeedback, laughter,
stressors, increases patient’s focus on self, which in turn
music, aromatherapy, and therapeutic

36
Nursing Interventions Rationale

touch). increases the level of pain.

May decrease inflammation, muscle spasms, reducing

Provide cutaneous stimulation (heat or associated pain. Note: Heat may increase bleeding and
cold, massage). edema following acute injury, whereas cold may further
reduce perfusion to ischemic tissues.

Patients may be reluctant to report pain for reasons such as

fear that disease is worse; worry about unmanageable side
effects of pain medications; beliefs that pain has meaning,
Be aware of barriers to cancer pain such as “God wills it,” they should overcome it, or that pain
management related to patient, as well is merited or deserved for some reason. Healthcare system
as the healthcare system. problems include factors such as inadequate assessment
of pain, concern about controlled substances or patient
addiction, inadequate reimbursement or cost of treatment
modalities.

Evaluate pain relief and control at regular

Goal is maximum pain control with minimum interference
intervals. Adjust medication regimen as
with ADLs.
necessary.

Inform patient and SO of the expected

This information helps establish realistic expectations,
therapeutic effects and discuss
confidence in own ability to handle what happens.
management of side effects

Discuss use of additional alternative or

May provide reduction or relief of pain without drug-related
complementary therapies (acupuncture
side effects.
and acupressure).

Administer analgesics as indicated:

 Opioids: codeine, morphine

(MS Contin), oxycodone
(oxycontin) hydrocodone
(Vicodin), hydromorphone A wide range of analgesics and associated agents may be
(Dilaudid), methadone employed around the clock to manage pain. Note: Addiction
(Dolophine), fentanyl to or dependency on drug is not a concern.
(Duragesic); oxymorphone
(Numorphan);

 Acetaminophen Effective for localized and generalized moderate to severe

37
 Nursing Interventions Rationale

(Tylenol); and nonsteroidal pain, with long-acting and controlled-release forms

anti-inflammatory drugs available.
(NSAIDs), including aspirin,
ibuprofen (Motrin, Advil)

Routes of administration include oral, transmucosal,

 piroxicam (Feldene)
 indomethacin (Indocin)
 Corticosteroids:
dexamethasone (Decadron)
transdermal, nasal, rectal, and infusions (subcutaneous, IV,
intraventricular), which may be delivered via PCA. IM use is
not recommended because absorption is not reliable, in
addition to being painful and inconvenient. Note: Research
is in process for oral transmucosal agent (fentanyl citrate
[oralet]) to control breakthrough pain in patients using
fentanyl patch.
Adjuvant drugs are useful for mild to moderate pain and
can be combined with opioids and other modalities.
May be effective in controlling pain associated with
inflammatory process (metastatic bone pain, acute spinal
cordcompression and neuropathic pain).

Altered Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements:Intake of nutrients insufficient to meet metabolic

needs.

May be related to

 Hypermetabolic state associated with cancer

38
  Consequences of chemotherapy, radiation surgery, e.g anorexia, gastric irriatation, taste

distortions, nausea

 Emotional distress, fatigue, poorly controlled pain

Possibly evidenced by:

 Reported inadequate food intake, altered taste sensation, loss of interest in food, perceived/ actual

inability to ingest food

 body weight 20% or more under ideal for height and frame, decreased subcutaneous fat/muscle

mass

 sore/ inflamed buccal acitivity

 diarrhea and or constipation, abdominal cramping

Desired outcome

- demonstrate stable weight/ progressive weight gain toward goal with normalization

of laboratory values and be free of signs of malnutrition

- verbalize understanding of individual interferences to adequate intake

- participate in specific interventions to stimulate appetite. Increase dietary intake.

Nursing Interventions Rationale

39
Nursing Interventions Rationale

Monitor daily food intake; have patient

Identifies nutritional strengths and deficiencies.
keep food diary as indicated.

Measure height, weight, and tricep

skinfold thickness (or other If these measurements fall below minimum standards,
anthropometric measurements as patient’s chief source of stored energy (fat tissue) is
appropriate). Ascertain amount of recent depleted.
weight loss. Weigh daily or as indicated.

Assess skin and mucous membranes for Helps in identification of protein-calorie malnutrition,
pallor, delayed wound healing, enlarged especially when weight and anthropometric
parotid glands. measurements are less than normal.

Encourage patient to eat high-calorie,

Metabolic tissue needs are increased as well as fluids
nutrient-rich diet, with adequate fluid
(to eliminate waste products). Supplements can play an
intake. Encourage use of supplements
important role in maintaining adequate caloric and
and frequent or smaller meals spaced
protein intake.
throughout the day.

Create pleasant dining atmosphere;

Makes mealtime more enjoyable, which may enhance
encourage patient to share meals with
intake.
family and friends.

Often a source of emotional distress, especially for SO

Encourage open communication
who wants to feed patient frequently. When patient
regarding anorexia.
refuses, SO may feel rejected or frustrated.

Adjust diet before and immediately after The effectiveness of diet adjustment is very
treatment (clear, cool liquids, light or bland individualized in relief of posttherapy nausea. Patients
foods, candied ginger, dry crackers, toast, must experiment to find best solution or combination.
carbonated drinks). Give liquids 1 hr Avoiding fluids during meals minimizes becoming “full”

40
Nursing Interventions Rationale

before or 1 hr after meals. too quickly.

Control environmental factors (strong or

noxious odors or noise). Avoid overly Can trigger nausea and vomiting response.
sweet, fatty, or spicy foods.

Encourage use of relaxation techniques, May prevent onset or reduce severity of nausea,
visualization, guided imagery, moderate decrease anorexia, and enable patient to increase oral
exercise before meals. intake.

Psychogenic nausea and vomiting occurring before

Identify the patient who experiences
chemotherapy generally does not respond to antiemetic
anticipatory nausea and vomiting and take
drugs. Change of treatment environment or patient
appropriate measures.
routine on treatment day may be effective.

Administer antiemetic on a regular

Nausea and vomiting are frequently the most disabling
schedule before or during and after
and psychologically stressful side effects of
administration of antineoplastic agent as
chemotherapy.
appropriate.

Individuals respond differently to all medications. First-

Evaluate effectiveness of antiemetic. line antiemetics may not work, requiring alteration in or
use of combination drug therapy.

Certain therapies (antimetabolites) inhibit renewal of

epithelial cells lining the GI tract, which may cause
Hematest stools, gastric secretions.
changes ranging from mild erythema to severe
ulceration with bleeding.

Review laboratory studies as Helps identify the degree of biochemical imbalance,

41
Nursing Interventions Rationale

indicated (total lymphocyte count, serum malnutrition and influences choice of dietary
transferrin, and albumin or prealbumin). interventions. Note: Anticancer treatments can also
alter nutrition studies, so all results must be correlated
with the patient’s clinical status.

Provides for specific dietary plan to meet individual

Refer to dietitian or nutritional support needs and reduce problems associated with
team. protein, calorie malnutrition and micronutrient
deficiencies.

In the presence of severe malnutrition (loss of 25%–

Insert and maintain NG or feeding tube for 30% body weight in 2 mo) or if patient has been NPO
enteric feedings, or central line for total for 5 days and is unlikely to be able to eat for another
parenteral nutrition(TPN) if indicated. week, tube feeding or TPN may be necessary to meet
nutritional needs.

Fatigue

Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental

work at usual level.

May be related to:

42
  Decreased metabolic energy production, increased energy requirement (hypermetabolic state and

effects of treatment)

 Overwhelming psychological/emotional demands

 Altered body chemistry: side effects of pain and other medications, chemotherapy

Possibly evidenced by:

 Unremitting/ overwhelming lack of energy, inability to maintain usual routine, decreased

performance,impaired ability to concentrate, lethargy/ listlessness

 Disinterest in surroundings

Desired outcomes:

 Report improved sense of energy

 Perform ADLs and participate in desired activities at level of ability.

Nursing Interventions Rationale

Have patient rate fatigue, using a numeric

scale, if possible, and the time of day Helps in developing a plan for managing fatigue.
when it is most severe.

43
Nursing Interventions Rationale

Frequent rest periods and naps are needed to restore

Plan care to allow for rest periods.
and conserve energy. Planning will allow patient to be
Schedule activities for periods when
active during times when energy level is higher, which
patient has most energy. Involve patient
may restore a feeling of well-being and a sense of
and SO in schedule planning.
control.

Establish realistic activity goals with Provides for a sense of control and feelings of
patient. accomplishment.

Assist with self-care needs when

indicated; keep bed in low position, Weakness may make ADLs difficult to complete or
pathways clear of furniture; assist with place the patient at risk for injuryduring activities.
ambulation.

Encourage patient to do whatever

possible (self-bathing, sitting up in chair, Enhances strength and stamina and enables patient to
walking). Increase activity level as become more active without undue fatigue.
individual is able.

Monitor physiological response to activity Tolerance varies greatly depending on the stage of the
(changes in BP, heart and respiratory disease process, nutrition state, fluid balance, and
rate). reaction to therapeutic regimen.

Perform pain assessment and provide

Poorly managed cancer pain can contribute to fatigue.
pain management.

Presence of anemia and hypoxemia reduces

Provide supplemental oxygen as
O2available for cellular uptake and contributes to
indicated.
fatigue.

44
Nursing Interventions Rationale

Programmed daily exercises and activities help patient

maintain and increase strength and muscle tone,
Refer to physical or occupational therapy.
enhance sense of well-being. Use of adaptive devices
may help conserve energy.

Risk for Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.

Risk factors may include

 Inadequate secondary defenses and immunosuppression, e.g., bone marrow suppression (dose-
limiting side effect of both chemotherapy and radiation).
 Malnutrition, chronic disease process
 Invasive procedures

Desired Outcomes

 Remain afebrile and achieve timely healing appropriate.

 Identify and participate in interventions to prevent/ reduce risk of infection.

Nursing Interventions Rationale

Promote good handwashingprocedures by

Protects patient from sources of infection, such as visitors
staff and visitors. Screen and limit visitors
and staff who may have an upper respiratory infection
who may have infections. Place in reverse
(URI).
isolation as indicated.

Limits potential sources of infection and secondary

Emphasize personal hygiene.
overgrowth.

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Nursing Interventions Rationale

Temperature elevation may occur (if not masked by

corticosteroids or anti-inflammatory drugs) because of
various factors (chemotherapy side effects, disease
Monitor temperature.
process, or infection). Early identification of infectious
process enables appropriate therapy to be started
promptly.

Assess all systems (skin, respiratory,

Early recognition and intervention may prevent
genitourinary) for signs and symptoms of
progression to more serious situation or sepsis.
infection on a continual basis.

Reduces pressure and irritation to tissues and may

Reposition frequently; keep linens dry and
prevent skin breakdown (potential site for bacterial
wrinkle-free.
growth).

Limits fatigue, yet encourages sufficient movement to

Promote adequate rest and exercise
prevent stasis complications (pneumonia, decubitus,
periods.
and thrombusformation).

Development of stomatitis increases risk of infection and

Stress importance of good oral hygiene.
secondary overgrowth.

Avoid or limit invasive procedures. Adhere Reduces risk of contamination, limits portal of entry for
to aseptic techniques. infectious agents.

Bone marrow activity may be inhibited by effects of

Monitor CBC with differential WBC and chemotherapy, the disease state, or radiation therapy.
granulocyte count, and platelets as Monitoring status of myelosuppression is important for
indicated. preventing further complications (infection, anemia, or
hemorrhage) and scheduling drug delivery.

Obtain cultures as indicated. Identifies causative organism(s) and appropriate therapy.

May be used to treat identified infection or given

Administer antibiotics as indicated.
prophylactically in immuno- compromised patient.

NURSING MANAGEMENT FOR LYMPHEDEMA

Treatment

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There's no cure for lymphedema. Treatment focuses on reducing the swelling and controlling the pain.
Lymphedema treatments include:

 Exercises. Light exercises in which you move your affected limb may encourage lymph fluid
drainage and help prepare you for everyday tasks, such as carrying groceries. Exercises shouldn't
be strenuous or tire you but should focus on gentle contraction of the muscles in your arm or leg.
A certified lymphedema therapist can teach you exercises that may help.

 Wrapping your arm or leg. Bandaging your entire limb encourages lymph fluid to flow back
toward the trunk of your body. The bandage should be tightest around your fingers or toes and
loosen as it moves up your arm or leg. A lymphedema therapist can show you how to wrap your
limb.

 Massage. A special massage technique called manual lymph drainage may encourage the flow of
lymph fluid out of your arm or leg. And various massage treatments may benefit people with active
cancer. Be sure to work with someone specially trained in these techniques.

Massage isn't for everyone. Avoid massage if you have a skin infection, blood clots or active
disease in the involved lymph drainage areas.

 Pneumatic compression. A sleeve worn over your affected arm or leg connects to a pump that
intermittently inflates the sleeve, putting pressure on your limb and moving lymph fluid away from
your fingers or toes.

 Compression garments. Long sleeves or stockings made to compress your arm or leg encourage
the flow of the lymph fluid out of your affected limb. Wear a compression garment when exercising
the affected limb.

Obtain a correct fit for your compression garment by getting professional help. Ask your doctor
where you can buy compression garments in your community. Some people will require custom-
made compression garments.

If you have difficulties putting on or taking off the compression garment, there are special
techniques and aids to help with this; your lymphedema therapist can review options with you. In
addition, if compression garments or compression wraps or both are not an option, sometimes a
compression device with fabric fasteners can work for you.

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  Complete decongestive therapy (CDT). This approach involves combining therapies with lifestyle
changes. Generally, CDT isn't recommended for people who have high blood pressure, diabetes,
paralysis, heart failure, blood clots or acute infections.

In cases of severe lymphedema, your doctor may consider surgery to remove excess tissue in your arm or
leg to reduce swelling. There are also newer techniques for surgery that might be appropriate, such as
lymphatic to venous anastomosis or lymph node transplants.

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REFERENCES

Hinkle, Janice Cheever, Kerry 2014. Brunner and Suddarth’s Textbook of Medical and Surgical Nursing 13th edition.

1680-1709.

https://nurseslabs.com/cancer-nursing-care-plans/7/

https://www.cancer.org/cancer/breast-cancer/understanding-a-breast-cancer-diagnosis/types-of-breast-
cancer.html

https://en.wikipedia.org/wiki/Cancer_cell

https://www.medicalnewstoday.com/articles/37136.php

https://www.mayoclinic.org/diseases-conditions/lymphedema/diagnosis-treatment/drc-20374687

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