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R
eview of theAnatomy and Physiology
of the Breast
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What is breast cancer?
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Common causes Gender is the biggest risk because
breast cancer occurs mostly in women.
Age is another critical factor. Breast
cancer may occur at any age, but it ismore common in age 40 and up.
A woman with a personal history of
cancer in one breast . Genetic causes. Family history has long
been known to be a risk facto for
breast cancer.
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Common causes Lifestyle and diet. Breast cancer seems
to occur more frequently in countries
with high dietary intake of fat, and
being overweight or obese is a knownrisk factor for breast cancer,
particularly in postmenopausal
women.
Environmental causes like exposure
from radiation.
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Symptoms Early breast cancer has no symptoms. It is usually
not painful.
A lump in the armpit or above the collarbone
that does not go away.
Breast discharge. Discharge is most concerning ifit is from only one breast or if it is bloody.
Nipple inversion. Nipple inversion is a common
variant of normal nipples, but nipple inversion
that is a new development can be of concern. Changes in the skin of the breast include redness,
changes in texture, and puckering. These changes
are usually caused by skin diseases but
occasionally can be associated with breastcancer.
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Diagnostic Tests
Examination ofthe Breast
A complete breast examination includes
visual inspection and careful palpation
(feeling) of the breasts, the armpits,and the areas around your collarbone.
During that exam, your health-care
provider may palpate a lump or just feela thickening.
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Diagnostic TestsMammography
Mammograms are x-rays of the breast that
may help define the nature of a lump.
Mammograms are also recommended for
screening to find early cancer. Usually, it is possible to tell from the
mammogram whether a lump in the breast is
breast cancer, but no test is 100% reliable.
Mammograms are thought to miss as manyas 10-15% of breast cancers.
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Diagnostic TestsUltrasound
Ultrasound of the breast is often done
to evaluate a breast lump.
Ultrasound waves create a "picture" of
the inside of the breast.
It can demonstrate whether a mass is
filled with fluid (cystic) or solid. Cancers
are usually solid, while many cysts arebenign.
Ultrasound might also be used to guide
a biopsy or the removal of fluid.
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Diagnostic TestsMRI
MRI may provide additional information
and may clarify findings which have
been seen on mammography or
ultrasound.
MRI is not routine for screening for
cancer but may be recommended in
special situations.
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Diagnostic TestsBiopsy
The only way to diagnose breast cancer withcertainty is to biopsy the tissue in question.
Biopsy means to take a very small piece of
tissue from the body for examination and
testing by a pathologist to determine if canceris present. A number of biopsy techniques are
available.
Fine-needle aspiration consists of placing a
needle into the breast and sucking out some
cells to be examined by a pathologist. This
technique is used most commonly when a
fluid-filled mass is identified and cancer is not
likel .
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Diagnostic Tests Core-needle biopsy is performed with a
special needle that takes a small piece oftissue for examination. Usually the needle is
directed into the suspicious area with
ultrasound or mammogram guidance. This
technique is being used more and morebecause it is less invasive than surgical biopsy.
It obtains only a sample of tissue rather than
removing an entire lump. Occasionally, if the
mass is easily felt, cells may be removed witha needle without additional guidance.
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Diagnostic Tests Surgical biopsy is done by making an
incision in the breast and removing thepiece of tissue. Certain techniques
allow removal of the entire lump.
Regardless of how the biopsy is taken,the tissue will be reviewed by a
pathologist. These are physicians who
are specially trained in diagnosing
diseases by looking at cells and tissues
under a microscope.
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Diagnostic Tests If a cancer is diagnosed on biopsy, the tissue
will be tested for hormone receptors.Receptors are sites on the surface of tumor
cells that bind to estrogen or progesterone. In
general, the more receptors, the more
sensitive the tumor will be to hormonetherapy. There are also other tests (for
example, measurement of HER-2/neu
receptors) that may be performed to help
characterize a tumor and determine the typeof treatment that will be most effective for a
given tumor.
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Stages ofbreast cancer Stage 0 is noninvasive breast cancer, that is,
carcinoma in situ with no affected lymph nodes or
metastasis. This is the most favorable stage of breast
cancer.
Stage I is breast cancer that is less than 2 cm (3/4 in)
in diameter and has not spread from the breast.
Stage II is breast cancer that is fairly small in size buthas spread to lymph nodes in the armpit OR cancer
that is somewhat larger but has not spread to the
lymph nodes.
Stage III is breast cancer of a larger size, greater than5 cm (2 in), with greater lymph node involvement, or
of the inflammatory type.
Stage IV is metastatic breast cancer: a tumor of any
size or type that has metastasized to another part of
the body. This is the least favorable stage.
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TreatmentRadiation therapy is used to kill tumor cells if there are
any left after surgery.
Radiation is a local treatment and therefore works
only on tumor cells that are directly in its beam.
Radiation is used most often in people who have
undergone conservative surgery such as lumpectomy.
Conservative surgery is designed to leave as much ofthe breast tissue in place as possible.
Radiation therapy is usually given five days a week
over five to six weeks. Each treatment takes only a
few minutes. Radiation therapy is painless and has relatively few
side effects. However, it can irritate the skin or cause
a burn similar to a bad sunburn in the area.
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TreatmentChemotherapy consists of the administration
ofmedications that kill cancer cells or stop them from
growing. In breast cancer, three different
chemotherapy strategies may be used:
1. Adjuvant chemotherapy is given to people who have
had curative treatment for their breast cancer, such
as surgery and radiation. It is given to reduce thepossibility that the cancer will return.
2. Pre-surgical chemotherapy is given to shrink a large
tumor and/or to kill stray cancer cells. This increases
the chances that surgery will get rid of the cancer
completely.
3. Therapeutic chemotherapy is routinely administered
to women with breast cancer that has spread
beyond the confines of the breast or local area.
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TreatmentHormonal therapy may be given because breast
cancers (especially those that have ampleestrogen or progesterone receptors) are
frequently sensitive to changes in hormones.
Hormonal therapy may be given to prevent
recurrence of a tumor or for treatment ofexisting disease.
Tamoxifen (Nolvadex), an antiestrogen (a
drug that blocks the effect of estrogen), hasbeen the most commonly prescribed
hormone treatment. It is used both for breast
cancer prevention and for treatment.
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Treatment Fulvestrant (Faslodex) is another drug
that acts via the estrogen receptor, butinstead of blocking it, this drug
eliminates it. It can be effective if the
breast cancer is no longer responding to
tamoxifen. Fulvestrant is only given to
women who are already in menopause
and is approved for use in women with
advanced breast cancer. Toremifene (Fareston) is another anti-
estrogen drug closely related to
tamoxifen.
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Treatment
Aromatase inhibitors, which block theeffect of a key hormone affecting the
tumor, may be more effective than
tamoxifen in the adjuvant setting. Thedrugs anastrozole (Arimidex),
exemestane (Aromasin), and letrozole
(Femera) have a different set of side
effects and risks than tamoxifen.
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At the time of lumpectomy, the axillary lymph
nodes (the glands in the armpit) need to be
evaluated for the spread of cancer. This can
be done by either removing the lymph nodesor by sentinel node biopsy (biopsy of the
closest lymph node to the tumor).
If a sentinel node biopsy is done at the time
of lumpectomy, it may allow the surgeon to
remove only some of the lymph nodes. In this
procedure, a dye is injected into the area of
the tumor. The path of the substance is then
followed as it travels to the lymph nodes. The
first node reached is the sentinel node. This
node is considered most important to biopsy
when evaluating the spread of the tumor.
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Radical mastectomy involves removal ofthe breast and the underlying chest wall
muscles, as well as the underarm
contents. This surgery is no longer done
because current therapies are less
disfiguring and have fewer
complications.
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Prevention
Mammograms are recommended every one to two
years starting at age 40 years. For women at high risk
for the development of breast cancer, mammogramscreening may start earlier, generally 10 years prior to
the age at which the youngest close relative developed
breast cancer.
Obesity after menopause and excessive alcohol intakemay increase the risk of breast cancer slightly.
Physically active women may have a lower risk. All
women are encouraged to maintain normal body
weight, especially after menopause and to limit excess
alcohol intake. Hormone replacement should belimited in duration if it is medically required.
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Nursing Interventions
Monitor for adverse effects of radiation therapy such
as fatigue, sore throat, dry cough, nausea, anorexia.
Monitor for adverse effects of chemotherapy; bone
marrow suppression, nausea and vomiting, alopecia,
weight gain or loss, fatigue, stomatitis, anxiety, and
depression.
Realize that a diagnosis of breast cancer is adevastating emotional shock to the woman. Provide
psychological support to the patient throughout the
diagnostic and treatment process.
Involve the patient in planning and treatment.
Describe surgical procedures to alleviate fear.
Prepare the patient for the effects of chemotherapy,
and plan ahead for alopecia, fatigue.
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Nursing Interventions
Administer antiemetics prophylactically, as directed,
for patients receiving chemotherapy. Administer I.V.
fluids as indicated.
Help patient identify and use support persons or
family or community.
Suggest to the patient the psychological interventions
may be necessary for anxiety, depression, or sexualproblems.
Teach all women the recommended cancer-screening
procedures.
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THE END.
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