question

most common malignancy in american women except for skin cancer

answer

breast cancer it is second only to lung cancer as the leading cause of death from cancer in women

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incidence of breast cancer is slowly

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decreasing

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Risk factors most associated with breast cancer (2)

answer

female gender advancing age

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After age ___ the incidence of breast cancer increases dramatically

answer

60

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the hormones _____ and ______ may act as tumor promoters to stimulate breast cancer growth if malignant changes in the cells have already occurred

answer

estrogen and progesterone

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combined hormone therapy (estrogen plus progesterone) increases

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the risk of breast cancer and also the risk of having a larger more advanced breast cancer at diagnosis

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The use of estrogen therapy along for longer than __ years (for women with a prior hysterectomy)

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increases a wonan's long term risk for breast cancer 10 years

question

Modifiable risk factors

answer

excess weight gain during adulthood sedentary lifestyle smoking dietary fat intake obesity alcohol intake radiation exposure

question

risk factors

answer

age >60 hormone use family hx BRCA1 or BRCA2 play a 5-10% role of breast cancer cases (genetic) Personal hx of breast cancer, colon, endometrial, ovarian cancer EARLY menarch (before age 12), late menopause (after 55) first full term pregnancy AFTER age 30, nulliparity benign breast disease with atypical epithelial hyperplasia, lobular carcinoma in situ dense breast tissue weight gain and obesity after menopause exposure to ionizing radiation alcohol consumption physical inactivity

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family hx of breast cancer is an important risk factor, esp if the involve family member also had

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ovarian cancer, was premenopausal, had bilateral breast cancer, or is a first degree relative

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Having any first degree relative with breast cancer increases a woman's risk of breast cancer

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1.5-3 times

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about ______ % of all breast cancers are hereditary

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5-10%

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most inherited breast cancers are associated with mutations in BRCA1 and BRCA2

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everyone has BRCA geness BRCA1 is located on chromosome 17 and is a tumor suppressor gene that inhibits tumor development when functioning normally BRCA2 located on chromosome `11 is another tumor suppressor gene

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women with BRCA mutations are also at a higher risk for developing

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ovarian colon pancreatic and uterine cancers

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most people who develop breast cancer do NOT inherit an abnormal breast cancer gene and they DO NOT have a family

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hx of breast cancer

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Risk factors for men

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hyperestrogenism family hx radiation exposure men with abnormal BRCA gene also have increased risk of developing prostate cancer

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in women with BRCA1 or BRCA 2 mutations, prophylactic bilateral oophorectomy can

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decrease the risk of breast cancer and ovarian cancer Removing ovaries lowers risk of breast cancer bc the ovaries are the main source of estrogen in premenopausal women Removing the ovaries DOES NOT reduce the risk of breast cancer in POSTMENOPAUSAL women bc the ovaries are not the main producers of estrogen in these women

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younger women with hereditary (non-BRCA) early stage, estrogen receptor negative breast cancer may have a

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higher risk of developing a secondary primary breast cancer in the unaffected breast

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In general, breast cancer arises from the

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epithelial lining of the ducts (milk passages that connect the lobules and the nipple) [ductal carcinoma] or from the epithelium of the lobules (lobular carcinoma) lobules are milk producing glands

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breast cancers can be in situ or invasive

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within the duct arising from the duct and invading through the wall of the duct

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Metastatic breast cancer is breast cancer that has

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spread to other organs

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MOST COMMON sites of metastatic breast cancer

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bone liver lung brain

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Axillary node involvement

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more nodes involved, the worse the prognosis

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Factors that affect cancer prognosis

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tumor size axillary node involvement tumor differentiation estrogen and progesterone receptor status human epidermal growth factor receptor w (HER-@): a protein that helps regulate cell growth: it is overexpressed in about 25% of pts with breast cancer

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breast cancer can be classified as

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noninvasive invasive ductal lobular

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noninvasive breast cancer

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These include: ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS)

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Ductal carcinoma in situ (DCIS) tends to be

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unilateral and may progress to invasive breast cancer if left untreated

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management of DCIS

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breast conserving (lumpectomy) mastectomy with breast reconstruction radiation therapy and/or hormone therapy:

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Lobular carcinoma in situ

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although it is a risk factor for developing breast cancer, it is not known to be a premalignant lesion NO SURGICAL OR RADIATION TREATMENT IS INDICATED FOR LCIS Hormone therapy may be used as a preventive measure to reduce breast cancer risk for some pts

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Invasive (infiltrating) ductal carcinoma

answer

MOST COMMON TYPE OF BREAST CANCER it starts in the milk duct and then breaks through the wall of the duct, invading surrounding tissue From there it may metastasize to other parts of the body

question

Types of invasive (infiltrating) ductal carcinoma include

answer

medullary carcinoma: occurs in women in late 40s and 50s manifesting with cells that resemblel the medulla of the brain Tubular carcinoma: usually found in women over 50. Colloid (muninous) carcinoma: these tumors, which prouce mucus, usually have a favorable prognosis

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Tubular carcinoma has

answer

an excellent prognosis

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Colloid (mucinous) carcinoma produce mucus and usually have a

answer

favorable prognosis

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Inflammatory breast cancer is an aggressive and fast growing breast cancer with a high risk for

answer

metastasis the lymph channels in the skin of the breast become blocked by cancer cells BC of skin involvement, the breast often looks red, feels warm, and has a thickened appearance that is often described as resembling an orange peel (peaud'orange) Sometimes the breast develops ridges and small bumps that look like hives A breast mass may or may not be present

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Paget's disease

answer

a rare breast malignancy characterized by a persistent lesion of the nipple and areola with or without a mass Most women with paget's disease have underlying ductal carcinoma. Only in rare cases is the cacer confined to the nipple itself Itching, burning, bloody nipple discharge with superficial skin erosion and ulceration may be present Diagnosis: confirmed by pathologic exam of lesion Nipple changes are often diagnosed as an infection of dermatitis, which can lead to treatment delays Treatment: surgical removal of involved tissue (central lumpectomy or mastectomY) Radiation may also be used after surgery Prognosis is good when the cancer is confined to the nipple

question

invasive (infiltrating lobular carcinoma)

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begins in the lobules of the breast Cancer cells can break out of the lobule and have the potential to metastasize to other areas of the body Invasive lobular carcinoma is a type of breast cancer that usually appears as a subtle thickening in the upper outer quadrant of the breast Often positive for estrogen and progesterone receptors, these tumors respond well to hormone therapy

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breast cancer occurs most often in the

answer

upper, outer quadrant of the breast, which is the location of most of the glandular tissue

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If palpable, breast cancer is characteristically (5)

answer

hard and may be irregularly shaped, poorly delineated nonmobile and nontender

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A small percentage of breast cancers cause nipple discharge The discharge is usually unilateral and may be cear or bloody Nipple retraction may occur

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peau d/oragne may occur due to plugging of the dermal lymphatics In large cancers, infiltration, induration, and dimpling (pulling in) of the overlying skin may also occur

question

the main complication of breast cancer is

answer

recurrence

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Recurrence may be

answer

local or regional

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Widely disseminated or metastatic disease involves the growth of colonies of cancerous breast cells in parts of the body distant from the breast.

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Metastases primary occur through the lymphatics, usually those of the axilla

question

Metastases primarily occur through the

answer

lymphatics

question

However, the cancer can spread to other parts of body without invading axillary noes even when the breast tumor is small

answer

even in patients who do not have lymph node involvement (node negative breast cancer) there is a possibility of distant metastasis

question

diagnostic

answer

radiologic and biopsy Axillary lymph node status tumor size estrogen and progesterone receptor status cell proliferative indices genomic assays

question

lymphatic mapping and sentinal lymph node dissection (SLND)

answer

help the surgeon identify lymph nodes that drain first from the tumor site is less invasive than axillary lymph node dissection In SLND: a radioisotope and/or blue dye is injected into the affected breast, and intraoperatively it is determined in which sentinal lymph nodes the radioisotope or dye is located A local incision is made in the axilla and the surgeon dissects the blue stained or radioactive SLN

question

the larger the tumor

answer

the poorer the prognosis

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The more well differentiated (more like the original cell type) the tumor

answer

the LESS agressive it is

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The cells of poorly differentiated (unlike the original cell type) tumors appear

answer

morphologically disorganized and they are more aggressive

question

receptor positive tumors

answer

commonly show histologic evidence of being well differentiated, frequently have a diploid (more normal) DNA content and low proliferative indices, have a lower chance for recurrence, and are frequently hormone dependent and responsive to hormone therapy

question

Receptor negative tumors

answer

are often poorly differentiated histologically have a high incidence of aneuploidy (abnormally high or low DNA content) and higher proliferative indices frequently recur usually unresponsive to hormone therapy

question

diploid tumors have been shown to have a significantly LOWER risk of

answer

recurrence than aneuploid tumors

question

Patients with cells that have high S phase fractions have a

answer

higher risk for recurrence and earlier cancer death

question

Another prognostic is the marker HER-2 Overexpression of this receptor has been associated with

answer

unusually aggressive tumor growth, a greater risk for recurrence, and a poorer prognosis in breast cancer

question

A patient whose breast cancer tests negative for all three receptors (estrogen, progesterone, and HER-2) has

answer

tiple negative breast cancer The incidece of triple negative breast cancer is higher in hispanics, aas, younger women, and women with BRCA1 mutation These pts tend to have more aggressive tumors with a poorer prognosis

question

genomic assay is a test that uses a sample of the breast cancer tissue to analyze the activity of a group of genes

answer

knowing whether certain genes are present or absent, or overly active or not active enough, can provide info about the risk of recurrence and the likely benefit of chemo or hormone therapy mammaPrint and Oncotype DX

question

Cancer markers for breast cancer include

answer

CA 15-3 and CA27-29 these proteins are produced by the MUCU1 gene breast cancer ells shed copies of these proteins into the bloodstream These markers are NOT specific or sensitive enough to be used as a screening tool to detect early breast cancer These may be used to monitor a patient's response to treatment of invasive breast cancer and detect recurrence of disease

question

most widely accepted staging method for breast cancer is the TNM system

answer

Tumor size (T) nodal involvement (N) presence of metastasis (M) to determine the stage of disease

question

stages run from O to IV

answer

with 0 being in situ cancer with NO lymph node involvement and NO metastasis Stage IV indicates metastatic spread, regardless of tumor size or lymph node involvement

question

primary treatment for breast cancer

answer

surgery breast conservation surgery (lumpectomy) nonmodified radical mastectomy most women diagnosed with early stage breast cancer (tumors smaller than 4-5 cm) are candidates for either treatment choice

question

treatment survival rate with lumpectomy and radiation is about

answer

the same as that with modified radical mastectomy

question

breast conserving surgery (lumpectomy)

answer

involves removal of tumor along with a margin or normal surrounding tissue After surgery, radiation therapy is delivered to the entire breast if evidence exists that the risk for recurrence is high, chemo may be administered before radiation Contraindications to breast conserving therapy: breast size too small in relation to tumor size to yield an acceptable cosmetic result, masses and calcifications are multifocal(within the same breast quadrant), masses are multicentric (in more than one quadrant),

question

contraindications to radiation

answer

active lupus or prior radiation therapy in the radiation field

question

axillary lymph node dissection is often performed when (ALND)

answer

breast conserving surgery is done a typical ALND involves removal of 12-20 nodes Sentinal lymph node dissection (SLND) has become the standard of care, with ALND reserved for pts when clinically indicated

question

Lymphedema (accumulation of lymph in soft tissue)

answer

can occur as a result of the excision or radiation of lymph nodes When the axillary nodes cannot return lymph fluid to the central circulation, the fluid accumulates in the arm, hand, or breast causing obstructive pressure on the veins and venous return Pt may experience heaviness, pain, impaired motor function in arm numbness an paresthesia of fingers fever and a red, painful rash may also be present with infection of the affected arm Cellulitis and progressive fibrosis of the skin can result from lymphedema

question

modified radical mastectomy

answer

removal of the breast and axillary lymph nodes, but it preserves the pectoralis major muscle This surgery would be selected over breast conserving surgery if the tumor were too alrge to excise with good margins and attain a reasonable cosmetic result The pt has the option of breast reconstruction. If the pt chooses to have reconstrucitve surgery, it can be performed immediately after the mastectomy, or itc can be delayed until postop recovery is complete

question

Postmastectomy pain syndrome

answer

can occur in pts after a mastectomy or an axillary node dissection Common symptoms: chest and upper arm pain, tingling down the arm, numbness, shooting or pricking pain, unbearable itching that persist beyond the normal 3 month healing time Theory: injury to intercostobrachial nerves, which are sensory nerves that exit the chest wall muscles an provide sensation to the shoulder and upper arm

question

treatment of postmastecomy pain syndrome

answer

NSAIDS, antidepressantss, topical lidocaine patches, EMLA: local anesthetics: lodocaine and prolocain Antiseizure drugs: gabapentin Others: imagery, biofeedback, PT to prevent "frozen shoulder" syndrome as a result of inadequate movement and psychologic counseling with a therapist trained in the mnmgt of chronic pain syndromes

question

Radiation therapy is one form of

answer

adjuvant therapy that can be used after surgery

question

when radiation is a primary treatment:

answer

it is usually performed after excision of the breast mass. Decision to use: is based on probablility that local residual cancer cells are present In traditional whole breast radiation treatment: area is radiated 5 days/week over the course of 5-7 weeks An external beam of radiation is ued to deliver an approx total dose of 45-50Gy A "boost" is a dose of radiation delivered to the area in which the original tumor was locaetd It can be given by exetrnal beam and adds five to eight more treatments to the total number given

question

side effects of external beam radiation therapy

answer

fatigue skin changes breast edema Radiating a localized area will not prevent distant metastasis

question

brachytherapy (internal radiation)

answer

used for partial breast radiation as an alternative to traditional external radiation treatment for early stage breast cancer Radiation is delivered directly into the cavity left after a tumor is surgically removed by a lumpectomy Minimally invasive way to deliver radiation Concentrated and focused on the area with highest risk for tumor recurrence, internal radiation only requires 5 days (traditional last 5-7 weeks) Delivered using a multicatheter method or balloon catheter system

question

Multicatheter method

answer

many very small catheters are placed in the breast at the site of the tumor The SAVI is inserted through a small incision, and the catheter bundle expands uniformly the ends of the catheters tick out through little holes in the skin Small radioactive seeds placed in the catheters Seeds lift in place just long enough to deliver radiation does (5-10 mins) Tiny seeds inserted only during treatment and then removed The radiation does not remain in the body between treatments or after the final treatment is over

question

Balloon catheter system

answer

balloon is placed where the tumor is located Balloon filled with fluid to keep it in place Radioactive seeds inserted Radiation emitted by a tiny radioactive seed attached by a wire on the way to an afterloader, a computer controlled machine The seed travels through the mammosite applicator into the inflated balloon The radiation does not remain in the body beween treatments or after the final treatment is over

question

radiation is also used to treat

answer

symptomatic lesions in such sites as bone, soft tissue organs, brain, and chest Relieves pain and is successful in controlling recurrnet or metastatic disease

question

Drug therapy used to destroy tumor cells that have

answer

spread to distant sites Nearly all women will have some type of drug therapy

question

Many breast cancers are responsive to

answer

chemo In some pts ,chemo is given preoperatively It may decrease size of tumor with the goal of less extensive surgery

question

the use of combo drugs is usually

answer

superior to the use of a single drug

question

Most common side effects involve rapidly dividing cells in the GI bone marrow and hair follicles

answer

nausea anorexia weight loss anemia alopecia

question

Cognitive changes during and after treatment, esp with chemo have been reported in pts with cancer "chemobrain" phenomenon

answer

changes include difficulties in concentration, memory, focus, attention It is not clear if chemo brain is r/t specific cancer treatments of is an overall systemic rxn

question

Estrogen can promote the growth of breast cancer cells if the cells are estrogen receptor positive Hormone therapy can block the effect and source of estrogen, thus promoting tumor regression

answer

Both estrogen and progesterone receptor status assays have been developed to identify women whose breast cancers are likely to respond to hormone therapy These assays predict whether hormone therapy is a treatment option Hormone therapy can: block estrogen receptors suppress estrogen synthesis by inhibiting aromatase, an enzyme needed for estrogen synthesis

question

aromatase inhibitors

answer

interfere with enzyme aromatase which is needed for the synthesis of estrogen Used in treatment of breast cancer in postmenopausal women Do not block production of estrogen by ovaries Are of little benefit and may be harmful in premenopausal women

question

follow up and survivorhip care how often?...

answer

after treatment for brest cancer, the pt will have ongoing survivorship care Recommended followup exams generally occur every 3-6 months for the first 5 years and then annually after Survivorship care plans summarize a pt's care and care pan for ongoing surveillance In addition, advise womtn to perform monthly BSE and self chest wall exams and report any changes to HCP Local recurrence of breast cancer is usually at the surgical site

question

____ women have a higher incidence of breast cancer than other ethnic groups

answer

white aas have lower survival rates from breast cancer than white women Triple negative: high incidence in hispanic and AAs

question

women with abnormal BRCA1 or BRCA2

answer

prohylactic oophorectomy may reduce their risk of developing breast cancer

question

restoring arm function on the affected side after mastectomy and ALND is a key nursing goal

answer

Hospital: place woman in semi-fowlers with arm on affected side elevated on pillow Flexing and extending fingers should bein in recovery room with progressive increases in activity encouraged Posop arm and shoulder exercises are instituted gradually: these are designed to prevent contractures and muscle shortening, maintain muscle tone, and improve lymph and blood circulation

question

Goal of all exercise

answer

gradual return to full ROM within 4-6 weeks

question

Post op discomfort: administer analgesics regularly when pt is in pain and

answer

30 mins before initiating exercises When pt can shower, the warm water on involved shoulder often relazes the muscle and reduces joint stiffness

question

Application of ice, except where contraindicated with plastic surgery procedures:

answer

can reduce swelling, inflammation, and pain

question

incidence of arm lymphedema ranges fro 2-65% and it can develop 1-5 yrs after surgery

answer

Teach measures to prevent lymphedema: NO BP readings, venipunctures or injections on affected arm Affected arm should NOT be depended for long periods, caution should be used to prevent infection, burns, or compromised circulation on affected

question

lymphedema education prevention

answer

NO BP readings, venipunctures or injections on affected arm Affected arm should NOT be depended for long periods, caution should be used to prevent infection, burns, or compromised circulation on affected

question

if trauma occurs to arm:

answer

area should be washed throroughly with soap and water and observed Topical antibiotic ointment and a bandage or other sterile dressing may be applied

question

When lymphedema is acute

answer

complete decongestive therapy recommended Massage like techniques to mobilize sub q accumulation of fluid Compression bandage and intermittent pneumatic compression sleeve: facilitates lymph drainage toward heart Elevation of arm so it is level with heart, diuretics, and isometric exercises may be used to reduce fluid volume in arm To maintain max volume reduction, the pt may need to wear a fitted compression sleeve during waking hours and preventively during air travel

question

Immediately after surgery, advise pt to report to HCP symptoms such as

answer

fever inflammation at surgical site erythema postop constipation unusual swelling

question

For women who have mastectomy without bresat reconstruction a variety of products ar available

answer

garments such as camisoles with soft breast prosthetic inserts or fitted prosthesis with bra There is a certified fitter for prosthesis generaly for 4-8 weeks postop

question

Present all choices without judgment

answer

there are no physical reasons why a mastectomy would prevent sexual satisfaction The woman taking hormone therapy may have a decreased sexual drive or vaginal dryness May need to use lubrication to prevent discomfort

question

older women are less likely to have

answer

mammograms screening and treatment decisions for breast cancer should be based on a woman's general health status rather than biologic age, since health status has a greater influence on tolerance to treatment and long term prognosis For healthy older women: breast cancer survival rates are similar to those of younger women when matched by cancer stage

Lewis pg 1243-1255 Breast cancer – Flashcards

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