breast 2 – Flashcard

• Surgery • Radiation Therapy • Chemotherapy • Hormonal Therapy

a cornerstone of treatment for breast cancer. the stage of the cancer, the age of the patient, and the preferences of the treatment team.

a lumpectomy or one of three types of mastectomy (surgery to remove the breast).

patient's age, general health, and the size, type, and stage of the tumor

adjuvant systemic therapy:chemotherapy, hormonal therapy, or targeted biological therapy such as Herceptin.

•Lumpectomy •Modified Radical Mastectomy •Radical Mastectomy (rare) Reconstruction

• If the tumor is small and confined to a single location in the breast, breast- conserving surgery, also called a lumpectomy. • The goal of this relatively simple procedure is to remove the whole tumor, while conserving as much breast tissue as possible. • A margin of normal breast tissue is also removed to make sure no malignant cells are left behind.

This procedure removes as much of the breast tissue as possible, including the nipple and the areola, and a number of axillary lymph nodes, but not the muscles. Used when tumor > 5 cm

treat invasive breast cancer

removed the entire breast, the lymph nodes in the armpit, and one of the major muscles of the chest wall

rarely used, and only for very extensive cancers that spread to the muscles.

used today

removal of the breast. A mastectomy may be performed when a lumpectomy is not possible or based on the preference of the woman.

simple, modified radical, and radical.

removal of the other breast preventive measure. reduces the risk of breast cancer recurrence, but it is not an absolute guarantee because of the systemic nature of the disease.

Some women with cancer in one breast may choose to have the other breast removed at the time of their mastectomy

rarely used today. This type of mastectomy is generally limited to cases when cancer has spread to the chest wall muscles.

involves removal of the entire affected breast, the underlying chest muscles, the lymph nodes under the arm (axillary node dissection), along with some additional fat and skin.

involves the removal of the entire breast, including the skin, areola, and nipple, along with the axillary lymph nodes, but leaves the chest wall muscles intact.

involves the removal of the breast tissue, skin, areola, and nipple, but not the lymph nodes. This procedure is generally used when axillary lymph nodes do not need to be removed, as evidenced by a negative sentinel node examination.

Involves removal of a large number of axillary lymph nodes for examination by a pathologist. Formerly a part of all breast cancer surgeries, axillary dissection has been replaced in many cases by a newer procedure called sentinel lymph node biopsy.

AKA: sentinel lymph node dissection This newer procedure offers a less traumatic alternative for determining whether the cancer has spread beyond the breast. The SLNB procedure focuses on finding the specific lymph nodes (sentinel nodes) that are first to receive drainage from the breast tumor. SLNB is most appropriate for women with early-stage breast cancer with clinically negative axillary nodes

tiny vessels within the entire lymphatic system.

the excess fluid that is not absorbed by blood vessels.

bacteria and cancer cells, as part of the body's immune system.

Lymphedema

• Assess tissue perfusion and capillary refill • Arm exercises and elevating arm above heart several times per day • Teach: prevention of trauma to affected arm

• Arm injury on affected side Management Causes • Inflammatory changes • Aging • Spread of metabolic disease • Tumor in upper outer quadrant • Implanted CVAD • Scarring from chemotherapeutic agents

• BP • Blood draws • Vaccinations • Cuts, injuries to prevent infection • Avoid constricting garments • Compression sleeve or glove • Extreme increases in temperature

Maintain integrity of skin and underlying structures, reducing fluid volume • Massageandmanual drainage • Compression sleeve with selected range of pressures while awake • Intermittent pneumatic compression devices

• Complains of heaviness or ache • Tightness feeling more pronounced skin folds • Jewelry or clothing tight • Inspect skin of skin color, texture, integrity • Measure circumference of extremities prior to surgery or radiation and at intervals to compare

1. Atriskforinfection,r/t surgical incision 2. Ineffectivetissue perfusion, r/t edema 3. Acute pain, r/t surgical intervention 4. Disturbedbodyimage,r/t surgical removal of breast 5.Decisionalconflictabout treatment, r/t concerns about risks and benefits 6. Interrupted family processes, r/t effect of surgery 7. Fear, r/t disease process/prognosis 8. _______________

• Patient verbalizes understanding of disease, diagnosis, treatment options, and prognosis • Patient demonstrates reduced level of anxiety evidenced by use of positive coping strategies • Patient verbalizes feelings related to body image changes and accesses available resources to assist in related lifestyle adjustments • Patient verbalizes adequate pain control on a 0-10 pain scale and demonstrates effective use of pain management techniques

When the procedure is completed, one or two tubes called drains will be placed under the skin to help remove the fluid that accumulates at the site of surgery.

Avoid using affected arm for Positioning for comfort and to facilitate drainage: • HOB elevated 30 degrees • Arm elevated on pillow Assess for pain: analgesics as prescribed Assess incision and skin flap for integrity: • Bleeding, hematoma • Infection signs and symptoms: • Poor tissue perfusion Ambulation with arm support Regular diet • BP readings Injections Blood draws • • Vital signs: Report temp >100.4 • Every30minx2 • • Every 1hour x2 Every 4 hours Dressing: Assess bleeding & JP drainage flow, amount, color Monitor amount and color drainage

A

D

Pre and Post Expander and Implant

•Radiation Therapy •Chemotherapy •Hormonal Therapy All are options for adjuncts to surgery depending on stage of cancer

surgical procedure performed by a plastic surgeon and may require a longer recovery than mastectomy alone. Reconstruction can be performed at the same time as a mastectomy (immediate reconstruction), or it can be done later (delayed reconstruction). Immediate reconstruction may not be possible if the tumor is advanced and radiation is recommended. With immediate reconstruction, chemotherapy treatments are usually delayed for at least 2-3 weeks after surgery. There are options available with reconstructive surgery, but they are not all appropriate for every candidate. Basically, there are two categories: implant-based reconstruction and autologous tissue reconstruction (e.g., the transverse rectus abdominus myocutaneous flap, or TRAM flap). For both implant-based and autologous reconstruction, the areola and nipple can be reconstructed using a specific surgical technique and tattooing, which can look quite realistic. However, patients should be aware there will be no return of erogenous feeling to the reconstructed nipple. Autologous transplants have a higher and longer rating of satisfaction in acceptable appearance than do implants (Platt et al., 2011). As a first step in the reconstruction process, most women need to undergo tissue expansion to stretch the skin for placement of an implant. The process begins with the insertion of a temporary implant called a tissue expander. The implant can be placed at the time of mastectomy or later if delayed reconstruction is chosen. Over a period of months, sterile saline is injected into the tissue expander in order to slowly stretch the skin of the chest where the implants will be placed. After the tissue expansion is complete, a second surgery removes the tissue expander and a breast implant is placed. Breast implants may be filled with either saline or silicone gel. Nipple reconstruction can also be accomplished with the new breast mound after a period of healing is allowed. Although a diagnosis of cancer can feel like an urgent situation, there usually is time to talk about, research, and consider treatment options. Ideally, once a definitive diagnosis is made and the need for a mastectomy is determined, the patient will discuss reconstruction options with the breast surgeon and the plastic surgeon. Women who are exploring their options for surgery should be encouraged to have someone with them and to take notes when consulting with the breast and plastic surgeons. Some examples of important questions and points for consideration include: Am I a candidate for breast reconstruction? When is the best time to have this done? What type do you think is the best for me and why? How long will I be in the hospital? How long is total recovery time? Will I need help at home after surgery? How many of these procedures have you done? What are some of the possible complications? Do you have pictures I can see of some of the final results? What is the average cost? Does insurance usually cover this? Will my new breast look and feel different from my other breast? When will I be able to exercise again? Are there any restrictions? (Hartmann & Loprinzi, 2012) It is very helpful to view photos of other women post-reconstruction in order to have a realistic expectation of possible outcome. It is also beneficial to speak to other women, such as in an in-person or online support group, about their experiences, both positive and negative. Some women may prefer to forego reconstructive surgery altogether and choose an external prosthesis. Many prosthetics, or breast forms, are available today for both lumpectomy and mastectomy patients. They can look quite natural under clothing and serve to help a woman feel balanced in her appearance. There are also a number of products available to accommodate breast forms, such as mastectomy bras, active wear, lingerie, and swimwear Breast forms may also be worn on a temporary basis between mastectomy and reconstruction surgeries, especially when prolonged treatment time is required during the interim.

• Radiationtherapyuses high-energy beams to destroy cancer cells. • Thebeamsresemblethe X-rays that are used to create an image of the chest, or of a broken bone. • Fortreatmentpurposes, the rays are of higher intensity.

• Fatigue • Skinreactions • Arm Swelling • Lung, nerve damage • Redness • • Bruising • BreastPain • Infection

Chronic Lymphedema • Cardiovascular Secondary malignancies

• Wash the radiated area gently with warm (not hot) water and a mild soap such as Ivory, Pears, or Neutrogena • Don't shower more than once per day; limit baths to twice weekly for less than 30 minutes per bath • Avoid rubbing, scrubbing, or scratching the skin • Be careful not to wash off the ink markings needed for radiation therapy • Wash off any lotions or creams from sites prior to RT, as their presence can intensify burns • Gently pat skin dry after bathing • Avoid deodorant or talcum powder on the radiated side • Wear soft clothes and use cotton sheets • Avoid adhesive tape, bandages, or other types of sticky tape on the treatment area • Avoid chlorinated swimming pools and hot tubs during radiation treatment • Always protect the radiated area from exposure to the sun or tanning beds, even after treatment ends • Promptly report pain, swelling, exudate, or other skin changes to the primary care provider

Cells go through several steps in the process of cell division. Chemotherapy drugs interfere with various parts of this cycle, making it difficult for the cells to reproduce and for the tumor to grow. The faster the growth, the more opportunity the chemotherapy drug has to disrupt the cycle. Chemotherapy treatment affects both normal cells and cancer cells, but because cancer cells generally divide more rapidly, and are less effective at self-repair, they are more affected by the therapy than normal cells. As a result, more cancer cells than normal cells are killed. With proper choice and timing of chemotherapy, the tumor can be destroyed without excessive damage to normal tissues. There are dozens of different chemotherapy drugs, each designed to interfere with a different part of the cell's duplication process. By using a combination of two or three different drugs, it is possible to affect several phases of the duplication cycle and increase the effectiveness of the treatment.

Usually a combination of agents Via Central venous access device (port-a-cath)

cardiotoxic effects Alopecia Nausea Vomiting Mucositis Bone marrow suppression • Fatigue • SOB • Chronic cough Edema Infertility

• Nausea and vomiting • Alopecia • Peripheralneuropathy • Cognitiveimpairment • Myelosuppression • Fatigue • Anti-emetics • Wigs, short haircut • Dosereduction • Rest, support coping • s/s of anemia, infection- • Hematapoieticgrowthfactorsto minimize neutropenia and anemia • Avoid crowds, wear mask, hand washing • Correctcachexia,depression, insomnia, electrolyte imbalances

Avoiding infection • Hand washing • Avoidcrowds • Vigilantfors/sinfection:check temperature every day at same time, CVAD site, mouth sores, sore throat • Denture care every meal, mouth rinses • Nutrition:proteinand fluids/avoid alcohol

Block effects of estrogen in Estrogen Receptor positive women Tamoxifen taken for 5 years for risk reduction Side effects: • hot flashes • weight gain • Endometrial cancer • • Thromboembolic events

Acts on body fat sources of estrogen in post menopausal women Inhibits conversion of androgen to estrogen Side effects: • Loss of bone density • Osteoporosis Faslodex (Fulvestrant)

• Drugs target specific characteristics of cancer cells • Herceptin: HER2 gene • Avastin:inhibitstumorgrowth factor and stopping formation of blood vessels that nourish tumor • Fewer side effects because it does not harm normal, healthy cells • Side effect risk: cardiotoxocity

Autologous or allogeneic stem cell transplantation from bone marrow is an option for patients at high risk for recurrence or with advanced disease

Nutritional supplements Dietary changes Herbal supplements Exercise, yoga, tai chi Meditation/Relaxation Massage Acupuncture Guided imagery Prayer

low fat diet Vitamins & Minerals • • Echinacea • Boost/Ensure Inform about evidence suggesting a relationship between dietary intake of soy and breast cancer risk • • • Vitamin C & E St. John's Wart Garlic extract

Support/Relationships Husband Physical scars Body image Communication of feelings both negative and positive Threat to sexuality Concerns about childbearing Teaching Avoid sexual intercourse for 4-6 weeks Use of birth control during therapy Community resources at local, state and national levels American Cancer Association

• Gather information • Consider treatment options • Stress there is support • Patients make individual choices • The journey is personal and unique Record keeping: • Treatments • Procedures • Medications • Appointments • Labs/Diagnostics • Insurance • Legal • Journal

• Telling family and friends • Informing an employer • HIPAA

• • • • • Education • Encouragement • Referrals: support • groups, reliable websites • Know symptoms needing attention ReviewChart73-4 Recovery from Breast Cancer Surgery Ignatavicius p. 1607 increase self efficacy Focus on wellness Counseling Rash, abdominal or bone pain, swelling, redness, edema, new lumps or changes, weight loss Surveillance,screenings

practical information to patients.

which may help decrease fear and anxiety associated with recurrence risk

eating a healthy diet, getting enough sleep and exercise, paying attention to symptoms, and getting regular checkups.

ache or pain can trigger anxiety.

Chronic bone pain or tenderness (persistent) Skin rashes, redness, or swelling (persistent) New lumps in the breasts or chest Changes in the breasts Chest pain and any shortness of breath (persistent) Abdominal pain (persistent) Changes in weight, especially weight loss when not intentional

within the first five years after diagnosis

slower growing and may take longer to recur.

annual PAP smears especially in younger women. This is also a highly curable cancer when caught early, but it can be very deadly if not.

Colorectal cancer and it is the only cancer that can be detected early enough to be completely cured by surgery alone.

5-Year Survival (%) 10 year survival Stage 0 95 90 Stage I 85 70 Stage II 70 50 Stage III 55 30 Stage IV 5 2

• Local • Regional • Metastatic • Surgery • Highdosechemotherapy • Palliativecare

local/regional or systemic and can range from surgery alone to high-dose chemotherapy.

Location and size of the new tumor(s) Length of time since the initial cancer diagnosis Degree of lymph node involvement Whether distant organs are involved

Breast cancer most commonly recurs locally—in or near the site of the original tumor, for example in or around the scar.

When recurrent cancer is confirmed, the physician orders blood tests and a bone scan to determine whether the cancer has spread beyond the breast. Any cancer that recurs locally is regarded as aggressive and resistant to treatment. When cancer recurs locally after lumpectomy, mastectomy is the preferred treatment.

When breast cancer cells have spread to the adjacent lymph nodes (usually in the axilla) or to the chest wall,

may require surgical treatment and/or localized radiation therapy as well as systemic treatment

Cancer in a different part of the breast or in the contralateral (opposite) breast may be a new cancer, This cancer may be an entirely different cell type and may be treated successfully with surgery alone, depending on the stage and tumor type. The biopsy may or may not be able to determine whether the new tumor is recurrent disease or a second primary, but it will help determine the treatment.

Once breast cancer has spread to distant organs (stage IV), cure is no longer possible. However, palliative care measures, including radiation, chemotherapy, hormone therapies, targeted therapies, and bisphonates, can significantly improve survival length and quality of life. The most common sites of metastasis for breast cancer are the bone, brain, lungs, and liver. Breast cancer that metastasizes to the bone can be treated with targeted radiation therapy, either stereotactic external beam or with radiopharmaceuticals. Therapies such as zolodronic acid (Zometa, a bisphosphonate) and Denusamab can help reduce the pain of bone metastases, strengthen bones, and decrease morbidity due to skeletal-related events (SREs) (Hartmann & Loprinzi, 2012). There may be the need for surgical intervention, in some cases for rod placement, to either treat or prevent fracture in large, weight-bearing bones that are affected by disease. Patients with cancer in the bone should be cautioned about the increased risk of fracture. Metastatic cancer that develops in the brain or around the spinal cord can also be treated to improve quality of life. Steroid medications can be given to decrease pain, swelling, and neurological symptoms. Whole brain radiation or localized brain radiation (Gamma Knife treatment) can be used to treat women whose cancer has spread to the brain.

Palliative care can be offered during this time. Palliative care specialists work together with the healthcare team, such as nurses, nutritionists, social workers, chaplains, pharmacists, and others, to focus on creating an individual plan to address any lasting treatment side effects, pain, emotional aspects, and other concerns of the cancer patient. The idea is to treat the whole person—including the physical, emotional, social, and spiritual aspects. Palliative care is often confused with hospice care, which is provided for people who have a terminal diagnosis. Palliative care can be provided at any time during a cancer diagnosis, not just at the end of life. The inclusion of palliative care may include positive benefits such as: The ability to fully complete treatment Improved quality of life during treatment Increased ability to perform daily activities Living longer Improved ability to deal with the emotions Increased connection to social support Fewer hospitalizations

Collaborative Care • Social work • Counseling • Psychotherapy Peer support groups • Chaplains • Family • Healthcare • Hospice

providing the best quality of life possible during the time remaining for the patient.

the side effects of treatment and take control of their lives.

such as social work, certified counseling/psychotherapy, peer support groups, and chaplains.

• Family time (trips, outtings) • Focus on pain symptom relief/comfort • Communication • Legacycreation • Friends

• Advance directives • Do not resuscitate • Legalissues • Wills/estate planning • Hospice • Organ donation • Funeral and memorial

plan a trip or outing that they have always wanted to take together

communicating their love for others, forgiveness, and/or gratitude)

writing letters or recording family stories or videotaped messages

who are supportive

getting one's affairs in order

• Undescended testicles • Orchiectomy • Infertility • Gynecomastia • Mastitis • Chest wall trauma • BRCA1mutation manifestations • Painless sub-areolar lump • Nippleretraction • Localizedpain • Nippleulceration • Bleeding/discharge

Examination of male breast and axilla The nipple and areola are inspected for masses and nipple discharge

is the firm enlargement of glandular tissue beneath and immediately surrounding the areola