Learning Objectives
By the end of this section, you will be able to:
- Recognize the structure and function of the breast and the lymphatic system
- Remember how to perform a nursing assessment of the breast and the lymphatic system
- Examine common abnormalities in the breast and the lymphatic system assessment
The immune system is the complex collection of cells and organs that destroys or neutralizes pathogens that would otherwise cause disease or death. For most people, the lymphatic system is associated with the immune system to such a degree that the two systems are virtually indistinguishable. The lymphatic system is the system of vessels, cells, and organs that carries excess fluids to the bloodstream and filters pathogens from the blood. The swelling of a lymph node during an infection and the transport of lymphocytes via the lymphatic vessels are but two examples of the many connections between these critical organ systems. Breast tissue contains a large network of lymphatic vessels and nodes, which is why the breasts and the lymphatic system are discussed together here.
Structure and Function of the Lymphatic System
A major function of the lymphatic system is to drain body fluids and return them to the bloodstream. Blood pressure causes leakage of fluid from the capillaries, resulting in the accumulation of fluid in the interstitial space—that is, spaces between individual cells in the tissues. In humans, 5.3 gal (20 L) of plasma are released into the interstitial space of the tissues each day due to capillary filtration. Once this filtrate is out of the bloodstream and in the tissue spaces, it is referred to as interstitial fluid. Of this, 4.5 gal (17 L) are reabsorbed directly by the blood vessels. But what happens to the remaining 0.8 gal (3 L)? This is where the lymphatic system comes into play. It drains the excess fluid (lymph) and empties it back into the bloodstream via a series of vessels and ducts (Figure 23.16). Once the interstitial fluid has entered the lymphatic system, it’s called lymph. When the lymphatic system is damaged in some way, such as by being blocked by cancer cells or destroyed by injury, protein-rich interstitial fluid accumulates (sometimes “backs up” from the lymph vessels) in the tissue spaces, and may lead to serious medical consequences.
Lymph Nodes
Cells of the immune system not only use lymphatic vessels to make their way from interstitial spaces back into the circulation, but they also use lymph nodes as major staging areas for the development of critical immune responses. A lymph node is one of the small, bean-shaped organs located throughout the lymphatic system.
Structure and Function of the Breast
The breasts are part of the female reproductive system, and their main function is to supply infants with milk for nutrition. However, for the purposes of this chapter, the focus of discussion about breasts is their relationship with the lymphatic system. As shown in Figure 23.16, the breasts contain a large network of lymphatic vessels and nodes. This is significant because the lymphatic system is involved in the spread, or metastasis, of breast cancer. More information about this phenomenon is discussed later in this chapter.
External Breast Anatomy
The external features of the breast include a nipple surrounded by a pigmented areola (Figure 23.17). The areola is typically circular and can vary in size from 1 to 4 in (25 to 100 mm) in diameter. The areolar region is characterized by small, raised areolar glands that secrete lubricating fluid during lactation to protect the nipple from chafing. When a baby nurses, or draws milk from the breast, the entire areolar region is taken into the mouth.
Internal Breast Anatomy
Breast milk is produced by the mammary glands, which are modified sweat glands. The milk itself exits the breast through the nipple via fifteen to twenty lactiferous ducts that open on the surface of the nipple. These lactiferous ducts each extend to a lactiferous sinus, which connects to a glandular lobe within the breast itself that contains groups of milk-secreting cells in clusters called alveoli (Figure 23.17). The clusters can change in size depending on the amount of milk in the alveolar lumen. Once milk is made in the alveoli, myoepithelial cells that surround the alveoli contract to push the milk to the lactiferous sinuses. From here, the baby can draw milk through the lactiferous ducts by suckling. The lobes themselves are surrounded by fat tissue, which determines the size of the breast; breast size differs between individuals and does not affect the amount of milk produced. Supporting the breasts are multiple bands of connective tissue called suspensory ligaments that connect the breast tissue to the dermis of the overlying skin.
Because of the large network of lymphatic vessels and nodes located within the breast tissue, the lymphatic system plays a big role in the development of breast cancer. Cancerous cells that arise within the breast tissue are easily carried through the lymphatic system into nearby lymph nodes as well as other distant sites through metastasis. Breast cancer is the most commonly diagnosed cancer in women, so this underscores the importance of the nurse conducting a thorough breast assessment for early detection (Rinaldi et al., 2023).
Nursing Assessment of Breasts and Lymphatic System
Assessment of the breast and lymphatic system focuses on early detection of abnormalities (e.g., lumps or masses) in the breast that may be indicative of cancer. Additionally, nearby and distant lymph nodes should be assessed for abnormalities that may indicate the spread of cancer or development of an infection.
Collecting Subjective Data
Collection of subjective data begins with a patient interview to collect a health history and any other pertinent information from the patient directly. During the interview, the nurse should make note of any risk factors for breast cancer including
- age over 50,
- family or personal history of breast or ovarian cancer,
- known genetic mutations (e.g., BRCA1 or BRCA2),
- early onset (before age 12) menstruation and/or late menopause (after age 55),
- first pregnancy after age 30 and/or not breastfeeding,
- alcohol use,
- sedentary lifestyle,
- having a higher weight, and
- history of or currently using hormone replacement therapy.
The nurse should ask the patient how often (if at all) they are performing self-breast exams. And if they are doing them regularly, it is important to ask the patient if they have felt any abnormal lumps or masses in the breasts. Any mention of a new lump or mass should be investigated further by the nurse during the interview. It is important to ask how long ago the patient noticed the mass, how large it is, if it is firm or soft, and if the patient is experiencing any other symptoms such as fever or swollen lymph nodes. After collecting this information, the nurse should relay it to the treating clinician as soon as possible to ensure quick follow-up and treatment, if indicated.
Patient Conversations
Subjective Interview with Patient at Risk for Breast Cancer
Scenario: Nurse is performing a physical assessment on a 56-year-old patient being seen in the clinic for an annual wellness exam. The patient expresses concern about developing breast cancer, as her older sister was just diagnosed.
Nurse: Hi, my name is Anna, and I’ll be your nurse today. I see that you’re here for an annual checkup. Before we get started, do you have any specific concerns you’d like to discuss?
Patient: Hi, Anna. It’s nice to meet you. My sister was actually just diagnosed with stage 3 breast cancer and I’m terrified that’s going to happen to me too. Am I at higher risk since she has it?
Nurse: I’m so sorry to hear about your sister. I know that must be difficult for her and for you. While there is a genetic component, that doesn’t necessarily guarantee that you will get it too. Can I ask you a few questions to get a better idea of any risk factors you might have?
Patient: Sure, go ahead.
Nurse: You mentioned that your sister was recently diagnosed. Has anyone else in your family been diagnosed with breast or ovarian cancer?
Patient: No one else has had breast cancer but my maternal grandmother died from ovarian cancer.
Nurse: I’m so sorry about that. Have any providers ever talked to you about getting genetic testing done?
Patient: I feel like a long time ago someone mentioned it, but they never followed through with more information about it and I had forgotten about it until my sister was diagnosed.
Nurse: I’ll make a note here in your chart so that the provider can give you some more information about the testing and we will be sure that we follow through on it if you decide it’s something you want to do. Do you remember how old you were when you got your first period?
Patient: Oh gosh that was forever ago. Maybe 12 years old? Why does that matter?
Nurse: Sometimes women who get periods early or go through menopause later than usual are at higher risk for breast cancer because they are exposed to the female hormone, estrogen, for longer periods of time.
Patient: Oh, that makes sense. Well for what it’s worth, I’m 56 and still haven’t gone through menopause. Should that worry me?
Nurse: Not necessarily but I’ll note it in your chart for future reference. Can you tell me about your lifestyle? How is your diet and do you exercise regularly?
Patient: I walk a few miles every morning before work but I won’t lie, my diet isn’t the healthiest.
Nurse: Can you expand on that a little? What does unhealthy eating mean to you?
Patient: I eat out for most meals because I work long hours. I’ve been trying to be better about prepping my meals but it’s often just easier to grab fast food on the way home.
Nurse: I get it for sure, but making good choices about food can be a great way to stay generally healthy and possibly prevent cancer and other diseases. How about alcohol? Do you drink at all?
Patient: Nope, hardly ever. Occasionally, like once a month, I might have a glass of wine but that’s it. I don’t like the way it makes me feel.
Nurse: Got it. Do you ever perform self-breast exams at home?
Patient: I never have. At least not until my sister was diagnosed with cancer. She never did them either. Her doctor felt it at her checkup.
Nurse: I see. I will perform an exam today after we finish this interview and I can show you how to perform them yourself at home so you can start doing it on your own. Does that sound okay?
Patient: Yes, that sounds great. I want to do everything I can to prevent getting breast cancer. Thank you!
Collecting Objective Data
Objective data are collected during a physical assessment of the breast and lymphatic system. The nurse first performs a visual inspection of the breasts and lymphatic system and then moves to palpation. Expected assessment findings for each of these techniques are listed in Table 23.10 and Table 23.11.
| Technique | Expected Findings |
|---|---|
Inspection:
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Palpation:
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| Technique | Expected Findings |
|---|---|
Inspection:
|
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Palpation:
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Abnormalities in Breasts and Lymphatic System
Abnormalities found in the breast and lymphatic system warrant further investigation by the nurse as they may be indicative of cancer or some kind of infection. Though this is not always the case, a thorough follow-up of the abnormal finding will help determine the underlying cause and initiate early intervention, if necessary. Some abnormalities may be seen visually during inspection, while others are not visible to the eyes but can be felt during palpation.
Abnormalities Noted on Inspection
Visual inspection of the breasts should be performed bilaterally as abnormalities are often found only on one side. Abnormal asymmetric findings during inspection of the breasts include the following:
- variations in breast size (note that this can be normal in many cases)
- skin color changes
- skin “dimpling” (skin looks like an orange peel) or retractions (Figure 23.18)
- spontaneous nipple discharge
- obvious mass (note that these are not usually visible without palpation unless they are large)
- rash around the nipple or areola
- sunken nipple
During inspection of the lymphatic system, the nurse should look for any obvious areas of lymph node swelling, also known as lymphadenopathy (Figure 23.19). Swollen lymph nodes may indicate that the patient has an infection of some kind or, more rarely, that some kind of cancer has spread to the lymphatic system.
Another abnormality of the lymphatic system that can be seen during inspection is called lymphedema, which is an accumulation of protein-rich interstitial fluid in the tissue spaces because of lymphatic system blockage or damage (Figure 23.20). Causes of lymphedema include infection, cancer, scar tissue from radiation therapy, surgical removal of lymph nodes, or inherited conditions. There is no cure for lymphedema, but elevation of the affected extremity is vital. It is also important to remember to avoid taking a blood pressure measurement on a patient’s extremity with lymphedema.
Abnormalities Noted on Palpation
Palpation of the breast and lymphatic system is vital, as it provides much more information about the patient’s condition than a simple visual inspection. While palpating the breasts, the nurse should feel for any abnormal lumps or masses, which could possibly indicate the development of breast cancer. If a lump or mass is present, the nurse should attempt to describe its characteristics. Specifically, the nurse should note if the mass is soft or hard and if the mass is mobile, meaning it is easily able to be moved between the fingers. There is no “typical” type of mass specifically associated with breast cancer, so any abnormal mass should be reported to the provider immediately so that appropriate follow-up and evaluation can be initiated. In addition to palpating for masses, the nurse should also feel the skin on the breast to make sure that it is warm, dry, and intact. Any dryness, redness, open sores, or edema should be noted in the patient’s record and investigated further. When palpating the lymph nodes, the nurse will note any swelling or hard lumps felt. Lymph nodes most commonly affected are those in the neck and axillary regions, so the nurse should focus the assessment in these areas. Any swelling or tenderness of the lymph nodes should be documented and reported to the provider so that further investigation can be conducted.
Life-Stage Context
Breast Cancer Screening Guidelines for Women
According to the American Cancer Society (2022), the following general screening guidelines are recommended for women of various ages and life stages:
- Women between ages 40 and 44 have the option to start annual mammograms.
- Women between age 45 and 54 should get mammograms annually.
- Women 55 and older can switch to getting mammograms every other year or continue getting them annually. Screenings should continue if the woman is in good health and expected to live at least ten more years.
For women at high risk (typically based on family history and genetic factors), a breast MRI and mammogram should be done every year beginning at age 30.