8.2 Cancer of the Breast

Risk Factors

The primary risk factors for breast cancer are having been assigned female at birth and increasing age; however, several other factors are also associated with an increased risk of breast cancer. Risk factors are modifiable (meaning they can be changed by behavior) or nonmodifiable (they cannot be changed). Table 8.3 presents both types of risk factors specific to breast cancer.

The nurse plays an important role in educating patients about these risk factors and how they interact, as well as whether increased surveillance is necessary.

Breast Self-Exam

Once the mainstay of breast cancer screening, monthly breast self-exams are no longer recommended by most medical organizations. This recommendation was removed from the U.S. Preventive Services Task Force in their 2009 breast cancer screening guidelines due to the risk of false positives and the potential harm that could result (American College of Obstetricians and Gynecologists [ACOG], 2017). Instead, providers now suggest that patients become familiar with their breasts, how they look and feel, and the signs and symptoms of breast cancer. Patients should be encouraged to contact their health-care provider about any changes to their breasts or concerning symptoms.

Clinical Breast Exam

The American Cancer Society (2022) no longer recommends regular clinical breast exams by a health-care professional as a valuable part of screening for breast cancer, citing concerns about the lack of effectiveness in finding breast cancer, particularly when a person is getting regular mammograms. However, the National Comprehensive Cancer Network (NCCN) does recommend regular clinical breast exams every 1 to 3 years beginning at age 25 and increasing to once a year by age 40 (Susan G. Komen, 2022a). For persons at high risk, the NCCN may recommend more frequent clinical breast exams, depending on the person’s age and specific risk factors (Susan G. Komen, 2022b). It is important for the provider and patient to discuss these recommendations in the context of the person’s health and individual risk profile before deciding on a screening plan.

Screening Tests

The development of screening tests like the mammogram have been very successful in detecting breast cancers early in their development and reducing mortality. Like the self-exam and clinical breast exams, the decision about when to start regular screening and how often should be made based on a discussion between the person and health-care provider. The results of both mammography and ultrasound are reported using standardized language, known as the Breast Imaging Reporting and Data System (BI-RADS) (American Cancer Society, 2022a). BI-RADS scores range from zero to 6, with 6 being proven malignancy. The mammogram report should also note whether the patient has dense breasts, which can interfere with the ability of the radiologist to see small masses.

Mammography

The x-ray visualization of the breast tissue, obtained by compressing the breast between two plates, is called mammography (Figure 8.7). Images are typically obtained from multiple views, ensuring that all areas of the breast tissue are evaluated.

Figure 8.7 Mammogram A mammogram is performed by compressing the breast tissue between two imaging plates. (credit: “MammographyinprocessGraphic” by Alan Hoofring, National Cancer Institute/Wikimedia Commons, Public Domain)

Traditional film mammograms present the tissue as a series of black and white images:

• Low-density tissue like fat appears translucent (darker shades of gray against the black background).
• Higher-density tissue, like connective tissue, glandular tissue, and tumors, appears white.

Newer mammography procedures use digital technology, allowing the images to be sent directly to a computer. While the different types of tissue appear the same as with film mammography, using digital images does have several advantages:

• ability to manipulate the image to get a better view
• decreased need to retake images
• easy transmission of files to another provider for a second opinion
• production of better images for people with dense breasts
• the ability to use computer programs that help with the detection of tissue abnormalities (National Institute of Biomedical Imaging and Bioengineering, n.d.).

Mammograms can be performed for screening or for diagnostic purposes, such as when a person or health-care provider feels a lump or mass that requires additional testing. Mammograms can also be used to identify a calcium deposit in the breast tissue, or a calcification (Figure 8.8). Calcifications are usually a benign finding, certain patterns of calcification can be an early sign of breast cancer.

• Macrocalcifications: Found in about half of women over the age of 50, macrocalcifications appear as large white dashes or dots on the mammogram; these are completely benign and do not require any additional testing.
• Microcalcifications: These appear as small flecks or grains of salt on the mammogram. Calcifications that are tightly clustered together or have irregular edges may be an early sign of breast cancer and should trigger additional testing.

Figure 8.8 Mammography Images Breast calcifications are calcium deposits, which can sometimes be indicative of early breast cancer. (credit: “These images are examples of breast changes that may be seen on a mammogram” by National Cancer Institute, Public Domain)

Different recommendations for screening mammography are outlined in Table 8.4.

Group	Recommendations
American Cancer Society1	age 40–44: yearly mammogram is optional age 45–54: should have yearly mammogram age 55 and older: can continue having yearly mammograms or change to every other year
U.S. Preventive Services Task Force2	age 40–49: an individual choice, though it is believed that younger women are more likely to have a false positive. age 50–74: should have a mammogram every other year
National Comprehensive Cancer Network3	age 40 and older: mammogram every year
1Data from American Cancer Society, 2022.
2Data from Breast Cancer Screening, 2016.
3Data from Breast Cancer Screening: Average Risk, n.d.

Table 8.4 Mammography Screening Recommendations for People of Average Risk

Imaging Procedures

Along with screening, both mammograms and ultrasound testing can be used diagnostically. If a suspicious lesion is found on mammogram, an ultrasound scan may be indicated to get a better view. In some cases, magnetic resonance imaging (MRI) may be necessary, though this is usually performed only when a patient has signs or symptoms of cancer or has had an inconclusive mammogram or ultrasound. MRI can also be used after breast cancer has been diagnosed to determine the exact location and size of a tumor or to look for other tumors.

Breast MRIs typically use contrast and are performed while the patient is face down, with the breasts placed in a special opening in the table to avoid compression of the tissue during the scan. In addition to ensuring that the consent form is signed and preparing the patient and room for the test, the nurse should ask about allergies, especially to contrast dye, and ensure that the patient does not have any metal on or inside them, including pacemakers, piercings, aneurysm clips, or cochlear implants. The test typically takes about 30 to 45 minutes.

Biopsy

In many cases, biopsy of the suspicious lesion or mass is the next step in diagnosis. During this procedure, a small sample is removed and sent to the pathologist for analysis. Several different biopsy procedures can be performed, depending on the size and location of the lesion, the patient’s health and preferences, and whether multiple lesions are present.

• During fine needle aspiration (FNA), a small needle (21 g to 25 g) is placed into the lesion to obtain a tissue or fluid sample. This procedure can be done with ultrasound guidance or without if the lesion is palpable below the skin surface. The procedure should be performed using sterile technique. A local anesthetic can be injected if the lesion is deep, the patient is anxious about the procedure, or the provider anticipates making multiple passes with the needle.
• A core needle biopsy (CNB) is similar to an FNA but removes a larger amount of tissue because it uses a hollow needle with a larger gauge than the one used for the FNA (Figure 8.9). CNB is typically the biopsy of choice when breast cancer is suspected because more tissue can be removed and analyzed. Like the FNA, it can be performed with or without ultrasound guidance, depending on the lesion’s size and location. Local anesthetic is injected before this type of biopsy because a larger amount of breast tissue, called a core, is removed by the needle. A tissue marker, or clip, may be placed in the location where the biopsy was taken to guide in identifying the area for monitoring or further follow-up. This clip can be visualized in imaging procedures so that the provider can quickly find the area in question.

  Figure 8.9 Core Needle Biopsy The core needle biopsy procedure removes a small sample of cells from an unidentified lesion so that the cells can undergo histologic evaluation. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
• Surgical biopsy: In rare cases, surgical biopsy may be indicated. This is usually performed when an FNA or a CNB is inconclusive. An incisional biopsy removes only part of the lesion; an excisional biopsy removes the entire lesion and sometimes a small margin around it to ensure that all the suspicious tissue is removed. This procedure is usually performed in a hospital or outpatient surgery center with the patient under intravenous (IV) sedation or general anesthesia.
• Lymph node: If breast cancer is identified, the next step may be to biopsy the nearby lymph nodes to determine whether the cancer has spread to other parts of the body. If the axillary lymph nodes are enlarged, small samples may be removed using FNA or CNB. If they are not enlarged, they will still need to be biopsied, usually during the surgical procedure to remove the breast cancer.

During a sentinel lymph node biopsy (SLNB), only a few lymph nodes, the ones most likely to have cancer spread to them, are removed. A special dye or radioactive substance is injected into the tumor or the area around it. The lymph will carry the dye through the lymph vessels to the nearby nodes, allowing the provider to identify the sentinel nodes and remove them for biopsy.

An axillary lymph node dissection is the other option for lymph node biopsy and involves the removal of around 10 to 20 lymph nodes from the axilla to be checked for cancer. This can be performed during the cancer-removing surgery or later if an SLNB is positive for three or more lymph nodes or if FNA/CNB showed cancer in the nodes.

Tumor Characteristics

Once breast cancer is diagnosed, it is important to evaluate the tumor characteristics to identify how best to treat it. During biopsy or surgery, any cells identified as cancerous may be checked to determine whether the cells have receptors for estrogen or progesterone on the surface. The presence of these receptors means that the cells are responsive to estrogen and progesterone and can be treated using hormone therapy.

• If a tumor has receptors for estrogen and progesterone, it is known as hormone receptor positive (ER positive for estrogen and PR positive for progesterone).
• If a tumor does not have receptors for estrogen and progesterone, it is known as hormone receptor negative (ER negative for estrogen and PR negative for progesterone).

Most of the time, cancers that are ER positive tend to also be PR positive, and cancers that are ER negative tend to also be PR negative. Most cancers, around 70 percent to 80 percent, are hormone receptor positive (Susan G. Komen, 2023d).

Another biomarker often used in the diagnosis and staging of breast cancer is a protein known as HER2 (human epidermal growth factor receptor 2). This protein is important in cell growth: When it is found in high levels in breast cancer cells, the cancer tends to grow more quickly and spread more aggressively. However, it is also more likely to respond to certain types of medications that specifically target that protein.

• If cancer cells have high levels of HER2, they are known as HER2 positive.
• If cancer cells have low levels of HER2, they are known as HER2 negative.
• Cancer that is positive for HER2 protein and estrogen/progesterone receptors is triple positive cancer.
• Cancer that is negative for HER2 protein and estrogen/progesterone receptors is triple negative cancer.

Triple negative breast cancers are more difficult to treat because hormone targeted therapies and HER2 targeted therapies will not be effective in treating the cancer. These types of tumors also tend to grow and spread more aggressively than other types of cancers. Triple negative breast cancers are more common in women younger than 40, women who are Black, and women with the BRCA1 gene mutation (American Cancer Society, 2021a).

Some providers may also measure the cell proliferation rate, or how quickly the breast cancer cells are dividing and growing. In general, cancers with a high proliferation rate (percentage of cells actively dividing) tend to be more aggressive and have a worse prognosis (Susan G. Komen, 2023d).

Clinical Manifestations

The clinical manifestations associated with breast cancer depend on the type of cancer (Table 8.5).

Type of Cancer	Description	Clinical Manifestations
(credit: modification of “Breast Cancer Ductal Carcinoma in Situ” by Don Bliss/National Cancer Institute (NCI), Public Domain)	localized cancer of the ducts noninvasive or preinvasive	often asymptomatic may be found on mammogram as small white spots may cause a palpable lump or nipple discharge
(credit: modification of “Breast Cancer Ductal Carcinoma in Situ” by Don Bliss/National Cancer Institute (NCI), Public Domain)	IDC is the most common type of breast cancer: forms in the cells of the milk ducts and spreads into nearby tissues able to metastasize to other tissues via lymphatic and circulatory systems ILC is much rarer than IDC: starts in the milk glands and can spread to other parts of the body more likely to affect both breasts	swelling or irritation of the breast nipple retraction peau d’orange nipple discharge skin changes of the breast, including thickening and redness nipple or breast pain swelling or lump in the axilla
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)	rare and aggressive disease that progresses quickly are mostly IDC cancers lymphatic vessels blocked by cancer cells, leading to edema and swelling	swelling or inflammation of the breast changes to the skin of the breast, including dimpling, pitting, welts, hives, warmth, and discoloration nipple flattening or inversion enlarged lymph nodes pain, tenderness, or itching of the breast tissue
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)	rare cancer of the nipple and areola that usually accompanies another form of breast cancer (DCIS or IDC)	crusty, red, or scaly skin in affected area nipple discharge made out of blood or yellow fluid sometimes initially confused with eczema
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)	rare breast tumor that initiates in the breast connective tissue mostly benign and noncancerous but can also be borderline or malignant	firm and painless breast lump may be painful occasionally may be large enough to stretch the skin may be seen first on mammogram or ultrasound

Table 8.5 Clinical Manifestations by Type of Breast Cancer

Stages of Breast Cancer

Staging a breast cancer helps the provider to understand the patient’s prognosis and how the cancer should be treated. Several criteria are considered when staging breast cancer, including the hormone and HER2 receptor status and other characteristics of the tumor. The tumor is staged pathologically using the TNM system:

• T: Tumor size
• N: Nodes (degree of lymph node spread)
• M: Metastasis

The patient is assigned a clinical stage, which informs prognosis and treatment decisions. The clinical stage is between 0 and IV, whereby a patient with stage 0 cancer has a localized tumor with a good prognosis for full recovery, and a patient with stage IV cancer has an aggressive tumor that has spread to distant organs and has a poor prognosis for survival.

Nursing Support of Patients Who Have Just Been Diagnosed with Breast Cancer

The nurse has a complex role in caring for a person who is undergoing testing for breast cancer or whose cancer is newly diagnosed. In addition to clinical nursing interventions involved in patient care, such as preparing for surgery and prepping for and assisting during diagnostic testing, the nurse must provide patient education and emotional support. This time in a person’s life is difficult; they face their own mortality, the loss of health and well-being, changes in body image and sexual function, financial and career concerns, and loss of role or function within the family and community. This can trigger feelings of shame, helplessness, hopelessness, anxiety, and fear. The nurse acts as a key member of the health-care team by teaching the patient about the various types of diagnostic testing, helping the patient navigate the complex world of breast cancer diagnosis, and answering questions and listening to concerns.

If cancer is the diagnosis, the patient and family may go in and out of periods of anger, shock, denial, and disbelief. Initiating education at this time will not be effective because it is unlikely that the patient will be able to retain any of the teaching. It is important to provide all information in terms families can understand and to be prepared to repeat or reinforce it as needed. As time goes on and the person begins to adjust to the diagnosis, the nurse can initiate more education and involve the patient with care planning. This is also a great time to refer the patient and family to counseling that will support them through the different stages, leading to acceptance through the diagnosis and treatment phases.

If the patient tests negative for cancer, the nurse still has an important role in supporting this patient in their next steps, whether that consists of planned follow-up or routine screening. The nurse can also help the patient work through their feelings of relief that they are cancer free and possible anxiety about the future.

Surgery

Surgical removal of the tumor is often recommended for patients newly diagnosed with breast cancer. Options include breast-conserving surgery (BCS), mastectomy, and, eventually, reconstruction. The nurse can provide anticipatory guidance on preparation and recovery related to these procedures.

Mastectomy

Removal of the entire breast, including the nipple and areola, is called mastectomy. Patients who are better candidates for mastectomy rather than BCS are those with larger or multiple tumors that occupy a large area of the breast, those with invasive cancer, or those who have had radiation to the breast. In addition to treating an existing breast cancer, mastectomy can be performed as a preventive measure, usually in patients at high risk or who carry the BRCA1 or BRCA2 gene.

There are several different ways that mastectomy (Figure 8.10) can be performed:

• Total simple mastectomy: Removes the entire breast, nipple, areola, and sentinel lymph nodes.
• Modified radical mastectomy: Removes the entire breast, nipple, areola, and axillary lymph nodes but leaves the chest wall intact.
• Skin-sparing mastectomy: Removes the breast tissue, nipple, and areola but leaves the skin of the breast intact, similar to an empty balloon. This allows the placement of an implant for immediate reconstruction during the procedure or a tissue expander for reconstruction later.
• Nipple-sparing mastectomy: Removes the breast tissue, but leaves the skin, areola, and nipple intact. This allows for reconstruction during surgery or later, using an implant or fat tissue from elsewhere on the body. A tissue expander can be placed in the pocket if the patient is having reconstruction later. For this type of procedure, the tumor must be at least 2 cm away from the nipple and areola.

Figure 8.10 Mastectomy Options Mastectomy can be performed in several ways, depending on the clinical picture and the patient’s preference for reconstruction. The main types are (a) simple mastectomy, (b) modified radical mastectomy, (c) skin-sparing mastectomy, and (d) nipple-sparing mastectomy. (modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Like BCS, mastectomy is often combined with chemotherapy or radiation once the patient has recovered from surgery. There is a lot of debate about whether mastectomy or BCS gives a better chance at survival. A study published in the Journal of the American Medical Association followed close to 50,000 people in Sweden for 6 years after they had been diagnosed with breast cancer (de Boniface et al., 2021). The researchers found a higher survival rate among people treated with BCS and radiation therapy than among people with a mastectomy (when accounting for key confounders; de Boniface et al., 2021). A study published by Mburu et al. in 2022 supported these results, finding that BCS with radiation was more effective at treating people with triple negative breast cancer than BCS alone, mastectomy alone, or mastectomy with radiation. While further research is needed, patients should discuss with their providers whether BCS may improve their prognosis.

Clinical Judgment Measurement Model

Evaluating Outcomes

The nurse teaches the patient about the process of mastectomy and recovery from the surgery. The following are ways to determine if the patient understands the teaching in order to evaluate the outcomes of the teaching.

1. Teach-back: Ask the patient to explain the process of the mastectomy in their own words.
2. Ask open-ended questions, such as what to expect before, during, and after surgery.
3. Summary: Ask the patient to summarize the information provided by the nurse.

Breast Reconstruction

Surgical breast reconstruction can occur during the mastectomy or later. It is important for the patient to consult with their providers to discuss the different options and which would be most appropriate for the specific clinical scenario. Several factors can influence which option is best:

• overall health status
• size/location of tumor
• breast size and shape
• type of breast cancer surgery
• amount of tissue available for reconstruction
• insurance coverage and costs
• Personal preferences (desire to closely match the other breast, preference for surgery on one or both breasts, willingness to have more than one surgery) (American Cancer Society, 2021c)

There are two main types of breast reconstruction:

• Implants: Implants made of saline or silicone are placed under the skin and muscle. These can be inserted at the time of mastectomy or later.
• Flap procedures: Flap procedures are highly technical procedures performed by plastic microsurgery specialists. Fat and tissue from elsewhere on the body (abdomen, hips, back, buttocks, etc.) are taken and used to recreate the appearance of a breast (Figure 8.11). Many centers still use the abdominal, latissimus dorsi, or gluteal muscle to create the flap, which can cause the patient to have weakness at the donation site and lifting restrictions for the rest of their life.

Figure 8.11 Breast Reconstruction Surgery: The Flap Procedure The flap procedure removes a flap of tissue from a different area on the body to re-create and reconstruct a new breast. TRAM, transverse rectus abdominis myocutaneous. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

A patient who has had these procedures may require nipple reconstruction later, depending on what type of mastectomy was initially performed. Some people may also choose to have a tattoo to create the image of areolar tissue. Other options may include the use of a prosthesis or an aesthetic flat closure of the mastectomy scar.

It is important for the nurse to recognize that breast reconstruction is a very personal decision. What’s right for one patient may not be right for the next. Some people may choose to have immediate reconstruction (if a candidate), while others may elect to avoid reconstruction altogether. The nurse should support the patient’s decision, whatever that may be. The nurse should also prepare the patient for the outcomes of those decisions. For example, a flap procedure will cause scarring, not only of the reconstructed breast, but also at the site of the donated tissue.

Chemotherapy

Chemotherapy is the administration of cytotoxic medication that kills cancer cells. These drugs are most commonly given before or after surgery and in combination regimens to improve survival outcomes. Chemotherapy given before surgery, known as neoadjuvant chemotherapy, is used to reduce the size of the tumor so that the surgery is less extensive. It is also used to determine the best therapeutic regimen before removing the tumor or to delay surgery, giving people time to complete genetic testing or discuss reconstructive surgery. Chemotherapy given after surgery is known as adjuvant chemotherapy. This type of chemo is used to destroy any cancer cells that were left behind after surgery or that have metastasized but have not yet been seen on imaging tests. Both neoadjuvant and adjuvant chemotherapies reduce the risk of cancer coming back or metastasizing to other organs.

Chemotherapy is most often administered as a combination of drugs to be most effective in treating both early and advanced breast cancer. Chemotherapy is usually administered intravenously, in a hospital setting or infusion center. It can occasionally be administered subcutaneously or orally. How frequently the medication is administered and for how long depends on the specific dose and regimen. When given IV, it is most commonly given through a large central line due to the risks of tissue damage if extravasation occurs. Long-term administration will require the placement of a peripherally inserted central catheter (PICC) line or a port placed on the side opposite from the breast cancer. The nurse must monitor this access point for patency and signs of infection and teach the patient how to care for it at home. Informed consent for both the access procedure and administration of chemotherapy will also need to be signed. While the nurse is not responsible for obtaining informed consent, they are required to ensure that the form has been signed and that the patient understands the procedure they are undergoing and medication they are taking.

Chemotherapy can have several side effects, depending on the drug, dose, and length of treatment. Because these medications work on rapidly dividing cells, their side effects include

• hair loss,
• nausea/vomiting,
• fatigue,
• diarrhea,
• hot flashes,
• loss of appetite or weight loss, and
• mouth sores.

The nurse should assess for these side effects during and after each treatment and intervene as necessary. For example, if the patient becomes nauseated after therapy, the nurse can collaborate with the provider to order an antiemetic and provide education about strategies to minimize nausea/vomiting with future treatments. Ongoing evaluation is necessary to ensure that these interventions are successful or to adjust the care plan to try other interventions as needed. Most side effects resolve after chemotherapy has been completed.

Because chemotherapy cannot specifically target cancer cells, the medications can affect normal tissue as well. This is particularly true in the cells of the immune and hematologic systems, leading to increased risk of infection, bleeding, and anemia. Regular monitoring of blood counts will be needed to monitor these parameters. As a result, the patient will need to be extra cautious about exposure to illness by wearing a mask in public or avoiding crowded spaces. Other potential complications could include:

• cardiomyopathy
• neuropathy
• myelodysplastic syndromes
• infertility

While infertility is a common consequence of chemotherapy, the nurse must inform the patient of the significant risk of birth defects if conception does occur. While receiving chemotherapy treatment, the patient and partner must use birth control if there is any chance that sex will result in pregnancy.

Biologic Response Modifiers

A medication that uses the patient’s own immune system to recognize and get rid of cancer cells is called a biologic response modifier. This therapy is often combined with chemotherapy to treat triple negative breast cancer. The main class of drugs used to treat breast cancer comprises checkpoint inhibitors. Checkpoints are found in the immune system and help the immune system to distinguish “self” from “foreign.” These checkpoints can be turned on or off to initiate the immune response against foreign or tumor cells. However, some breast cancers have developed the ability to bind with these checkpoints and turn them off so that the immune system does not attack them. Checkpoint inhibitors turn on the immune response against the breast cancer tumor cells.

Biologic response modifiers are used along with chemotherapy to treat triple negative breast cancer. These drugs can cause an infusion reaction, which can include fever, chills, flushing, wheezing, shortness of breath, rash/itching, and dizziness (American Cancer Society, 2021e). It is important for the nurse to monitor the patient for these symptoms frequently during and after the infusion. The patient should also be educated about this reaction and instructed to notify the provider immediately if they start feeling unwell. If symptoms occur during treatment, the nurse should stop the infusion immediately and notify the provider. The nurse can also discuss premedication for the patient’s symptoms.

Hormonal Therapy

Cancers that are hormone receptor positive for estrogen and progesterone can often be treated with hormone therapy. These medications block the hormone receptors, which prevents the cancer cells from growing. The medications are often started after surgery to remove the tumor and are taken for about 5 years, and sometimes longer if it is determined that a patient has a high chance of the cancer returning. Cancers that are hormone receptor negative will not respond to these types of medications. These drugs can be used in many ways, and the exact protocol or regimen will depend on the provider, the patient, the cancer, and a number of other factors.

Radiation

Radiation therapy is used frequently after lumpectomy or breast-conserving surgery (BCS) to remove any remaining cancer cells. Some patients with large tumors may have radiation before surgery to reduce the size of the tumor and make the surgery easier. There are two main types of radiation therapy for breast cancer: external beam radiation therapy and brachytherapy.

External Beam Radiation Therapy

External beam radiation therapy (EBRT) directs radiation at the breast or other structures (Figure 8.12). Which areas of the body receive radiation depend on what type of surgery was done and what type of cancer is present. Someone who had a mastectomy and no cancerous lymph nodes will likely have radiation to the mastectomy scar, the chest wall, and the locations of drains after surgery. If cancer is found in the lymph nodes, radiation may be directed to the areas containing the axillary, supraclavicular, infraclavicular, or internal mammary lymph nodes as well. Someone who had BCS or lumpectomy will likely have whole-breast radiation therapy.

Figure 8.12 External Beam Radiation Therapy EBRT is usually used in conjunction with surgery for early-stage breast cancers. (credit: “COL. (Dr.) Ghaed, right, and Technician J. Butler prepare a patient for cancer treatment on a linear accelerator at the Fitzsimmons Army Medical Center” by Theodore Moore, NARA & DVIDS Public Domain Archive/The U.S. National Archives, Public Domain)

Radiation is typically started after the mastectomy site has healed or, if chemotherapy is prescribed, after the chemotherapy. Radiation is given 5 days a week for 6 or 7 weeks, depending on the provider’s prescribed regimen. Some providers also use accelerated partial breast irradiation (APBI), which consists of higher doses of radiation that are limited to the wound bed to reduce the risk of cancer coming back at the site of the original tumor.

The nurse must advise the patient of potential side effects, which can include:

• swelling in the breast
• fatigue
• skin changes similar to a sunburn
• heaviness in the breast
• lymphedema if radiation is used in the axillary lymph nodes

Some side effects do not appear until later; the breast may become smaller and firmer over time. Radiation can affect the ability to breast-feed or the ability to have reconstruction later due to changes in the skin and breast tissue. Brachial plexopathy (nerve damage causing numbness and pain in the upper limb), lymphedema, and weakening of the ribs leading to fracture can result from radiation (Demarco, 2023).

The primary nursing intervention when caring for a patient undergoing radiation is education and support. It is important to teach the patient and support persons what to expect during radiation therapy, what side effects are common, how they can be alleviated or managed, and what symptoms need to be reported to the provider. The nurse may also implement and teach the patient and the family about comfort measures for the skin after radiation treatment. These can include:

• keeping the skin well moisturized and hydrated
• using hydrogel pads to reduce heat and irritation
• avoiding underwire, nylon, or lace bras
• avoiding shaving the armpits to reduce irritation to the skin

The nurse must continue to monitor and assess the patient regularly for pain, fatigue, and other side effects. Nurses should wear monitor badges measuring their exposure to radiation.

Preoperative Nursing Care

Preoperative care of the patient before a mastectomy is the same as before any other surgical procedure. The nurse will do the following:

• Ensure that the consent form has been signed and witnessed and that the patient has had all of their questions answered.
• Schedule any required preoperative testing, such as chest x-ray, additional imaging, blood testing (complete blood count [CBC], blood chemistry, and blood typing).
• Assist with scheduling the surgery with the surgery center or hospital.
• Provide preoperative teaching, including what to expect during recovery, pain management, equipment that will be in place during the recovery and postoperative period, signs or symptoms that require follow-up care, and any restrictions that may be in place after surgery.
• Provide preoperative instructions, such as staying NPO after midnight, what time to arrive at the surgery center, if there are oral medications that can be taken or should be skipped on the morning of surgery, and wearing comfortable clothing that morning.
• Ensure that the patient has all the equipment and medication they will need in the postoperative period.
• Teach the patient how to deep-breathe and cough and why these actions are important.

On the morning of the surgery, in the immediate preoperative period, the nurse will do the following:

• Perform the initial nursing assessment, including vital signs, medical history, and physical exam.
• Ensure that the patient fully understands the procedure and has no remaining questions and that the consent form has been signed.
• Ask about advance directives. If the patient has them in place, ensure that the medical provider and surgeon are aware of them and that they are in the chart.
• Assess for allergies.
• Ensure that the patient has been NPO and has taken any and all preoperative medications as instructed.
• Administer preoperative medications as ordered.
• Help the patient cope with any preoperative fear or anxiety.
• Ensure that someone is available to take the patient home if they will be discharged the same day.

Specific tasks may vary depending on facility, so the nurse must be aware of the policies and procedures at their specific institution.

Postoperative Nursing Care

In the immediate postoperative period, priority nursing interventions center on the safe recovery from anesthesia and surgery. Vital signs must be checked according to policy, usually every 5 to 15 minutes in the first hour after surgery and then decreasing in frequency with time. The patient must be assessed frequently, with a focus on the management of pain, nausea, and vomiting, particularly in the immediate postoperative period. Breath sounds should also be auscultated, drains examined, and assessment for signs of shock, hemorrhage, or infection completed. Abnormal assessment findings should be reported to the provider promptly. Other nursing care activities may include encouraging the patient to turn, cough, and deep-breathe, assisting with active range of motion exercises, reinforcing and assessing surgical dressings as needed, assisting with ambulation and personal care needs, and providing parenteral fluids as ordered. The nurse should anticipate and plan for discharge early in the recovery process. For expected times of discharge, see (Table 8.6).

Before discharge, extensive patient teaching should occur for both patient and support person. Ideally, this should reinforce any preoperative teaching that was done, including:

• how to manage and care for dressings and any drains that are in place
• how to take all prescribed medication, including PRN medications for pain or nausea
• when to return to the hospital for emergency care or follow-up
• how to perform arm exercises that should be done at least 4 times a day after axillary lymph node dissection; physical therapy may be ordered for some patients
• When to return for routine follow-up care with the oncologist, breast surgeon, and, if applicable, the plastic surgeon (usually within 1 week after surgery)

It is also incredibly important to teach the patient about what to expect when they remove the bandages, particularly if this has not happened in the hospital. Losing a breast can affect a person’s self-image, and seeing the surgical site can be an emotional time. If the patient sees the wound for the first time in the hospital, the nurse should ask who they would like to be present. The nurse can provide emotional support as needed. If this will happen at home, the nurse should prepare the patient and support person for what they will see so that it will not be as shocking. The patient should be reassured that the wound and scar will improve and that ongoing reconstruction procedures will also continue to improve body image and breast appearance over time. The nurse can suggest using an external prosthesis as a temporary measure (or a permanent one if the patient has declined reconstruction), advising the patient to seek the assistance of a company that specializes in this service and can provide additional support for the patient.

Supportive Posttreatment Care

The patient’s need for support does not end with discharge from treatment. Considerable time must be spent on education and preparation for the transition to posttreatment life. Discharge planning should start early and be a comprehensive overview of what the patient will need for this next stage in their life.

Patient Education: Community Agencies and Other Resources

In addition to providing direct patient support, the nurse can and should provide a list of community resources that the patient and support person can also access. Table 8.7 lists and describes several community and Internet resources that the nurse can suggest to patients who are in treatment for cancer.

Many of these organizations also offer support and resources for caregivers, as well as patients. It can be difficult to manage the care of someone who is sick or undergoing chemotherapy. In addition to the exhausting physical challenges of providing care, such as tending to medical needs and helping with activities of daily living, the caregiver is also dealing with stress and fear of the unknown. As a result, it is important for the nurse to assess not only the patient at each visit but also the caregiver. How are they doing? What do they need on this journey? Do they have any questions or needs that can be met by the medical or social work team? It is important for the caregiver to find ways to cope and manage their stress, as well as find a supportive community to help them through their challenges.

Nurses working in cancer care must be aware of other local resources for patient and caregiver support. It may be helpful to curate a list of local programs available at community centers, churches, and even the medical or cancer center. The nurse can also consider volunteering for these organizations to increase their community involvement and be more aware of what is actually available for patients. This may lead to finding opportunities for the nurse to initiate such programs in the community or at the medical center.