20.6 Disorders of the Breast

Pathophysiology of Breast Cancer

The breasts are considered part of the female reproductive system and are composed of tissue that produces and secretes breast milk to feed offspring. Each breast contains approximately 15 to 20 lobes that branch into several lobules where milk is produced (Johns Hopkins Medicine, 2023). The lobules are connected via small ducts to the nipple, which is located centrally in the breast and contains openings for the milk to be secreted. Figure 20.13 shows an illustration of the different parts of the breast.

Figure 20.13 The main function of the female breast is to produce and secrete milk to feed offspring. (credit: Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The underlying pathophysiology of breast cancer is intricate and thought to be multifactorial, caused by a combination of genetics, hormones, and environmental risk factors. There are several specific types of breast cancer that are classified by their anatomic location and histology, or the study of the microanatomy of cell and tissue types, but all types involve an overgrowth of cancerous cells within the breast tissue. The growth rate of these cancerous cells can also be influenced by the presence of the female sex hormone, estrogen. The following are risk factors for breast cancer development (Alkabban et. al., 2022):

• alcohol and tobacco use
• BRCA1 or BRCA2 genetic mutations
• early menarche and/or late menopause
• environmental factors (e.g., contaminated water, radiation exposure, some pesticides)
• female sex
• first-degree relative with or personal history of breast or ovarian cancer
• history of using hormone replacement therapy
• increasing age
• nulliparity (having no children) or late age at birth of first child
• obesity and/or high-fat diet

Clinical Manifestations of Breast Cancer

The most common and often first clinical manifestation of breast cancer is the development of a lesion (or lump) within the breast tissue. Because screening has become more readily available, breast cancer nodules are often found before any other signs or symptoms of cancer appear.

Assessment and Diagnostics

After a lump in the breast has been palpated by the patient or provider, further diagnostic tests are indicated. These screening tests are also indicated for patients without the presence of a palpable lesion but who have multiple risk factors for developing breast cancer. Current screening recommendations suggest that women should begin mammograms as early as age 40 years and every other year from ages 40 to 74 (Breast Cancer Research Foundation, 2023). For women at especially increased risk because of family history or genetic mutations, annual screening may start at an even earlier age.

Mammograms are usually the first diagnostic test indicated. This procedure involves taking low-dose X-ray images of the breast tissue. These X-rays can enable visualization of growths in the breast that may be indicative of cancer. It is important for women to obtain mammograms as suggested by current screening guidelines, because tumors may be detected on X-ray before they are physically palpable, allowing for earlier intervention and effective treatment. If suspicious lesions are found on the mammogram, it is likely the patient will need to undergo further imaging tests, such as an ultrasound of the breast tissue to confirm the presence and characteristics of the tumor. If the presence of a tumor(s) has been confirmed, the next step is a biopsy of the mass or tumor.

During the biopsy procedure, breast tissue and fluid are removed and sent to the pathology laboratory for analysis and staging of the cancer. The different types of biopsy procedures are described in Table 20.10.

Medical Therapies and Related Care

With focused research over the past several years, treatment options for breast cancer have become more readily available and much more effective. In some cases, treatment can even be provided before the patient receives an official cancer diagnosis. The complete removal of breast tissue before any cancer diagnosis is known as prophylactic mastectomy and greatly decreases the patient’s risk of developing breast cancer. This procedure should be considered for patients with certain risk factors, including a strong family history of breast cancer, presence of genetic mutations, or personal history of other cancers. In most cases, the patient will undergo the prophylactic procedure and immediately undergo reconstructive breast surgery for cosmetic benefits.

Mastectomy can also be performed after receiving a breast cancer diagnosis and is used to treat more invasive types of cancer that affect large portions of the breast tissue. This can be performed as a total mastectomy (removal of the entire breast and surrounding tissue), or a mastectomy with breast conservation, for which the aim is to remove as much of the tumor as possible while maintaining as much breast tissue as possible for cosmetic purposes. The surgical procedure is made with consideration of the cancer’s stage and characteristics, surgeon recommendations, and patient preferences.

In addition to surgery, treatment with radiation therapy or chemotherapy may be considered. These therapies may be instituted after surgery or as a standalone therapy, depending on specific patient and cancer characteristics. There are two main types of radiation therapy that can be used: EBRT and brachytherapy. External beam radiation therapy is administered externally, meaning it is noninvasive and administered on top of the skin to treat the underlying breast tissue. This therapy is typically administered daily (5 days/week) for a month or two. The goal of this therapy is to irradiate cancer cells within the breast tissue to completely destroy the cancer and cause remission. Brachytherapy, on the other hand, is administered internally. Radioactive seeds are placed within the breast tissue and continuously give off radiation, killing cancer cells in the breast. The type of radiation therapy to be used depends on the specific cancer type present and its stage and severity. Both types of radiation therapy have some associated adverse effects, including pain or redness at radiation site, infection, breast tissue damage, and fatigue.

Chemotherapy is another option for the treatment of breast cancer. This therapy is systemic, meaning it is administered throughout the entire body as opposed to just treating localized breast tissue, like with radiation therapy. Chemotherapy involves the administration of powerful drugs that kill the fast-growing cells in the body, which includes cancer cells. It is often performed as an adjuvant therapy, meaning that it is given in conjunction with another therapy, often before or after surgical intervention. When administered before surgery (neoadjuvant chemotherapy), the goal of therapy is to shrink the tumor so it is easier to remove during surgery. If administered after surgery (adjuvant chemotherapy), the goal is to eliminate any residual cancer cells that may not have been fully removed during the initial surgical intervention. Chemotherapy is typically administered through a central venous catheter, most often an implanted port in the patient’s chest. This allows for easy and quicker administration into the patient’s systemic circulation. Though highly effective at destroying cancer cells, chemotherapy is also potent to healthy cells, which can result in unpleasant side effects, including

• anemia
• fatigue
• gastrointestinal disturbances (e.g., anorexia, nausea, vomiting, diarrhea)
• hair loss
• immunosuppression (and associated low white blood cell count)
• mouth sores

Hormone therapy is another treatment option that may be indicated for breast cancer. This therapy is also usually a type of adjuvant therapy and involves the administration of medications that either lower levels of estrogen in the body or block estrogen from binding to receptors. By limiting the amount and function of estrogen in the body, cancer cell growth can be slowed or stopped. These medications are administered in oral pill form and are usually prescribed to be taken for approximately five years to prevent cancer recurrence. Common side effects of these medications include hot flashes, vaginal dryness, and muscle pain.

Nursing Care of the Patient with Breast Cancer

Because of the nature of cancer care, patients will often require an interprofessional team of providers to ensure the best possible outcome. The nurse plays a vital role on the team by creating a comfortable environment and providing necessary interventions.

Recognizing and Analyzing Cues

Common lesions may be found by the patient during a self-breast exam or by the provider during a physical examination. These nodules can be found anywhere within the breast but are often found in the upper outermost portion of the tissue. Their shape and characteristics may vary slightly, but they are usually immobile, hard, and nontender. The later signs of breast cancer include skin dimpling, nipple retraction, and changes in skin color and texture, likely due to stretching of the skin to accommodate growth of the tumor. Other late clinical manifestations associated with breast cancer are depicted in Figure 20.14.

Figure 20.14 Late physical breast changes that may indicate the development of breast cancer include lumps, skin dimpling, changes in skin color or texture, change in nipple appearance, and clear or bloody nipple discharge. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Evaluation of Nursing Care of the Patient with Breast Cancer

Nurses, as part of the patient’s care team, will be involved with the patient long after the initial treatment is complete. The nurse will be part of the patient’s follow-up care, including the patient’s physical and emotional needs.

Evaluating Outcomes

The optimal patient outcome after receiving treatment for breast cancer is the complete destruction and elimination of the cancer cells and a state of remission without cancer recurrence. Part of the follow-up process for patients who receive treatment for breast cancer involves close monitoring of breast tissue for the development of more tumors. These follow-ups will vary in frequency depending on provider preference and specific patient characteristics. Additionally, as part of the evaluation process, the nurse should assess how the patient is coping. Even after being treated effectively for breast cancer, there are still uncertainties about whether the cancer will come back, so it is important that patients are able to effectively cope with these unknowns. If the patient expresses concerns or difficulties with coping, the nurse can spend some time discussing these with the patient and finding resources such as support groups, which may help the patient improve their coping skills for the future.

Clinical Safety and Procedures (QSEN)

Patient-Centered Care: Breast Self-Examinations

Disclaimer: Always follow agency policy.

Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs.

Breast self-exams are noninvasive, facilitate intimate familiarization of native breast tissue, and increase breast self-awareness. Guidelines from the American College of Obstetricians and Gynecologists and American Cancer Society recommend that individuals begin breast exams as early as age 25 years. Nurses can provide education on the correct methods for conducting a breast exam.

• Exams can be done in the shower, at least every month.
• The patient should be instructed to place hands on hips and observe for discoloration, rashes, and nipple inversion.
• Educate the patient that it is normal for one breast to be larger than the other.
• After inspection is complete, educate the patient to lay with the arm of breast being examined under the neck. With the other hand, use one of the two following methods: (1) Use the pads of the finger in a zig-zag or “lawn-mowing method” across the breast tissue; and (2) use a concentric motion starting around the nipple and palpate the tissue.
• Axillary assessment should also be conducted, noting any hard, nontender lymph nodes. The patient performing the breast self-exam should observe any fixed, nontender hard lumps.

(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)