BREAST CANCER IN THE 21st CENTURY:
HOPE ON THE HORIZON
Online Course #9005 - 10 Contact Hours
Author: Marilyn Hanser, RN, BSN, MA
Editor: Peggy M. Goulding , Ph.D.
©2008 National Center of Continuing Education, Inc.

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About the Author

Marilyn Hanser, RN, BSN, MA graduated from Baylor University School of Nursing in 1976. Upon graduation, she joined the US Navy and was stationed at the Naval Regional Medical Center in Oakland, California where she achieved the rank of Ltjg before she was honorably discharged in 1978. Since 1994, she has managed her own Health Education and Consulting business specializing in women’s health issues. In that role, she facilitated support groups for women preoccupied with weight and dieting. She also taught classes on eating disorders and on menopause at the local community college and various community centers. She is currently teaching in the state of California’s Breast Cancer Early Detection Program.

About the Editor

Peggy M. Goulding, Ph.D., received a doctoral degree in educational psychology from the University of Texas at Austin and completed a post-doctoral program in clinical neuropsychology at the University of Houston. She has over twenty years of professional experience in a variety of settings, including state, local and Federal government; private industry; hospitals; rehabilitation facilities; nursing homes; and public and private schools. A former faculty member in neurology at the Saint Louis University School of Medicine, she has also taught at the University of Houston, University of Missouri, and Maryville University. In addition to her work with the National Center of Continuing Education, she currently is in private practice in Georgetown, Texas.

Table of Contents

Introduction
Physiology of the Breast
Normal Breast Changes
Benign Breast Conditions
Malignant Breast Conditions
Risks for Developing Breast Cancer
Prevention and Diagnosis of Breast Cancer Prevention
Diagnosis
Nursing Diagnoses Associated with Breast Cancer
Treatment and Follow-Up Care of Breast Cancer
Treatment
The Use of Alternative Medicine in the Treatment of Breast Cancer
Follow-Up
Nursing Interventions
Impediments to Receiving Care
Cross-Cultural Considerations
Patient Education
Stages of Change Model
Health Belief Model
Maslow's Hierarchy of Needs
Mind/Body Medicine
Helping Clients Choose Health Messages

INSTRUCTIONAL OBJECTIVES

According to the American Cancer Society, breast cancer is one of the most commonly diagnosed cancers in women; there are over 180,000 women diagnosed each year in the US alone. About three quarters of breast cancer diagnoses occur in women over the age of fifty. While there are no guaranteed prevention methods, it has been shown that early detection through regular self-breast exams, regular clinical breast exams, and regular mammography is the best way to reduce mortality. As a result, there is a decreasing likelihood that a woman will die of the disease.

There are several identified risk factors for the development of breast cancer and they will be discussed throughout this course. The primary risk factor, however, is being female which makes every woman a potential target. While men can develop breast cancer, the risk is 1000 times less than that for women. It is believed that the primary biological factor that makes women more susceptible is the possession of a far greater number of mammary cells. In addition, during pregnancy and lactation women's' breast cells are stimulated in ways that mens' breasts are never stimulated.

The apparent capriciousness of breast cancer as well as the uncomfortable diagnostic and treatment methods serves to increase fears about developing it. While there is no cure, in recent months breast cancer research has undergone a positive attitude shift as experts discover new rays of hope for the prevention and the treatment of the disease. Statistics are no longer dominated by rising incidence rates and newly discovered risk factors.

Every nurse has a role to play in the prevention and treatment of breast cancer. We are often in a unique position to teach patients as well as the public about the risk factors, the latest prevention methods, and recent discoveries in treating the disease. We have the credibility to encourage women to effectively perform monthly self-breast exams, to get annual breast exams from their health care providers, and to stress the importance of annual mammography after the age of 40.

There are often barriers to convincing women to undergo regular screening exams. These barriers may be cultural, economic, emotional (women often say they do not do regular self breast exams because they are afraid they will find something), or simply due to a knowledge deficit about the risk of developing the disease. These barriers and the nurse's role in helping to overcome them will be discussed at length throughout the course.

PHYSIOLOGY OF THE BREAST

The breast lies on top of the pectoralis major muscle. Fibrous stroma provides the background structure of the breast while ligaments connect the skin to the pectoralis muscle. Breast tissue is drained by the axillary lymph nodes. There is usually a good arterial blood supply to the breast but venous drainage may vary.

Beyond this, there is no "standard" female breast. One woman may seem to have breasts that are filled with fine granular material while another woman's breasts may feel like they contain pea-sized gravel. An individual woman's breasts, at different times in her life and even at different times in her menstrual cycle, may undergo normal changes that cause her breasts to feel very different from how they felt previously or how they will feel in the future. All developed breasts, however, are an intricate network of ducts and lobules (which contain the mammary glands) cushioned by a layer of fat. The basic component of the breast lobule is the hollow alveolus or milk gland lined by a layer of milk-secreting epithelial cells. A crisscrossing of myoepithelial strands as well as a rich network of capillaries surround each alveolus. The alveolus is connected to an intralobular duct via a thin nonmuscular duct. The intralobular ducts, lined with contractile muscle cells, reach the exterior of the body through openings in the areola. This intricate breast tissue normally extends from the bra-line to the clavicle bones and into the armpit. 

Growth of this milk-producing system is dependent upon hormonal stimulation that typically occurs in two sequences, first at puberty and again with each pregnancy. At menopause, a reduction in hormonal stimulation once again causes changes to take place in breast composition as ductal tissue is replaced by fatty tissue and the breasts are rendered unable to produce milk.

Normal Breast Changes

Breast tissue begins to develop around the sixth week of fetal gestation. Prepubescent breasts are in a resting state with ducts present but nonfunctional. The first major changes in the breast occur at puberty and are the result of estrogen influence. The first response to pubertal estrogen stimulation (about age 11 to 14) is the formation of a mass of breast tissue just under the areola as well as a change in areola pigmentation and size. If left untreated these lumps will usually disappear in about six months. Once menstruation begins, a girl may notice swelling and tenderness in the breasts before and sometimes during her menstrual period. This tenderness and swelling is caused by the collection of extra fluids in the breast tissue as a direct result of hormonal changes associated with the menstrual cycle. Some girls may notice fibrocystic changes that make the breasts feel ropy, lumpy, and/or granular. This condition is most often benign.

As the pubescent breast changes into a more mature breast, the ducts elongate and side branches of the ducts and lobular elements form. After many ovulatory cycles, the breasts become pendulous with mature lobular elements remaining in a resting state until pregnancy occurs.

During pregnancy a woman may notice breast changes such as enlargement, increased sensitivity, and/or darkening of the areola. During this time and immediately after giving birth, there are breast changes taking place in order to prepare for lactation. Proximal ducts grow and branch while increased mammary blood flow leads to vascular engorgement and the lobules become dilated and engorged with milk.

In late pregnancy the nipples may secrete a protein-rich fluid known as colostrum. 

During menopause the normal breast undergoes changes in density and composition. Ductal and glandular tissue is replaced by adipose and fibrous tissue. Because the fatty tissue is less dense than the ductal and globular tissue, lumps are easier to feel and easier to see via mammogram than they are on a younger woman or on a woman taking post-menopausal hormone replacement therapy (the dense breast tissue of younger women   and those on hormones provides a white background against which tumors are difficult to detect).

Benign Breast Conditions

Several conditions may lead to the formation of a benign breast lump. These include such things as:

• Cysts - These are divided into two categories. A simple cyst is described as a thin fluid-filled capsule that may become enlarged and tender during the menstrual cycle. It usually disappears without treatment. A complex cyst has a thicker wall and contains both fluid and tissue. Both of these types of cysts are often referred to as fibrocystic changes in the breast and they occur in 40-50% of women. They do not increase a woman's risk of developing breast cancer.

• Fibroadenomas - These occur when a lump of breast cells forms outside the ducts. They may feel rubbery and mobile and usually subside on their own. However, if they continue to enlarge or if the diagnosis is uncertain they may need to be surgically removed.

• Fat necroses - These often occur with age as the fat in the breast is broken down. This degeneration may cause fat to clump together which can create a hard and round lump. These lumps often develop after a hard blow to the breast or at the site of a previous breast biopsy. A biopsy is needed to rule out malignancy.

• Sclerosing adenosis - This condition consists of benign excessive growth of breast tissue requiring a biopsy to distinguish it from cancer.

• Intraductal papillomas - These are small wart-like growths in a milk duct usually located near the nipple. They consist of dense/fibrous tissue, may be singular (usually in women nearing menopause) or multiple (usually seen in younger women). They may cause bloody nipple discharge and therefore a biopsy is necessary to rule out cancer. The presence of papillomas does not significantly increase one's risk of developing breast cancer.

• Calcifications - These are caused by deposits of calcium crystals in breast tissue. These deposits are often too small to be felt on a manual exam and are, therefore, usually discovered by mammography. They form for many different reasons, most of which are benign. However, calcifications may also be associated with some types of pre-malignant lesions and some types of cancer so they are usually biopsied to rule out the possibility of malignancy.

• Mastitis - This is an infection in one or both breasts usually caused by the obstruction of a mammary duct during lactation. The area around the clogged duct may become inflamed, swollen, and painful. Other symptoms include nausea, fever, and lack of appetite, fatigue, and blood-tinged discharge from the nipple. Often mastitis is the result of bacteria entering the breast through cracks that develop in the nipple during nursing. Antibiotics are the treatment of choice for this condition.

• Mammary duct ectasia - This condition affects perimenopausal women and women who smoke. Ducts near the nipple become thin, dilated, and may accumulate secretions leading to the formation of an abscess if the duct becomes infected.

• Galactorrhea - This condition results in the continued flow of milk from the breasts at times other than breast-feeding. It may happen in nulliparous women and even in men. It is usually caused by medication.

• Discharges - It is normal for the nipples to pass a little fluid if they are squeezed. Spontaneous discharges, however, may occur during times of increased prolactin production such as puberty and menopause. Some drugs may cause increased prolactin as well. These include birth control pills, antihypertensives, and some tranquilizers. Underlying conditions such as hyperthyroidism or a pituitary tumor may increase prolactin levels as well. Nipple discharges are seen more often in women who jog several miles a day or those who supplement their aerobic workout with weight lifting. This may be due to clothing that irritates the nipples or to stimulation of the chest muscles. Bilateral nipple discharge is usually benign while unilateral discharge may have a more serious underlying cause.

The woman herself discovers most breast lumps and 80% of them are benign. Even so, a provider who will determine whether further screening is necessary should check all lumps. A woman's age will play a major role in determining the type of screening she gets. Because younger women have denser breasts, mammography may not be particularly helpful while ultrasound can detect lumps even in dense breast tissue.

Cysts usually call for needle aspiration followed by microscopic evaluation to determine whether the fluid is suspicious. Solid lumps usually require outpatient biopsy to determine if they are benign or malignant. Sometimes the biopsy will indicate a pre-cancerous condition that merits further watching.

Just how much treatment benign breast changes require depends on several factors. These include the type of tissue involved, a woman's personal breast cancer risk, the amount of pain the condition is causing, and her desire to be rid of the anxiety-producing lump. Fibrocystic changes can be uncomfortable but usually require analgesia only. Anecdotal evidence suggests that eliminating caffeine, taking evening primrose oil, or increasing one's intake of vitamin E can ease symptoms. Aspirating the fluid may treat fluid-filled cysts. Fibroadenomas are usually removed surgically depending on such factors as the woman's age, the tumors shape, and the growth rate of the tumor. Mastitis pain is usually helped with warm compresses and antibiotics. However, if mastitis is not treated early an abscess may develop and that condition usually requires surgical draining. 

Malignant Breast Conditions

Breast cancer is not a homogeneous disease but, instead, may differ in histologic, biologic, and immunologic characteristics. As discussed in the previous section, breast masses can be placed into different categories, many of which are benign. Cancerous lumps differ in many ways from benign lumps. They are much harder than benign masses; they are also fixed and stationary while benign lumps are more movable.

A common form of breast malignancy is known as "infiltrating intraductal carcinoma." This type arises in the ducts leading from the milk-producing glands. This type may be well differentiated and slow growing, poorly differentiated and infiltrating, or highly malignant and undifferentiated with many multinucleated giant cells. Another form of breast cancer is called "infiltrating lobular carcinoma." This type occurs in breast tissue between either the ducts or elsewhere in mammary tissue. It may be multifocal as well and is more likely to be bilateral than is intraductal carcinoma. Inflammatory carcinoma of the breast is a particularly virulent form of malignancy that is characterized by breast enlargement, general breast redness with a purple area over the area of the tumor, and areas of induration caused by subdermal spread of the disease. Usually there is no palpable lump. Symptoms tend to progress rapidly and often the disease is not diagnosed until there is lymph node involvement and even gross distant metastasis. Inflammatory cancer is most common in women aged 50 to 55.

Breast cancer metastasizes both by lymphatic drainage and by hematologic involvement. 

Although breast cancer is a multicentric disease, almost half of all breast tumors occur in the upper outer quadrant of the breast. These tumors tend to drain to the axillary lymph node that is why, until recently, removing not only the affected breast but the axillary lymph nodes as well treated most diagnoses of breast cancer. The likelihood of axillary node involvement increases with the size of the tumor.

Sometimes, however, the axillary nodes are bypassed and the tumor drains into the supraclavicular and infraclavicular nodes. Secondary drainage patterns may extend from the axillary nodes into the nodes at the base of the neck. Medial lesions tend to drain into the internal mammary nodes as well as the axillary nodes. The incidence of disease recurrence is higher in those women with internal mammary node involvement and the prognosis is not as good as it is for women with axillary node involvement alone.

Breast cancer may metastasize widely and unpredictably either early in the course of the disease or late in its course (sometimes years after a woman appears to be disease-free). Factors affecting the speed of distant metastasis include the size of the tumor, the number of positive nodes, and the histologic grade of the tumor.

The pulmonary system is a common site of metastasis. Once pulmonary metastasis occurs, the tumor cells get into arterial circulation and metastasis then spreads easily to the brain and liver. A second common site of metastasis is the skeletal system, particularly the ribs, thoracic vertebrae, skull, pelvis, and upper femurs. The disease may also spread to the pleura, kidneys and adrenal glands, ovaries, pituitary gland, and the thyroid. 

When breast cancer is detected in its early stages, the chances of survival increase dramatically.  It is the goal of most early detection programs to make the diagnosis within three months of finding a lump. If this is done then 90% of cancers can be effectively treated.

RISKS FOR DEVELOPING BREAST CANCER

Experimental and clinical data indicate that the development of breast cancer is not a chance event. Rather, it is a process involving many factors that are influential in an ongoing battle between tumor growth and individual resistance level. As a result, experts find it difficult to determine all of the factors involved. It appears, however, that in all cases but those of hereditary genetic abnormalities, there must be direct damage to the cell DNA. Even though experts do not know everything that causes this damage they do know that most cancers begin growing as much as 10-20 years before they are detected (this is why so much emphasis is placed on early detection).

There are two major risk factors for the development of breast cancer - being female and having breasts. The risk increases with age. Other known risk factors include:

•  first degree relative with breast cancer i.e. a mother or a sister

•  personal history of atypical hyperplasia (usually from a previous breast biopsy)

• early menses and/or late menopause (both of which mean longer bombardment of the body with estrogen)

• never having been pregnant or never having breast-fed. Recent research suggests that premenopausal women who breast-feed, especially those who lactate at a younger age and for a longer period of time, have a significantly reduced risk for developing breast cancer. Laboratory observations show that human breast milk actually kills breast cancer cells through the use of a protein called alpha-lactalbumin, a substance which scientists have genetically engineered in lab settings and had good results with in animal testing. They hope to eventually use it as a treatment for breast cancer.

• first pregnancy after the age of 30

• a history of ovarian cancer

• a diagnosis of globular carcinoma in situ.

• Estrogen replacement therapy (ERT) - Hundreds of studies trying to determine whether estrogens are initiators, promoters, or neutral as causal agents in the development of breast cancer have failed to reach a consensus. There are studies that suggest that those on ERT are at a higher risk but there are also studies that do not show this. The difficulty is further increased by the fact that there is a wide variety of estrogens that affect the body - some are endogenous while others are exogenous. Some experts believe that the problem may not be the estrogens themselves but the way some women's bodies metabolize the hormone (estrogen metabolites and their influence on estrogen receptors in the breast may play a role in the development of the disease). In 2004, a large randomized controlled double-blind study (the kind of study researchers think is the most reliable) known as The Women's Health Initiative showed an increase in strokes in women who had used ERT for five years or longer but no significant increase in heart disease or breast cancer. Experts now recommend that women be on ERT for the shortest amount of time necessary to reduce the most troublesome menopause symptoms. 

• Estrogen/progestin combined hormone replacement therapy (HRT) - A recent report from the Iowa Women's Health Study indicates that HRT use may not raise the risk for developing the most common cancer types but that it may increase the risk for developing rarer (and less virulent) forms of the disease. These cancers are slow growing with orderly cell patterns when compared to the more common forms of breast cancer. Although this study is encouraging for long-term prognosis, these cancers are still treated the same way as the more common forms and as a result, the woman diagnosed with them may face surgery, radiation, and post-op drug treatment. Another recent study showed that women taking combined HRT for six months or more were more than twice as likely to develop lobular tumors than women who did not use HRT. Lobular tumors are harder to detect via mammography or physical exam but they do have higher survival rates. In 2003, The Women's Health Initiative (mentioned in the previous bullet section) found strong evidence that HRT was linked to an increase in breast cancer risk and heart disease in those who used it for five or more years. As a result, experts recommend HRT for menopausal symptoms only and strongly encourage women to get off the drugs as soon as possible.

• Abortion - This is a highly controversial and emotional issue and the link is far from proven. However, given the number of abortions performed each year and because there is some evidence to suggest a possible link, a discussion is warranted. The physiology behind this theory stresses that during pregnancy the increased hormonal stimulation causes many changes in the composition of the breast as the body prepares for the process of lactation. This is a time when more breast cells are vulnerable to cancer. A pregnancy carried to term results in a natural evening out of hormonal stimulation by the third trimester, leaving the delivered woman with fewer cancer-vulnerable cells than she had before she was pregnant. This is why pregnancy is believed to have a protective effect on the breast. However, an unnatural interruption of these hormones in the first trimester (such as occurs with elective abortion) leaves the body with estrogen levels twenty times what they would be in her non-pregnant state. Unlike a pregnancy carried to term, there is no chance for an evening out of hormonal stimulation to occur so the aborted woman is left with more cancer-vulnerable cells than she had in her pre-pregnant state. Interestingly enough, those women who miscarry do not appear at increased risk for breast cancer development. Experts suggest that miscarriages often occur because of disturbances in the hormonal system of the pregnancy, leaving the spontaneously aborted woman with fewer vulnerable cells than a woman who chooses abortion. Those supporting this theory cite a meta-analysis study performed by Joel Brind, PhD (now a professor of biology and endocrinology at the City University of New York) and his colleagues from the Pennsylvania State Medical College. It was published in the British Medical Association's Journal of Epidemiology and Community Health. According to this study, using data gathered from 1957 on, elective abortion resulted in an overall 30% increased risk of breast cancer. Those who disagree cite a study from Denmark (published in the New England Journal of Medicine) that they claim proves there is no connection between elective abortion and the risk of breast cancer. Clearly, no definitive claims can be made yet and given the highly emotional nature of any discussion on elective abortion; it may be awhile before there is an answer to this question. However, experts on both sides of the abortion issue owe it to women to put aside their own agendas and try to find an answer to this question.

• Radial scars - This is a specific type of benign breast lesion that, according to one large recent study (conducted as part of the Nurses Health Study), may double a woman's chance of developing a malignant lesion later. A fibroelastic core from which ducts and lobules radiate characterizes them microscopically. These ducts and lobules often exhibit various alterations including cysts and proliferative lesions. Radial scars are usually discovered incidentally during diagnosis and treatment of other possible breast anomalies. However, larger radial scars are now being detected more frequently on mammogram. According to the Nurses Health Study, there is a correlation between the size of the scar and the risk of developing cancer: the larger the scar, the higher the risk of developing breast cancer. There is also a correlation between the number of scars and the risk of developing cancer: the larger the number of scars detected, the higher the risk. Because of their morphologic similarities to cancer as well as the detection of some malignant cells in the radial scars themselves, scientists have speculated that these lesions may represent a very early stage of some cancers. Until this study, however, the data to back up this suspicion was ambiguous. Clearly more studies are needed before any definitive conclusions can be reached regarding a connection between radial scars and the development of breast cancer. Until more data is available, researchers recommend that pathologists report the presence of radial scars and note the size and number of scars as well. They also recommend that these women be followed up as any other woman with a benign lesion associated with a moderate increase in breast cancer risk. 

• High dietary fat intake - There may be a link between breast cancer and dietary fat intake. An analysis of several observational studies indicated that as fat consumption increased so did the risk for breast cancer. However, researchers in the ongoing Nurses Health Study found no such link. They found that breast cancer risk fell slightly with increased fat consumption. Obviously more studies are needed before any clinical recommendations can be made.

• Obesity in postmenopausal women - According to a study released in July of 2000 by the University of Vermont, postmenopausal women who are overweight and have dense breast tissue (such as those on HRT) are more likely to develop breast cancer than are normal weight women with less dense breasts. Studies show that a healthy diet can help control breast density as well as curb obesity. As a result, clinicians are encouraged to stress the importance of healthy eating to women in this risk category.

• Alcohol consumption - It has also been suggested that there is a link between alcohol consumption and the risk of developing breast cancer. Studies on this topic are inconclusive although there does appear to be an increase in circulating estrogen in women who consume moderate amounts of alcohol (some studies show that even as little as one drink per day has been shown to increase the risk). This increase in circulating estrogens may be further increased if the woman is also taking HRT (due to an additive effect). The studies on alcohol consumption have been primarily observational in nature i.e. they rely solely on the report of women themselves. While observational studies can provide important clues to direct further research they cannot allow cause and effect conclusions to be drawn because too many variables exist which may skew results. As a result, further studies of a randomized controlled nature are needed before any conclusions can be made concerning the interaction of alcohol and estrogen levels in the body and whether any increase in estrogen level due to alcohol intake can cause the changes in the breast necessary for the development of breast cancer.

• Environmental factors may play a role in the prevention of breast cancer. One of the most compelling reasons behind this theory is the increase in breast cancer rates among women who migrate from one part of the world to another. For example, women in Japan have traditionally enjoyed a much lower breast cancer rate than women in the US. However, third generation Japanese-American women are at the same risk as American women in general. This may be due to dietary factors because the traditional Japanese diet is lower in fat and higher in soy than the American diet. Breast cancer rates are also lower in Africa and Scandinavia where the diets are higher in fiber content than the American diet. Estrogen-like substances found in pesticides, dry-cleaning agents, spermicides, and plastics may play a role in the development of breast cancer. If further research bears this out then common sense suggests that reducing our exposure to these chemicals might help prevent breast cancer.

• Homosexuality - A study in San Francisco showed that lesbians had three risk factors in common that were not seen as often in heterosexual women - fewer lesbians have been pregnant, lesbians tend to have a higher body mass-index, and lesbians have had more breast biopsies. The first factor was no surprise, as researchers already knew about the link between pregnancy and reduction of breast cancer risk. The other two factors, however, have researchers puzzled. More research is needed before conclusions on clinical application of this information can be determined.

Until there is definitive evidence on how to prevent breast cancer, early detection remains the best way to decrease the risk of dying from the disease.

PREVENTION AND DIAGNOSIS OF BREAST CANCER

Prevention

Some of the best recent advances in breast health have been in the area of prevention. Two recently identified genes are thought to be responsible for the majority of cases of familial breast cancer. The BRCA1 gene was identified in families with high clusters of both breast and ovarian cancers. However, it is also found in about 5% of breast cancers in the general population as well. The BRCA2 gene is found in the same percentages as BCRA1 but is not associated with ovarian cancer. The discovery of these two genes has allowed providers to estimate the chances of some women's risk for developing the disease that, in turn, provides them with greater treatment options. 

Although considered by many to be a drastic measure, for those women at high risk for the development of breast cancer one preventive option is prophylactic mastectomy, either total or subcutaneous. Specific indications for prophylactic bilateral mastectomy include a family or personal history of breast cancer, multiple previous breast biopsies, unreliable physical exams due to nodular breasts, findings of dense breast tissue on mammography, mastodynia, and extreme fear of cancer. When making a clinical decision regarding the wisdom of this procedure the provider and patient should also consider the risks involved in breast reconstruction (because most of these women are young they generally choose to have reconstructive surgery). The effect of surgery on body image and sexuality, the irreversibility of the decision, and the fact that not all women who choose prophylactic mastectomy would necessarily have developed breast cancer had they not had the surgery (a woman without breast cancer at the time of evaluation has a 50% chance of carrying the gene that causes the cellular mutation of normal cells into malignant ones).

No prospective controlled trials have been completed to validate the efficacy of this procedure. However, one retrospective study conducted on 639 women with a strong family history of breast cancer showed that bilateral prophylactic mastectomy reduced the incidence of breast cancer and death from breast cancer by 90% in this group. Because this is the first study done on this topic, it is considered groundbreaking and of extreme importance to those women who are considering the procedure. Most experts, however, do not consider this to be the treatment of the future. Rather, they hope to find non-surgical treatments for this high-risk group of women as well. Until such non-surgical interventions are developed, prophylactic mastectomy does remain an option for those high-risk women who fear the disease more than they do the disfigurement of mastectomy. It is important to note that due to the extensive amount of breast tissue in the female body (from the axilla to the entire anterolateral portion of the chest wall), it is impossible to remove all breast tissue even with a total radical mastectomy. As a result, there have been case reports of breast cancer developing in some women even after total or subcutaneous bilateral mastectomy.

Recent studies on the psychosocial effects of genetic testing for women suspected of carrying the BRCA1 and BRCA2 genes show increases in anxiety, depression, family conflict, and stress at work for those who have undergone testing no matter the result of the tests. A positive test, however, may elicit stronger responses similar to those receiving a cancer diagnosis even though the test only shows the gene that predisposes one to cancer, but does not show that the disease itself is present. Furthermore, not everyone who tests positive for the genes will go on to develop cancer. Those patients exhibiting extreme distress should be referred to a mental health provider for assessment and follow-up.

Other problems with genetic testing include false negatives, which provide inaccurate reassurance, and ambiguous results that leave the woman with ongoing uncertainty and psychological distress. For these reasons experts recommend all nurses study the principles of human genetics, cancer genetics, and the implications of genetic testing in order to provide patients with the most accurate information concerning testing. Nurses should also have knowledge in the ethical, legal, social, and psychological consequences of genetic testing. As more studies are done in the area experts hope to provide this information to appropriate health care personnel.

There are drugs that may help in the prevention of breast cancer in post-menopausal women. Two of these drugs, tamoxifen, and raloxifene (both already FDA approved for the treatment of osteoporosis) have been tested in clinical trials funded by the government to determine scientifically their efficacy in preventing breast cancer. Halfway through the study the results on tamoxifen were so impressive that the researchers stopped the study and received FDA approval for the use of tamoxifen as a prophylactic against breast cancer. Last year raloxifene was also approved by the FDA. As a result, the government is now launching a large new trial called STAR that is designed to compare the two drugs to determine if one is more effective than the other is. Results are not expected for several years.

Arimidex is another drug currently used to reduce the recurrence rate of certain kinds of breast cancers. It is administered following surgery with or without radiation. Further follow-up is necessary to determine long-term results, side effects, and survival rates.

Diagnosis

Over the past 30 years in the US, the average size of malignant female breast cancers has decreased significantly due to regular screening and early diagnosis. Because early diagnosis has been shown to save lives (in the 1990ís alone the death rate dropped from 25 to 21 in every 10,000 women), it is important to stress to patients that following the established screening guidelines is imperative to good breast health. There are several components to a good early detection program; some are more economical than others are. The components of an early detection and diagnosis program include the following:

• Breast self exams (BSE) are done by the woman herself on a monthly basis throughout her adult life and most lumps are found this way.

• Clinical breast exams (CBE) are done by the health care provider at regularly scheduled check-ups or after a woman presents with a lump she has already felt herself. The goal is to find lumps before they reach the size of one cm. If this is done then vascular and lymphatic invasion can usually be prevented. The general recommendation is for annual CBEs after the age of 40.

• Screening mammography - The Mammography Quality Standardization Act has ensured that all women have access to the same quality standard of mammography and that they are notified of results within a week. This test is for asymptomatic women and should be done annually after the age of forty (at age 70 and above there is some controversy as to the value of annual screening. The likelihood of developing cancer increases with age but most of these women have slow-growing tumors that may make annual screening unnecessary). It is also recommended that a woman in her late thirties get a baseline screening mammography in order to have something with which to compare any future findings.

• Diagnostic mammography is a more extensive exam with more views taken and is done for women with symptoms such as a suspicious lump or with other breast conditions which make detection difficult e.g. breast implants.

• Digital mammography was FDA approved in January 2000. It is the first system for use in the US. This system is designed to generate digital imagery that can be used to determine the existence of suspicious lumps. It does this by storing the x-ray image on a computer disk, which then converts it into digital imagery for viewing on a high-resolution computer monitor where contrast adjustment and magnification procedures are possible. The images can also be adjusted to correct for over or underexposure without the woman having to come in for another mammogram. It also has a wide range that allows for examination of a larger percentage of breast tissue. Computer software programs are available to help recognize and flag suspicious areas. This test can be used as an alternative to traditional mammographic procedures. It is being touted in the press as "the single biggest advance" in mammography in 30 years.

• Scintimammography is a technique that uses radioactive contrast agents injected into the woman's arm. Once inside the body, they travel to the breast tissue where an image of the breast is taken with a gamma camera to detect tumor cells. Because this process also has the ability to determine the presence of cancer cells outside of breast tissue, it may prove to be an invaluable technique in detecting metastasis and may, eventually lead to the elimination of the need for node biopsy. However, it provides a higher radiation dose than traditional mammography and cannot detect some small tumors. It is often used as mammography follow-up.

• Fine needle aspiration is done in the health care provider's office. A needle is inserted into the breast lump and the fluid in the lump is aspirated and examined to determine the presence of a malignancy.

• Breast biopsies, until recently, were the only way to determine whether solid masses were cancerous or not. Biopsies can be very painful, especially if the lump is located deep in the breast near the chest wall. In recent years, about half of US hospitals have begun to use a simpler and less painful procedure called the MIBB (minimally invasive breast biopsy) to acquire the same information. In this procedure, the woman lies face down with one breast exposed through a hole in the examining table. The exposed breast is then pressed between two plates and a local anesthetic is applied. The physician locates the mass using a digital x-ray camera with a mechanical arm that also holds a hollow biopsy needle. Once the mass is located, a switch is flipped which causes the needle in the mechanical arm to enter the mass and withdraw tissue. Although a benign biopsy rules out the existence of cancer in the tested lesion, it may indicate certain conditions that increase the woman's risk for developing breast cancer in the future. Such conditions include the presence of benign proliferative disease or atypical hyperplasia in conjunction with the benign condition known as radial scars. For this reason, even women with benign breast biopsies should carefully weigh their treatment options and those with the above risk factors should be closely followed in the future.

• Sentinel lymph node biopsy is a new technique using blue dye or a nuclear medicine scanner to identify the sentinel lymph node; the node most likely to have cancer cells if the cancer has begun to spread. Once the sentinel node is identified, it is then biopsied. Research to date suggests that if the sentinel node is negative, then other axillary lymph nodes will be negative as well thus eliminating the need for more extensive axillary dissection. Further studies are being conducted to confirm these findings.

• Ultrasound is emerging as a diagnostic technique that, when used by an experienced radiologist, can pick out tumors too small to be seen on mammograms. It can also help distinguish between fluid-filled cysts and the more ominous solid mass. It is usually performed if there are suspicious findings on a mammogram, especially in women with very dense breast tissue. When used in conjunction with mammography the cancer detection rate increases from 70% to 94%.

• TC-99 tetrofosmin is another new diagnostic imaging technique for women with dense breasts. This test received FDA approval as a diagnostic tool in 1999. It has the capability of finding masses and determining the presence of a malignancy, even in dense breasts, about 90% of the time.

• Magnetic resonance imaging (MRI) uses high radio frequencies and a special dye to produce breast images based on water content. It appears to be effective in detecting invasive lobular carcinoma, a form of cancer that is hard to detect with mammography. More research is needed before efficacy can be completely determined but, for now, it is a promising technique on the horizon.

• Positron Emission Tomography reveals the metabolic processes of cells by using a radioactive agent to highlight tumors. Radioactive estrogen can give important information about the estrogen receptors on the cancer cells. This information has huge ramifications for treatment options, especially in cases of metastatic disease. At this time, scanners do not have the ability to detect small tumors or in situ disease.

• Thermography (also known as DII), a possible alternative to mammography screening, is being used by some chiropractors in the San Francisco Bay Area. It is based on the principle that chemical and vascular activity is higher in the areas surrounding both precancerous and malignant cells. This higher activity leads to higher temperatures in these areas. DII uses ultrasensitive infrared cameras to detect and analyze these hot spots. There is a great deal of interest in this technique because if it works it could eliminate many of the uncomfortable aspects patients associate with mammography e.g. the machine does not touch the body so breast compression is not necessary. It is done without radiation and, theoretically, it can find cancers at a much earlier stage of development than mammography is capable of doing. Experts differ on the clinical ramifications of DII and most insist that until more is known about its effectiveness, DII should not be used as the sole diagnostic tool but should be used in conjunction with traditional mammography. However, many researchers are excited about the possibility of using DII in the future to diagnose breast cancer in its earliest stages of formation where successful treatment is more likely.

• BreastScan IR   In March 2004, the FDA approved a new screening device that uses digital imaging to aid in the early diagnosis of breast cancer. The BreastScan IR can draw attention to potential areas of concern that might not be detected by mammography or ultrasound. The procedure takes about ten minutes and the results are immediately available to the physician. The breast is not touched during the procedure so no pain is involved. The device is considered an adjunct to regular mammograms and breast self-exams. It is not intended to function as an independent diagnostic tool.

Even with all of these new and potentially better detection techniques described above, mammography in combination with monthly self breast exams and annual clinical breast exams still remains the best form of early detection available to date. Mammography reports usually come back as category 0 through 5. Categories 0 through 2 represent normal breasts or the presence of benign breast disease. Category 3 is probably benign (90-95% of the time) but should be followed up in six months to be certain. Category 4 is considered suspicious and requires a biopsy. Category 5 is also suspicious because it usually means there is something noticed in one breast that is not in the other (known as asymmetry). Category 5s should be repeated in six months.

Once the diagnosis of breast cancer has been made it is then necessary to determine the stage of development of a particular tumor. Most cancers detected in this country are at Stage 0 or Stage 1 at the time of diagnosis. This results in early treatment and saved lives. Stage classifications are as follows:

• Stage 0 - This stage is also known as carcinoma in situ and is defined as a very small contained tumor with no lymph node involvement and no evidence of breast cancer cells in other parts of the body.

• Stage 1 - This tumor is less than 2 cm. in diameter with no node involvement and no evidence of breast cancer cells in distant parts of the body.

• Stage 2A - The tumor is 2-5 cm. with no node involvement and no evidence of breast cancer in distant parts of the body. A tumor of less than 2cm. with some node involvement but no distal body involvement is also classified as 2A.

• Stage 2B - This tumor is either 2-5 cm. with some node involvement or greater than 5 cm. with no node involvement.

• Stage 3 - This includes both small and large tumors with more extensive lymph node involvement.

• Stage 4 - This stage includes any sized tumor with or without lymph involvement, but with metastasis. 

• Stage 5 - This stage is for suspicious lumps found in only one breast.

Delayed diagnosis is the most common complaint leading to lawsuits. Delays may be caused by the health care provider failing to be impressed by findings on a CBE, improper follow-up, misread mammograms, and negative mammogram despite lump felt by either the patient or the health care provider (mammograms miss about 20% of lumps). It is for these reasons that both CBE and mammography are strongly recommended in order to ascertain the presence of a malignancy.

The breast self-exam, while not effective by itself, is an important part of a comprehensive early detection program. It has several advantages in that it is free, convenient, has no physical risk associated with it, and the individual woman has more time to devote to it than her clinician does. While the clinician may be more skilled at detecting suspicious lumps, a woman who has come to know her breasts through several years of regular examination knows what is abnormal for her (BSE will be discussed further in the "Patient Education" section at the end of this course). This is why both components are important to an early detection program.

Communication is extremely important in establishing patient/provider rapport. Some things to remember when preparing a patient for a CBE include:

• Clarify her expectations and concerns.

• Use basic professional terms (rather than technical ones) or lay terms.

• Explain the procedure and why it is necessary.

• Acknowledge that the procedure may be embarrassing and uncomfortable but reassure her that you will do your best to minimize these problems.

• Do not leave her undressed and alone for a long period in a cold room.

• Encourage her to give her provider feedback during the exam.

• Encourage the provider to discuss findings after the woman is dressed and make sure the setting is private and confidential.

• Check for patient understanding of the provider's findings and reinforce any follow-up recommendations that were made by the provider.

     The basic principles and steps of the clinical breast exam are as follows:

• Do a visual inspection of the breasts (both the frontal and lateral views) with the patient sitting. Breasts should be visually examined with the patient's arms resting by her side, her arms straight above her head, and with her hands pressing down on her hips with the elbows bent. Look for asymmetry between breasts, color and skin texture abnormalities, and dimpling.

• Examine all breast tissue. This tissue extends from the clavicle bones to the bra-line and from the sternum to the axilla and into the armpit. Most tumors are found in the upper outer quadrant of the search area (in the axilla and armpit area so this region should be done especially carefully). The nipple area is another common site for tumor development. It is recommended that each woman examine herself monthly by first looking in the mirror to ascertain whether there are distinct differences between the breasts that did not exist last month - normal breast tissue is remarkably symmetrical. She should also look for nipple discharge and/or nipple retraction.

Patterns of Search:
Large arrows indicate areas of breast tissue that may be missed by circular method.
Circular	Vertical Strip

There are three types of search patterns used when performing CBE or SBE. Most of us have been taught the "circular" method which involves searching in concentric circles beginning with the nipple and moving toward the outer breast tissue. This method, however, misses many of the cancers that develop in the outer edges of the breast tissue perimeters. The "vertical strip" method is more effective in detecting smaller lumps as well as lumps on the perimeter of breast tissue. It is the method currently recommended for both BSE and CBE. The "vertical strip" method involves a systematic search of all breast tissue beginning with the outer quadrant and working inward toward the nipple moving the fingers in vertical strips rather than in the more familiar circular pattern. A third method known as "wedge/radial" is also effective and may be used by some clinicians. To avoid confusion, however, experts recommend that women be taught the "vertical strip" method for performing BSE.

Palpation using the "vertical strip" method should be done using the pads (not the tips) of the three middle fingers of one hand. The hand should be bowed slightly with the tips of the fingers in an upward position. The fingers should move in a sliding motion without leaving the tissue surface and should be moved in slightly overlapping dime-sized circles as they move up and down the search area. The patient should look for evidence of asymmetrical thickenings, masses, or other abnormalities. Any abnormalities detected should be noted for location, size, shape, consistency, texture, mobility, and tenderness. She should immediately report these findings to her health care professional for follow-up.

Palpation pressure should be done at three levels every time the fingers move. This means that all breast tissue is searched superficially, at a medium depth, and at the deepest level to ensure that tumors growing at all levels are detected.

The following breast conditions or findings should receive further evaluation:

• Bloody aspirated cysts

• Aspirated cysts with residual palpable mass after aspiration

• Cysts that recur within a six-week period after aspiration

• Asymmetrical thickening which remains following menses in an ovulating woman

• Asymmetrical thickening in a non-ovulating woman

• Spontaneous nipple discharge

• Nipple retraction

• Nipple scaling that is unresponsive to treatment

• Skin erythema that is unresponsive to treatment

Nursing Diagnoses Associated with Breast Cancer

Several nursing diagnoses may be appropriate during the screening process as well as the diagnostic, treatment, and follow-up phases of breast cancer. These diagnoses encompass the physical, emotional, psychosocial, and spiritual health of the patient and include the following:

• Anxiety

• Body image disturbance

• Post-op constipation

• Ineffective coping methods

• Altered family processes

• Fatigue

• Fear

• Anticipatory grieving

• Dysfunctional grieving

• Hopelessness

• Knowledge deficit

• Impaired physical mobility

• Pain

• Altered parenting patterns (for women diagnosed at a young age)

• Personal identity disturbance

• Powerlessness

• Altered role performance

• Self-care deficit

• Self-esteem disturbance

• Altered sexuality patterns

• Impaired skin integrity

• Sleep pattern disturbance

• Impaired social interactions

• Social isolation

• Spiritual distress

• Ineffective management of therapeutic regimen

• Impaired tissue integrity

Appropriate nursing interventions for most of these diagnoses will be discussed in the next section of this course.

TREATMENT AND FOLLOW-UP CARE
OF BREAST CANCER

Treatment

The diagnosis of breast cancer, no matter how small the lump, is often overwhelming to both the woman and her family. The volume of information that follows a diagnosis can leave even the most self-confident women feeling indecisive. It is important to remind them that the five-year survival rate for early cancers is high. The goal of treatment is to eradicate the disease.

Once a diagnosis of breast cancer has been made, several pre-treatment tests need to be done. These include a chest x-ray, CBC, and liver function tests. A bone scan is also indicated if it is determined that the tumor has spread. Any tumor removed during a biopsy procedure should be tested for the presence of estrogen and progesterone receptors on the cells since experts believe those tumors with estrogen receptors present may indicate an increased risk of recurrence.

The choice of treatment is based on the type of cancer involved, the stage of the disease, the woman's age, her overall health status, her willingness to tolerate the side-effects of a given regimen, her willingness to participate in clinical trials, and whether or not she is planning on breast reconstruction after surgery. The most common treatment for breast cancer is surgery to remove the tumor and to sample the axillary lymph nodes to determine if the disease has spread. However, if metastasis has already been determined and surgery would not improve her chances for survival, then surgery is not indicated. The goal of any surgical procedure is to remove the entire tumor as well as a surrounding area of normal tissue, while saving the most breast tissue possible. There are several types of surgery used in the treatment of breast cancer. They include:

• Lumpectomy - The lump, a border of surrounding tissue, and a few axillary lymph nodes are removed. A biopsy of the nodes is done to determine whether the disease has spread. Even if no nodal involvement is found, lumpectomy is usually followed by several weeks of radiation therapy. For the majority of women with early stage cancer (tumors less than 2 cm.) this treatment is just as effective as a mastectomy. An article the journal Cancer, however, indicates that many women who qualify for this breast-conserving procedure are still having mastectomies. Experts believe this is due to regional standards of practice not catching up to the national guidelines. The individual doctor's personal preference for mastectomy may play a role as well. Lumpectomy is not recommended for those with large tumors or with very small breasts (too much of the breast tissue would be removed and the results would be very noticeable). 

• Partial Mastectomy - The tumor, a large segment of breast tissue (up to one-quarter of the breast), and all axillary lymph nodes are removed. This is followed by a course of radiation.

• Simple Mastectomy - The entire breast and several lymph nodes are removed. For early tumors, this may be enough but for more advanced tumors radiation is recommended as well.

• Modified Radical Mastectomy - The entire breast, all axillary lymph nodes, and the lining of the chest muscles (but not the muscles themselves) are removed. For those deemed at high risk for recurrence, radiation follows. If the woman is planning on post-mastectomy reconstructive surgery then her general surgeon should consult with the plastic surgeon to determine how to cut the skin during the mastectomy.

• Radical Mastectomy - The entire breast, all lymph nodes, and the chest wall muscles under the breast are removed. This procedure is considered overkill and is rarely done anymore.

The removal of the axillary lymph nodes may cause edema in the arm, a condition known as lymphedema. Though it is rarely life threatening, lymphedema is one of the most troublesome consequences of breast cancer surgery. The frequency is higher in those women who have radical mastectomy than in those who undergo one of the less radical procedures. Radiation to the axillary area also increases the risk of developing lymphedema. Lymphedema causes swelling of the affected arm, which can severely limit arm mobility, cause increased pain, and increase the risk of post-op infection. It may also serve as a constant reminder that cancer existed. This may result in devastating psychological consequences for some women. Women experiencing the symptoms of lymphedema should report them to their providers immediately.

Management of lymphedema is often difficult. Treatments such as pneumatic compression, the use of support garments, and massage therapy to induce draining are often cumbersome and ineffective, especially if they are not implemented early in the process of lymphedema development. Researchers continue to search for new methods to manage lymphedema. Most researchers, clinicians, and affected women consider this an important quality of life issue.

Recent technological advances are expected to transform the way nodes are tested (which may drastically reduce the incidence of lymphedema). Within three years, researchers expect that this new procedure will be standard practice. Instead of testing 20 to 30 nodes, as is currently the practice, this procedure uses a radioactive tracer injected into the tumor. The tumor is then massaged to spread this tracer through the lymph vessels so that doctors can see which node a cancer cell would reach first. Instead of removing all lymph nodes within the vicinity of the tumor, only this sentinel node is removed. If a biopsy determines that this node is not malignant then the other nodes are declared clear of cancer. Reducing the number of nodes removed greatly decreases a woman's chances of developing lymphemia.

Recent evidence from a German study suggests that a bone marrow test could soon become a significant tool in the treatment of breast cancer. This new test is primarily used to predict the chance of recurrence in the individual woman. It appears to be more effective at predicting recurrence than the currently used lymph node biopsy procedure. It uses proteins, known as cytokeratin-specific antibodies, which target small traces of cancer cells that have spread to the bone marrow. Those women who show evidence of micrometastasis to the bone marrow are considered at a much higher risk for recurrence and, therefore, should receive more aggressive post-op treatment such as chemotherapy even if all lymph nodes test clear. Conversely, those women who have negative nodes and negative marrow are a low-risk group and may not need any post-op treatment.

Radiation may be used before surgery to shrink tumor size, making its removal easier. Post-Operative radiation therapy is used to destroy cancer cells left behind in the breast, chest wall, or lymph nodes, and to relieve pain associated with bone metastasis. Patients with delayed wound healing, collagen vascular disease, or previous radiation to the same breast are not candidates for radiation therapy. Pregnant women diagnosed before the third trimester are also not good radiation candidates.

Post-Operative radiation begins when the wound is fully healed (usually two to three weeks after surgery). Usually patients receive external beam radiation with a carefully focused beam of high-energy protons. Treatment is given five days a week for five to six weeks and may cause fatigue, skin irritation, pruritus, infection, and pain. However, internal radiation in the form of implants may be the treatment of choice. The duration for this treatment is only one week.

Another form of radiation therapy, known as brachytherapy, involves the insertion of a small catheter (with radioactive substances inside it) into the affected area. This prevents damage to the surrounding tissue as is often seen in conventional radiation therapy. This is an in-patient procedure and duration of treatment depends on the type and stage of the cancer.

Chemotherapy is another option in the treatment of those women considered at high risk for recurrence. It is given by injection or p.o. and may involve a combination of several different drugs. It is given in cycles with each period of drug administration followed by a recovery period. The total course may last from four to nine months. Side effects depend on the particular drugs used and the length of treatment but often include nausea, vomiting, hair loss, decreased appetite, mouth sores, menstrual cycle disruptions, increased risk of infection, increased bleeding and bruising after minor injuries, and fatigue. There are effective drugs available to help manage most of these side effects.

Hormonal therapies may be used to treat some tumors. These usually involve drugs that have anti-estrogen properties such as Tamoxifen (mentioned earlier as a method of preventing breast cancer development). This drug is taken daily p.o. for a period of five years following a diagnosis of breast cancer and is usually given primarily to reduce the rate of recurrence. It may cause hot flashes, weight gain, mood swings, blood clots, and cataracts. It may also increase a woman's risk of developing endometrial cancer but in most cases this risk is considered necessary since most endometrial cancers are caught early and have a very high survival rate when compared with the survival rate for breast cancer.

In the last few years, advances in treatment of breast cancer have provided new rays of hope for those who suffer from this disease. Research presented at the annual meeting of the American Society of Clinical Oncology cites two new drugs that may delay recurrences and increase survival rates for women with breast cancer. The first drug, Taxol, is developed from compounds found in the yew tree. One study showed it to be effective in treating both early and advanced cancers. 

The second drug, Herceptin, is a laboratory-generated antibody to a protein (HER2) commonly found on breast cancer cells. When this antibody invades a cancer cell it interferes with the cell's basic functioning resulting in cell death. When this drug was administered (in conjunction with standard chemotherapy) to women with metastatic disease, progression of the disease was slowed for several months and the survival period was extended. When given to women in whom two forms of chemotherapy had been unsuccessful, the drug shrank tumors by 50% or more in 14% of the women studied. Side effects include transient chills and fever, diarrhea, and increased susceptibility to infection. Cardiac risk increased when the drug was used in conjunction with certain other chemotherapeutic agents such as anthracyclines and cyclophosamide. When given in conjunction with Taxol, however, cardiac risk did not increase. The drug has FDA approval for use alone or in combination with Taxol.

However, Herceptin's manufacturer has recently issued a warning (issued since the drug was approved by the FDA) to health care providers concerning potential serious side effects of Herceptin. These side effects may include allergic reactions, infusion reactions, pulmonary lung events, and even death. While the number of women having these adverse reactions was small in comparison to the number of women taking the drug, the new information is important because it identifies a group of women (specifically those with pulmonary problems prior to taking the drug) who may be at high risk for developing problems if placed on Herceptin therapy. Providers for pulmonary-compromised women are encouraged to use extreme caution in prescribing the drug and to discontinue the drug immediately should any severe adverse reactions occur.

A somewhat controversial type of hormonal therapy, known as Custom Hormone Preparation, is sometimes recommended to women as safer than the more conventional hormone preparations. These preparations, although not approved by the government, offer different types and amounts of estrogen (usually estriol, estrone, and/or estradiol) along with progestogen. They are administered orally, rectally, by nasal spray, by skin cream, and by subdermal implant. There is no data to support claims that these preparations are safer than other pharmaceutical drugs.

Ductal Carcinoma in Situ (DCIS) is a group of conditions that fall somewhere between benign conditions that are often associated with a risk of developing breast cancer and conditions of outright invasive breast cancer. DCIS does not develop as a lump but, instead, fans out along the milk ducts so that early detection by the woman herself is much harder (often the diagnosis is made during screening mammography where it shows up as calcifications). Because it is confined to the ducts, DCIS is a curable condition if caught early and if it is completely excised. However, if left untreated it will progress to invasive cancer at the site of the biopsy in over half the cases, usually within five to eight years. For this reason providers are encouraged to treat the disease somewhat aggressively. Treatment options for women with a diagnosis of DCIS are more ambiguous than the options for women with other breast cancer diagnoses. Mastectomy is recommended only for women with large and especially virulent patches of DCIS. Lumpectomy is the treatment of choice for most women diagnosed with this condition. There is controversy over whether the lumpectomy should be followed by radiation. For years, radiation was part of the standard of care but recent studies suggest that radiation may not be necessary for some women diagnosed with DCIS. Margin width, the distance between the edge of the lesion and the edge of the excised specimen, may be an important determinant of recurrence and, therefore determine the need for post-op radiation. The size and character of the cells also plays a role in deciding whether radiation is necessary.

In May 2000, the FDA approved the use of saline breast implants for breast reconstruction Almost any woman who has had a mastectomy can now have reconstructive surgery. This usually involves a saline-filled implant placed under the woman's skin. A new nipple and areola are constructed as well. Because this process often starts while a woman is undergoing mastectomy, the general surgeon and the plastic surgeon should consult with each other before the mastectomy procedure. Experts warn that implants do not last a lifetime and that a substantial number of women will need further surgery to replace or remove implants due to complications such as dimpling and puckering at the site, loss of nipple sensation, formation of scar tissue, and asymmetry. Several studies show that women who have implants following mastectomy are twice as likely to develop complications as women who undergo augmentation are. FDA approval stipulates that women must be warned of the risks of implants before surgery.

There is a great deal of information nurses can share with patients to help them cope with the side effects of radiation.

Tell them to:

• Nap often to conserve energy

• Engage in mild daily exercise

• Wash the affected area with mild soap and water followed by the application of oil-free and alcohol-free lotions

• Not shave the irradiated areas

• Wear loose clothing to prevent skin irritation

• Avoid exposing the skin to extreme temperatures

• Avoid sun exposure

• Teach chemo patients to

• Recognize the signs of infection

• Practice good hygiene, especially frequent hand washing

• Avoid crowds

• Eat small bland meals to avoid nausea and vomiting

• Buy wigs early if they are on a regimen that causes hair loss

• Accept that most women on chemo gain weight

Most women can return to their normal lives within a month or two after treatment. For those who need help during the recovery process, the American Cancer Society provides free services to help meet the emotional, physical, and cosmetic needs that many women have following breast cancer diagnosis and treatment. These "Reach to Recovery" volunteers provide comfort and support as well as practical information on how to obtain prostheses, what type of prosthesis is appropriate in a given situation, and how to prevent fluid build-up and infection in the affected arm. Because these volunteers are women who have had breast cancer themselves, their presence alone can be an indication of hope for a newly diagnosed woman who may be feeling depressed or overwhelmed by what is happening to her.

The health care delivery system for the treatment of breast cancer has changed significantly in the past few years. Until recently, women had to go from one medical facility to another for the different aspects of treatment and follow-up e.g. radiations in one facility, chemotherapy in another, tests in still another. Now there are comprehensive breast centers springing up all over the country so that women may get all of these services plus support group therapy and nutritional counseling in one place.

The Use of Alternative Medicine in the Treatment of Breast Cancer

Over the last two decades, the use of alternative medicine to treat a variety of illnesses has increased substantially. While there are no alternative therapies clinically shown to alter the course of breast cancer progression, many of these methods are effective in decreasing the side effects of conventional treatment methods e.g. acupuncture helps reduce the degree of nausea associated with chemotherapy use. Alternative approaches also help women decrease their stress levels and encourage healthier lifestyles.

The specific alternative approaches that are often useful in treating a breast cancer diagnosis include spiritual programs, relaxation methods, nutritional therapies, herbal and naturopathic remedies, homeopathic remedies, mental imagery, and hypnosis. Many of these fall into the category of mind/body techniques and can be used by nurses. Therefore, these mind/body techniques will be discussed in the section entitled "Nursing Interventions."

Studies show that at least one-third of cancer patients use some form of alternative treatment. It is not exactly clear what prompts patients to try alternative methods but speculation by experts suggests that there are a variety of reasons e.g. failure of standard medicine to find a cure, changes in the health care delivery system, patients' need to feel empowered, cultural differences, and a preference for a "natural" healing method. In general, those patients who use alternative approaches also see physicians. This suggests that they see alternative care as complementary to standard western medicine rather than as a substitute for it. On the other hand, studies show that many women do not report the use of alternative therapies to their physicians. When questioned about this, these women report they are afraid their physicians will not understand or approve of their choices, will be indifferent to the information, or will consider the information irrelevant to conventional treatment. Nurses should know that the information is indeed relevant and, therefore, they should ask patients directly, but in a non-threatening manner, about their use of alternative medicine. 

A study published in the New England Journal of Medicine on the use of alternative therapies in women with early stage breast cancer provides some interesting insights into why patients choose alternative methods and how they are affected by that choice. The study was conducted on 480 women with well-established prognoses and therapeutic options. In this group the use of alternative therapies was common. Many women began to use them immediately following diagnosis in conjunction with surgery, chemotherapy, and radiation. The study found that those women who initiated the use of alternative methods after breast cancer surgery suffered from more depression, worse general mental health, lower levels of sexual satisfaction, a greater fear of recurrence, and more frequent and severe somatic complaints than those women who did not use alternative medicine or those women who were already using alternative medicine prior to their breast cancer diagnosis. 

The researchers concluded that initiation of alternative therapies immediately after a breast cancer diagnosis may be a marker for psychosocial distress and therefore should alert providers to inquire further into her psychosocial situation so that appropriate referrals can be made to help her deal with any anxiety or depression she is experiencing as a result of the diagnosis. Other experts speculate that the women who turn to alternative therapies just after diagnosis are women who are afraid to talk about their concerns for fear that the provider will consider it a waste of time or because they are embarrassed about having such feelings. Whatever the reason it seems that all healthcare professionals should be aware of this potential marker for psychological distress and use it to assess the patient's need for a mental health referral. Most researchers agree that further studies are needed before conclusions that are more definitive can be reached.

Another study shows differences in the types of alternative therapies chosen by four different ethnic groups. According to this study, Black women were more likely to choose spiritual healing methods; Chinese women were drawn to herbal remedies; Latinas chose dietary and spiritual techniques; and White women picked dietary therapies, massage, and acupuncture. This study also found that more educated women, those with higher incomes, younger women, those with private insurance, those who exercised regularly, and those who attended support groups were more likely to choose alternative therapies than women who did not fall into these categories.

Specific alternative therapies used to treat women with breast cancer include the following:

• Homeopathic medicine for the treatment of lymphedema (homeopathy is a system of medicine based on the use of natural substances to stimulate the body's own healing powers in curing disease and relieving symptoms).

• Homeopathic remedies for the treatment of nausea from chemotherapy and radiation (Nurses should always encourage their patients to look for certified homeopathic practitioners. Certifying agencies include the American Board of Homeotherapeutics, the Council for Homeopathic Certification, and the North American Society of Homeopaths. All patients using homeopathic remedies should let their MD know so that both practitioners can work together for the good of the patient. In many cases, the homeopathic practitioner is also an MD; in other cases, the homeopath may be a chiropractor, naturopath or an acupuncturist. In all of these instances it is vital that both providers be informed about what the other one is doing for the patient).

• Acupuncture for the treatment of nausea associated with chemotherapy. Acupuncture is part of a Chinese system of medicine developed over thousands of years. It is characterized by the stimulation of points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or to normalize physiological functions, including pain control, for the treatment of certain diseases and dysfunctions of the body. Efficacy of the procedures has been demonstrated in several controlled studies. Insurance coverage varies from state to state, depending on licensure requirements and whether medical supervision is required for the treatment. Nurses should check into the licensing laws of their own states to determine how to talk to patients about this form of therapy.

There are many areas of research that yield interesting, yet inconclusive, results. One such study published recently in the Journal of Cancer Research and Clinical Oncology showed that women who drink the equivalent of five Japanese-sized cups or more of green tea per day had a decreased recurrence rate and a longer disease-free period than those women who drank less than four cups a day. Further research is necessary before any clinical conclusions are drawn about this specific remedy but the results of studies such as this one continue to spark interest in other dietary treatment methods.

Another question that needs further research before it can be answered adequately concerns the effect on the breast of phytoestrogen in the diet. Phytoestrogens are plant sources of estrogen and are commonly found in foods such as soy products and certain fruits and vegetables. Many experts believe that phytoestrogens may actually have a protective effect on the breast and thus reduce the risk of developing breast cancer. This is especially important as many women are choosing to use dietary sources of phytoestrogens (instead of HRT) as a means of controlling the unpleasant side-effects of decreased estrogen levels associated with menopause.

Follow-Up

Because breast cancer can recur at any time (even as many as thirty years after the original diagnosis), all women who have been treated for breast cancer should continue to receive follow-up care for the rest of their lives. The type and stage of cancer involved, the treatment given, and the risk of recurrence generally determines how often they should be examined.

In general, experts recommend that follow-up regimens include a physical exam every 3 to 4 months for the first two years following treatment. All patients should undergo regular mammography, chest x-rays and liver function tests at the appropriate intervals recommended for the stage of their disease and their prognosis. The intervals for all of these tests gradually increase to annually after five years without disease recurrence.

Nursing Interventions

Many of the interventions used by nurses fall under the category of "Patient Education" and will be discussed in that section of this course. However, some nursing interventions do not fall into that category but are still necessary. They deserve a separate discussion.

An important nursing intervention for treating the emotional, psycho-social, and spiritual nursing diagnoses is to make the diagnostic and treatment settings as patient-centered as possible. When attempting to teach patients about an issue as emotionally laden as that of breast cancer, experts encourage making the office environment in which the learning is to take place a welcoming one. The "environment" is defined as the physical setting as well as the interactions that take place there. This means that the environment starts with the phone call in which the appointment is made and extends through the follow-up process, including any mailings that take place both prior to and subsequent to the office visit. If necessary, the environment may include the hospital environment in which treatment is provided as well as any post-op follow-up care. Problems at any point in this process may result in non-compliance with the screening guidelines or treatment recommendations.

Some of the following considerations and suggestions for change require minimal effort on the part of the staff and, yet, may provide significant improvement in patient/provider communication. Other changes are more extensive and require a long-term commitment to successfully implement. The suggestions include:

§         Make the decor inviting to patients. Furniture should be laid out in a way that provides comfortable traffic patterns and adequate wheelchair access. Good lighting is important for filling out forms and for reading health education materials. Reading material should be selected to appeal to a wide variety of interests, ethnic groups, and reading levels. Signs should be welcoming in tone and encourage patients to ask questions if they are confused about any part of the process. Ideally, signs should appear in all of the major languages spoken by patients in each particular setting. A list of languages spoken by the staff as well as those languages with available translators should also be posted. Experts suggest that a sign reflecting the setting's non-discrimination policy be posted to reassure members of the various cultural subgroups that they will be treated respectfully by all staff members. 

§         Interactions between patients and staff should be respectful. Procedures and policies should be explained in terms that the patient can understand. If necessary, explanations should be calmly repeated until it is clear the patient understands what you are saying. If patients have to wait for long periods due to the inevitable delays that occur in health care settings, then sincere apologies should be given.

§         Some health education efforts such as teaching BSE, watching videos, providing individual counseling, and obtaining the health history should be done in a private and confidential setting (not in an open crowded waiting room) to insure patient comfort in giving as much information as possible. The more information you have the better you can assess whether she needs screening vs. diagnostic services, her perception of her risk level, and behavior changes she needs to make to comply with the recommended guidelines and treatment options. Once these assessments are made you can then tailor your health education messages to her specific need. 

§         Master the art of asking questions to ascertain as much information as possible during the office visit. Ask open-ended questions rather than closed ones. A closed question is one that can be easily answered with a "yes" or a "no" e.g. "Have you ever had a mammogram before?" An open-ended question is worded in such a way that it cannot be answered simply and thus allows you to gather more information e.g. "Tell me about your previous experiences with mammograms." When asked this way you will not only discover whether or not she has had a previous mammogram but you are more likely to find out if she considered it painful, embarrassing, etc. and you can tailor your responses accordingly. Questions may also be used to explore - "What does cancer mean to you?" to inform -"Has anyone ever shown you how to do a breast exam on yourself?" (If the answer is "no" you can arrange to demonstrate the proper way to perform SBE), and to clarify - "Where did you say you felt the lump?"

§         Listen actively and respond appropriately by reflecting what you hear her say. Check with her to see if you understood what she told you. To avoid misunderstandings make sure that your body language and words send a consistent message. For example, it can be confusing if you are verbally encouraging her to be open with you but your legs are crossed and your arms are folded across your chest indicating that you are not at all open to hearing what she has to say.

§         Listen for the emotional content of what she is saying and then respond to the emotions. Many women are scared to get screening services because they are afraid of what the exam will uncover or afraid of the pain that may be involved in some parts of the screening process. This can be especially true if a family member or close friends have had the disease. Often these women have not had an opportunity to express the strong emotions involved and, as a result, their anxiety levels remain high. Those in a high state of anxiety do not hear much of what they are told. However, if you allow them to express the feelings to you and you respond empathically, their anxiety level will drop and they are much more likely to hear the health education messages you are sending. Obviously, a woman who has just received a diagnosis of breast cancer is going to be in an even higher state of anxiety and may not hear much of what you tell her. It is a good idea to have a list of breast cancer support groups where those who have lost family members or those who have been diagnosed with breast cancer can go to express their emotional concerns about the disease. 

§         Patients should be told that feelings of depression are normal after a breast cancer diagnosis. These feelings may manifest themselves as a loss of self-esteem, fear of rejection, moodiness, crying spells, loss of appetite, and loss of interest in sex. She may wonder "Why me?" or "What have I done to deserve this?" While these feelings are normal in the beginning, for those women experiencing long-term problems such as hopelessness; a sense of powerlessness; disturbances in body image, self-esteem, personal identity, and sleep patterns; social isolation; fear; and/or dysfunctional grieving as result of the disease, it may be necessary to make a referral to a mental health professional, a support group, or a member of the clergy.

§         Women being screened, diagnosed, and treated for breast cancer also have other stressors in their lives. These stressors may affect their anxiety level and, as a result, negatively affect your educational efforts. Therefore, it is a good idea to give them the opportunity to express these concerns before you begin your teaching agenda. Such stressors include children leaving home, the symptoms associated with menopause, marital problems, responsibility for the care of aging parents, the death of friends, physical impairments, etc.

§         Learn to use humor effectively to reduce patient stress. It is important that you establish your competency and compassion before using humor. Attend to physical and emotional pain before attempting therapeutic humor. Never use humor immediately after giving a dire prognosis. However, once patients realize you are competent to care for them and you care about them as individuals, and then you can begin to use humor to strengthen the patient/provider bond. Individuals' sense of humor varies significantly so, what is funny to one patient may not be funny to another. Avoid ethnic, religious, sexual, and political humor, as these tend to alienate patients. Once alienated you must work much harder to win them back. Humor is not about being a clown but about using humor as a part of one's being to communicate empathy, understanding, and caring. Used in this way humor becomes integrated into your entire care system.

Studies show a relationship between stress and the development of breast cancer. Dealing positively with stress will often improve the quality of life of a patient already diagnosed but it may also act as a preventive measure in those women at high risk who have not yet been diagnosed. Nurses who understand this can teach a variety of stress-reduction techniques that have been grouped together under the heading of "Mind/Body Medicine." These include such techniques as prayer, meditation, progressive relaxation, guided imagery, breath therapy, and support group membership.

Prayer falls into the category of nursing interventions related to the spiritual dimension of human existence. Other interventions within this category include the use of scripture, providing a centered presence, active listening, and referral to clergy or other spiritual counselors. These will all be discussed under the heading of prayer.

Studies show that prayer is one of the methods of treatment commonly chosen by women to help them deal with the spiritual and emotional distress of a breast cancer diagnosis. Although the exact physiological mechanism by which prayer works has not been determined, prayer has been demonstrated to stimulate healing. Experts speculate that prayer stimulates the relaxation response and, as a result, enhances the immune system. Nurses in holistic practices recognize an element of mystery in the use of prayer for healing. Many attribute this mysterious component to the assistance of a "higher power" in the healing process. This "higher power" is often referred to as God.

In answer to the question, "Is prayer professional?" a recent editorial in the Journal of Christian Nursing stresses the important relationship between the healing of body, mind, and spirit. This is the foundation of holistic medicine's call to view the patient as a whole person. The editorial concludes that nurses who believe in God's power to heal are ethically obligated to pray for their patients' healing. Because most of Jesus' ministry was a public one, the editorial further concludes that the Christian nurse must pray individually for his/her patients and must ask the body of Christ (the church) to pray as well. The editorial further states that if one is asked by a patient to pray with him/her, the Christian nurse is ethically bound to do so. Thus the editor answers the question "Is prayer professional?" with a resounding "Yes!"

Holistic nurses report that intervention in the healing process with prayer helps clients cope with anxieties surrounding their diagnoses. Prayer is also seen as an important tool to deepen the crucial nurse/client bond. One nurse reports that a semicomatose cancer patient told her he felt an electrical current run through his body while she was praying over him and he knew that God was there. Some holistic practitioners suggest that contacting churches and other religious bodies within the community is an important nursing intervention. Such organizations may serve as support systems for clients both in the hospital setting and at home.

When using prayer as a nursing intervention you must constantly ask yourself,  "Whose need am I meeting - my own or the patient's?" The authors suggest that if you are attempting to meet a personal need, then a private prayer is appropriate. However, if you are attempting to meet the patient's needs then a shared prayer is the proper intervention.

Studies show that different populations and ethnic groups place varying emphasis on the use of prayer. Non-whites are more likely to turn to prayer for help in dealing with crises than are whites. These non-white groups demonstrate that the use of prayer/meditation, belief in God, and having a general sense of connectedness with nature and with other people contribute to a sense of inner strength and self-reliance which can be drawn upon when coping with difficult health issues.

So far, we have been talking about Christian spirituality. It is important, however, to remember that women from other ethnic groups may have a different spiritual tradition, which is equally as important to them as the Christian tradition, is to many of us. To appropriately intervene in the spiritual dimension the nurse must first learn about the patient's spiritual traditions, world-view, beliefs about health and wellness, and beliefs about God. Recognize that many religious traditions do not believe in the existence of God, as we understand God e.g. some traditions are polytheistic in nature. This is one reason why an understanding of multi-cultural issues and concerns is important to good nursing care (an entire section on the importance of multi-cultural concerns appears later in this course). 

Remember that members of the healthcare team are human beings as well. Many of us have our own emotional and spiritual concerns surrounding the diagnosis and treatment of breast cancer. These concerns often influence our relationships with patients. This is especially true if one is particularly fond of certain patients and must then be involved in the treatment and follow-up of a breast cancer diagnosis. Some team members are more comfortable dealing with emotions and spiritual concerns than other members are, often because it comes naturally to them. However, responding to emotions and spiritual issues (both the patient's and your own) is a vital skill that can be learned. With proper training, no team member needs to feel inadequate in this area.

Therapeutic touch is a healing method developed in the 1970s by Dolores Krieger, PhD, RN. It is based on the principle that the human energy system extends above the skin enabling the practitioner to use the hands as sensors to locate problem areas within the body. Disease is seen as a condition of energy imbalance that can be assessed by moving the hands over the body at a distance of two to four inches above the body surface. The practitioner serves as a conduit through which blocked energy flow is corrected. This method is used without touching the body so it is good for physical conditions in which the body cannot tolerate contact e.g. such as post-op or severe burns. The technique is taught in over eighty universities and is practiced by approximately thirty thousand health care professionals worldwide. When used as a nursing intervention its purpose is to reduce agitation, decrease pain, and promote psychological, spiritual, and physical healing. Some practitioners report that the technique has a calming effect on the practitioner as well.

 Impediments to Receiving Care

Impediments to receiving care may occur at any point in the process; at the time, the appointment is made, during the data gathering and health history phase, during the exam itself, during the explanation of test results and follow-up, during the treatment and follow-up phases, and during the plans for rescreening. If healthcare workers are aware of these impediments, they are more likely to be able to avoid them and/or deal with them effectively when they occur. Nurses are encouraged to learn about these impediments so we can assess the situation for each patient and then help her determine ways to reduce the specific impediments she faces. Impediments many women face include, but are not necessarily limited to, the following:

• Time factors e.g. can she get time off work or schedule an appointment outside her regular working hours.

• Transportation to the appointment and/or childcare concerns

• Language, cultural, and religious barriers (this will be discussed further in the section on "Cross-Cultural Considerations")

• Lack of knowledge about the disease and the screening guidelines

• Cost of the exams and/or treatment as well as the cost of transportation and childcare

• Privacy and modesty concerns, especially if she has ever been teased about the size of her breasts

• Misunderstanding insurance coverage/no insurance coverage

• Fear of getting cancer from the radiation involved in mammography, fear of finding cancer, and fear of any pain that may be associated with exams

• Illiteracy - one in five Americans cannot read the front page of the newspaper. This group has a nearly universal ignorance of basic health concepts such as "screening." Often they are unable to read appointment slips, understand the information on their medication bottles, or understand discharge instructions and consent forms. Many patients are ashamed of their inability to read and, therefore, hide it from the healthcare team. Increasingly nurses are being given the responsibility of identifying patients with reading problems. Asking patients to repeat in their own words what they have just read can reassure you that learning occurred. Be alert for patients who make excuses when asked to read something e.g., "I forgot my glasses" or "Can I fill this out later and return it to you?" For those you suspect of being illiterate you can ask, "What types of things do you like to read at home?" or "How do you like to learn about your health? Do you prefer reading, pictures, or verbal instruction?"

The healthcare system itself may present obstacles for members of the healthcare team. Team members often have a need for a personal connection with their patients. Obstacles to this connection may leave them feeling dissatisfied which may, in turn, affect patient satisfaction. Such obstacles include, but are not limited to, the following:

• Healthcare workers who don't believe they have any input into how the system functions and who, as a result, may experience morale problems

• Scheduling problems e.g. inadequate time for appointments and exams resulting in providers having too little time for adequate needs assessment