The choice of treatment for breast cancer depends on tumor type, size, and location, as well as clinical characteristics (staging). Therapy may include surgical intervention with/without radiation, chemotherapy, and hormone therapy. The use of gene therapy and stem cell rescue (autologous bone marrow transplantation) is under investigation. Breast reconstruction is often done at the time of cancer surgery because it does not compromise adjuvant treatment/interfere with cure of the cancer, and it improves the patient’s adjustment and acceptance. Some oncologists, however, prefer to postpone reconstruction until post-procedure therapy is completed, to reduce the risk of postoperative complications.
Types of surgery are generally grouped into three categories: radical mastectomy, total mastectomy, and more limited procedures (e.g., segmental, lumpectomy). Total (simple) mastectomy removes all breast tissue, but all or most axillary lymph nodes and chest muscles are left intact. Modified radical mastectomy (now the most common surgical option) removes the entire breast, some or most lymph nodes, and sometimes the pectoralis minor chest muscles. Major chest muscles are left intact. Radical (Halsted’s) mastectomy is a procedure that is rarely performed because it requires removal of the entire breast, skin, major and minor pectoral muscles, axillary lymph nodes, and sometimes internal mammary or supraclavicular lymph nodes. Limited procedures (i.e., lumpectomy) may be done on an outpatient basis because only the tumor and some surrounding tissue are removed. Lumpectomy is reserved for well-defined nonmetastatic tumors of less than 5 cm in size that do not involve the nipple. The procedure may be diagnostic (determines cell type) and/or curative when combined with radiation therapy.
CARE SETTING
Inpatient acute surgical unit.
RELATED CONCERNS
Cancer (for additional nursing interventions regarding cancer treatment)
Psychosocial aspects of care
Surgical intervention
Patient Assessment Database
ACTIVITY/REST
May report: Work, activity involving frequent/repetitive arm movements
Sleep style (e.g., sleeping on stomach)
CIRCULATION
May exhibit: Unilateral engorgement in affected arm (invaded lymph system)
EGO INTEGRITY
May report: Constant stressors in work/home life
Stress/fear involving diagnosis, prognosis, future expectations
FOOD/FLUID
May report: Loss of appetite, recent weight loss
PAIN/DISCOMFORT
May report: Pain in advanced/metastatic disease (localized pain rarely occurs in early malignancy)
Some experience discomfort or “funny feeling” in breast tissue
Heavy, painful breasts premenstrually usually indicate fibrocystic disease
SAFETY
May exhibit: Nodular axillary masses
Edema, erythema of involved skin
SEXUALITY
May report: Presence of a breast lump (usually painless); changes in breast symmetry or size
Changes in breast skin (pitting, dimpling), color or temperature (redness); unusual nipple discharge; itching, burning, or retracted nipple or changes in vein pattern
History of early menarche (younger than age 12); late menopause (after age 50); late first pregnancy (after age 35)
Concerns about sexuality/intimacy
May exhibit: Change in breast contour/mass, asymmetry
Dimpling, puckering of skin; changes in skin color/texture, swelling, redness or heat in breast
Retraction of nipple; discharge from nipple (serous, serosanguinous, sanguinous, watery discharge increase likelihood of cancer, especially when accompanied by lump)
TEACHING/LEARNING
May report: Family history of genetically transmitted breast cancer includes those with multiple relatives withbreast cancer (maternal and paternal), family history of ovarian cancer along with breast cancer,family history of bilateral or early-onset breast cancer, or breast cancer in a male relative. Note: Most breast cancer patients have no relatives with the disease, with only 5%–10% now thought to be attributable to hereditary factors.
Previous unilateral breast cancer, endometrial or ovarian cancer
Discharge plan
DRG projected mean length of inpatient stay: 4.1 days
May need assistance with treatments/rehabilitation, decisions, self-care activities, homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Mammography: Visualizes internal structure of the breast, is capable of detecting nonpalpable cancers or tumors that are in early stages of development.
Galactography (ductography): Contrast mammograms obtained by injecting dye into a draining duct.
Ultrasound: May be helpful in distinguishing between solid masses and cysts and in women whose breast tissue is dense; complements findings of mammography.
Xeroradiography: Reveals increased circulation around tumor site.
Thermography: Identifies rapidly growing tumors as “hot spots” because of increased blood supply and corresponding higher skin temperature.
Diaphanography (transillumination): Identifies tumor or mass by differentiating the way that tissues transmit and scatter light. Procedure remains experimental and is considered less accurate than mammography.
CT scan and magnetic resonance imaging (MRI): Scanning techniques can detect breast disease, especially larger masses, or tumors in small, dense breasts that are difficult to examine by mammography. These techniques are not suitable for routine screening and are not a substitute for mammography.
Positron emission tomography (PET) scintimammography: Helps detect malignant tissue outside the breast; may help determine status of lymph nodes to reduce the need for biopsy. Also can provide information regarding makeup of malignant tumors to guide treatment choices.
Breast biopsy (fine-needle aspiration, core sampling needle biopsy, or excisional): Provides definitive diagnosis of mass and is useful for histological classification, staging, and selection of appropriate therapies.
Sentinel node biopsy: May eliminate need for axillary dissection in small breast tumors, limiting damage to lymph ducts and nerves.
Hormone receptor assays: Reveal whether cells of excised tumor or biopsy specimens contain hormone receptors (estrogen and progesterone). In malignant cells, the estrogen-plus receptor complex stimulates cell growth and division. About two-thirds of all women with breast cancer are estrogen-receptor positive and tend to respond favorably to the addition of hormone therapy, which extends the disease-free period and increases survival time.
Chest x-ray, liver function studies, CBC, and bone scan: Help determine presence and location of metastasis.
Breast cancer genes: Researchers have now discovered BRCA-1 and BRCA-2. It is believed that if these genes are mutated, they may cause a high percentage of inherited-type breast cancers. The tests are not widely performed at this time.
NURSING PRIORITIES
1. Assist patient/SO in dealing with stress of situation/prognosis.
2. Prevent complications.
3. Establish individualized rehabilitation program.
4. Provide information about disease process, procedure, prognosis, and treatment needs.
DISCHARGE GOALS
1. Dealing realistically with situation.
2. Complications prevented/minimized.
3. Exercise regimen initiated.
4. Disease process, surgical procedure, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
Types of surgery are generally grouped into three categories: radical mastectomy, total mastectomy, and more limited procedures (e.g., segmental, lumpectomy). Total (simple) mastectomy removes all breast tissue, but all or most axillary lymph nodes and chest muscles are left intact. Modified radical mastectomy (now the most common surgical option) removes the entire breast, some or most lymph nodes, and sometimes the pectoralis minor chest muscles. Major chest muscles are left intact. Radical (Halsted’s) mastectomy is a procedure that is rarely performed because it requires removal of the entire breast, skin, major and minor pectoral muscles, axillary lymph nodes, and sometimes internal mammary or supraclavicular lymph nodes. Limited procedures (i.e., lumpectomy) may be done on an outpatient basis because only the tumor and some surrounding tissue are removed. Lumpectomy is reserved for well-defined nonmetastatic tumors of less than 5 cm in size that do not involve the nipple. The procedure may be diagnostic (determines cell type) and/or curative when combined with radiation therapy.
CARE SETTING
Inpatient acute surgical unit.
RELATED CONCERNS
Cancer (for additional nursing interventions regarding cancer treatment)
Psychosocial aspects of care
Surgical intervention
Patient Assessment Database
ACTIVITY/REST
May report: Work, activity involving frequent/repetitive arm movements
Sleep style (e.g., sleeping on stomach)
CIRCULATION
May exhibit: Unilateral engorgement in affected arm (invaded lymph system)
EGO INTEGRITY
May report: Constant stressors in work/home life
Stress/fear involving diagnosis, prognosis, future expectations
FOOD/FLUID
May report: Loss of appetite, recent weight loss
PAIN/DISCOMFORT
May report: Pain in advanced/metastatic disease (localized pain rarely occurs in early malignancy)
Some experience discomfort or “funny feeling” in breast tissue
Heavy, painful breasts premenstrually usually indicate fibrocystic disease
SAFETY
May exhibit: Nodular axillary masses
Edema, erythema of involved skin
SEXUALITY
May report: Presence of a breast lump (usually painless); changes in breast symmetry or size
Changes in breast skin (pitting, dimpling), color or temperature (redness); unusual nipple discharge; itching, burning, or retracted nipple or changes in vein pattern
History of early menarche (younger than age 12); late menopause (after age 50); late first pregnancy (after age 35)
Concerns about sexuality/intimacy
May exhibit: Change in breast contour/mass, asymmetry
Dimpling, puckering of skin; changes in skin color/texture, swelling, redness or heat in breast
Retraction of nipple; discharge from nipple (serous, serosanguinous, sanguinous, watery discharge increase likelihood of cancer, especially when accompanied by lump)
TEACHING/LEARNING
May report: Family history of genetically transmitted breast cancer includes those with multiple relatives withbreast cancer (maternal and paternal), family history of ovarian cancer along with breast cancer,family history of bilateral or early-onset breast cancer, or breast cancer in a male relative. Note: Most breast cancer patients have no relatives with the disease, with only 5%–10% now thought to be attributable to hereditary factors.
Previous unilateral breast cancer, endometrial or ovarian cancer
Discharge plan
DRG projected mean length of inpatient stay: 4.1 days
May need assistance with treatments/rehabilitation, decisions, self-care activities, homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Mammography: Visualizes internal structure of the breast, is capable of detecting nonpalpable cancers or tumors that are in early stages of development.
Galactography (ductography): Contrast mammograms obtained by injecting dye into a draining duct.
Ultrasound: May be helpful in distinguishing between solid masses and cysts and in women whose breast tissue is dense; complements findings of mammography.
Xeroradiography: Reveals increased circulation around tumor site.
Thermography: Identifies rapidly growing tumors as “hot spots” because of increased blood supply and corresponding higher skin temperature.
Diaphanography (transillumination): Identifies tumor or mass by differentiating the way that tissues transmit and scatter light. Procedure remains experimental and is considered less accurate than mammography.
CT scan and magnetic resonance imaging (MRI): Scanning techniques can detect breast disease, especially larger masses, or tumors in small, dense breasts that are difficult to examine by mammography. These techniques are not suitable for routine screening and are not a substitute for mammography.
Positron emission tomography (PET) scintimammography: Helps detect malignant tissue outside the breast; may help determine status of lymph nodes to reduce the need for biopsy. Also can provide information regarding makeup of malignant tumors to guide treatment choices.
Breast biopsy (fine-needle aspiration, core sampling needle biopsy, or excisional): Provides definitive diagnosis of mass and is useful for histological classification, staging, and selection of appropriate therapies.
Sentinel node biopsy: May eliminate need for axillary dissection in small breast tumors, limiting damage to lymph ducts and nerves.
Hormone receptor assays: Reveal whether cells of excised tumor or biopsy specimens contain hormone receptors (estrogen and progesterone). In malignant cells, the estrogen-plus receptor complex stimulates cell growth and division. About two-thirds of all women with breast cancer are estrogen-receptor positive and tend to respond favorably to the addition of hormone therapy, which extends the disease-free period and increases survival time.
Chest x-ray, liver function studies, CBC, and bone scan: Help determine presence and location of metastasis.
Breast cancer genes: Researchers have now discovered BRCA-1 and BRCA-2. It is believed that if these genes are mutated, they may cause a high percentage of inherited-type breast cancers. The tests are not widely performed at this time.
NURSING PRIORITIES
1. Assist patient/SO in dealing with stress of situation/prognosis.
2. Prevent complications.
3. Establish individualized rehabilitation program.
4. Provide information about disease process, procedure, prognosis, and treatment needs.
DISCHARGE GOALS
1. Dealing realistically with situation.
2. Complications prevented/minimized.
3. Exercise regimen initiated.
4. Disease process, surgical procedure, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
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