breast cancer- nurses responsibility and advoacy

complete data about breast cancer and nursing role

1. Breast cancer By- ms. Trupti sandesh tambe 2nd year p.b. BSc. nursing

2. What is cancer? C ancer is an abnormal growth of cells which tend to proliferate in an uncontrolled way and, in some cases, to metasize (spread).

3. Breast Cancer

4. ANATOMY OF BREAST

5. Definition “ Breast cancer is an uncontrolled growth of breast cells ” Or “ Breast cancer refers to a malignant tumour that has developed from cells in the breast”

6. Incidence And Statistics For india , for the year 2012: 144,937  women were newly detected with breast cancer. 70,218  women died of breast cancer So roughly, in india ,  for every 2 women newly diagnosed with breast cancer, one lady is dying of it. Cancer of breast with estimated 1.5 lakh( over 10 percent of all cancers) new cases during 2016.

7. Aetiology Age Ethnicity Ovarian and hormonal function Benign breast disease Family history Environmental and dietary factors

8. Risk factors

9. modifiable Alcohol Use Radiation Exposure Smoking Obesity Exposure To Hormones E.g. Pills, Combination Of Oestrogen And Progesterone

10. Early Menarche Late Menopause Nulliparaty Gender And Age Breast Condition, Density Family History And Genetics Non modifiable

11. TYPES OF BREAST CANCER

12. types of breast cancer

13. PATHOPHYSIOLOGY OF CANCER

14. PATHOPHYSIOLOGY OF BREAST CANCER

15. Breast cancers are malignant tumours that typically begin in the ductal lobular epithelial cells of the breast. Spread via the lymphatic system to the axillary lymph nodes. The tumour may then metastasize to distant regions of the body, including lungs , liver , bone and brain.

16. The findings of breast cancer in the axillary lymph nodes is an indicator of the tumours ability for potential distant spread and is not Marely contiguous growth into the adjacent regions of the breast. Most primary breast cancers are adenocarcinoma located in the upper outer quadrants of the breast.

17. Sign And Symptoms Most cancer present as painless. Non tender, hard, irregularly shaped non motile masses. About 60% of cancers are somewhat movable, 40% have irregular. borders by palpation , and 40% can feel soft or cystic.

18. Even when no mass is present , other physical findings such as nipple discharge , induration , and dimpling , can suggest malignancy. Heat and erythema of the breast skin may be related to inflammatory carcinoma. Oedema – due to invasive and obstruction of dermal lymphatic by the tumour.

19. Primary tumor (t) TX : Primary tumor cannot be assessed. T0 : No evidence of primary tumor. Tis : Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass) T1 : Tumor is 2 cm (3/4 of an inch) or less across. T2 : Tumor is more than 2 cm but not more than 5 cm(2inches) across. T3 : Tumor is more than 5 cm across. T4 : Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer

20. Near By Lymph Nodes (N) NX : Nearby lymph nodes cannot be assessed N0 : Cancer has not spread to nearby lymph nodes. N1 : Cancer has spread to 1 to 3 axillary (underarm) lymph node N1mi : Micrometastasis in 1 to 3 lymph nodes under the arm. N1a : Cancer has spread to 1 to 3 lymph nodes under the arm N1b : Cancer has spread to internal mammary lymph nodes N1c : Both N1a and N1b apply .

21. N2 : Cancer has spread to 4 to 9 lymph nodes under the arm N2a : Cancer has spread to 4 to 9 lymph nodes under the arm N2b : Cancer has spread to one or more internal mammary lymph nodes

22. N3 : Any of the following: N3a : either cancer has spread to 10 or more axillary lymph nodes OR Cancer has spread to the lymph nodes under the clavicle N3b : either cancer is found in at least one axillary lymph node OR Cancer involves 4 or more axillary lymph nodes N3c : Cancer has spread to the lymph nodes above the clavicle

23. Metastasis (M): MX : Presence of distant spread (metastasis) cannot be assessed. M0 : No distant spread is found on x-rays or by physical exam. M1:  Spread to distant organs is present. (The most common sites are bone, lung, brain, and liver).

24. Stages Of Breast Cancer.

25. Stage 0 – Abnormal cells in lining of the ducts or sections of the breast.

26. Stage 1 – Cancer in the breast tissues. Tumour less than 1 inches.

27. Stage 2 – Cancer in the breast tissues. Tumour less than 2 inches across may also spread to axillary lymph node.

28. Stage 3 – Tumour larger than 2 inches spread to axillary nodes ,possible dimpling , inflammation or change of skin colour.

29. Stage 4 – Spread of cancer beyond the immediate region of the breast.

30. DIAGNOSTIC EVALUATION History collection Physical examination- - Breast self examination - Clinical examination Mammography Breast ultrasound Biopsy- - Fine needle aspiration - Image guided core needle biopsy - Open biopsy CAD(computed assisted diagnosis)

31. History Collection Personal history Family, hereditary , genetic history Menstrual and menopausal history History of contraceptive methods, pills History of hormonal therapy

32. Physical Examination Self breast examination – It is done by patient herself. Clinical breast examination – It is done by the health personnel like doctors, nurses .

33. Mammography Mammography is x-ray of the breast Women (asymptomatic )40 years of age and older should have a mammogram every year. Mammogram should be done for women more than 40 years of age.

34. Breast ultrasound is uses sound waves to make image of breast tissue which hard to study with a mammogram It shows whether a breast lump is filled with fluid ( a cyst) or if it is solid lump. A ultrasound does not replace the need for mammogram , but it is often used to check abnormal results from a mammogram. Breast Ultrasound

35. biopsy Fine needle aspiration cytology-(FNAC) Performed on a outpatient bases . purpose is to determine whether a solid lump is a cyst or to confirm a clinically apparent diagnosis. If a mass turned out to be cyst, the lump should disappear after the aspiration .

36. 2. Stereotactic needle guided biopsy : stereotactic needle guided biopsy is used mainly to target and identify non-palpable lesions in the breast that have been detected with mammography

37. 3. Ultrasound core biopsy ultrasound guided breast biopsy is used when the lesion can be seen on ultrasound . it is easier for the client than a stereotactic biopsy because she can lie on her back and does not have her breast immobilized during the practice.

38. 4.Open Biopsy Excisional or open biopsy may be chosen when the lesion is determined in nature , when results of cytology , or histogic analysis are insufficient or when the clinical or mammographic findings suggest malignancy.

39. Computer Assisted Diagnosis (Cad) CAD uses a software program to target lesions suspected to be malignant. The specificity of the image is enhanced by on screen evaluation , which improves detection.

40. Breast Self Examination Woman can use breast self examination to assess their breast. When they perform breast self examination properly and regularly , they can note any changes in their breasts and seek further evaluation. Examination should be done every month and at end of menses in all menstruating women .

41. Direction For Palpation

42. Medical Management

43. Medical Management Involve Chemotherapy: As Adjuvant , postoperatively usually begins 4 weeks after surgery. Treatment are given every 3-4 weeks for 6-9 months. As Primary Treatment In Inflammatory Breast Cancer As Palliative Treatment in metastatic disease or recurrence .

44. Anti oestrogen such as tomoxifen are used as adjuvant systemic therapy after surgery Hormonal agents may be used in advanced disease to induce remissions that last for months to several years. Herceptin is a monoclonal antibody directed against Her-2/ oncogenes , may be effective for patients who express this genes .

45. Possible Side Effects Hair loss Mouth sores Loss of appetite Nausea and vomiting Increased chance of infections (due to low white blood cell counts) Easy bruising or bleeding (due to low blood platelet counts) Fatigue (due to low red blood cell counts and other reasons)

46. Long Term Side Effects Menstrual changes:  Neuropathy Heart damage Hand-foot syndrome Chemo brain Increased risk of leukemia

47. Drugs Commonly Used Cyclophosphamide (C) Doxorubicin (A) Epirubicin (E) Methotrexate (M) 5-fluorouracil (F) Taxanes (T) E.G. Docetaxel , Paclitaxel Etc Mitomycin (M) Mitoxantrone (M)

48. Radiation Therapy

49. Aim – To minimize the locoregional recurrence after surgery and possibly improve survival Indications – All patients undergoing BCT Tumour size > 5 cms >= 4 Axillary Nodes positive All LABC patients

50. External beam radiation This is the most common type of radiation therapy for women with breast cancer. The radiation is focused from a machine outside the body on the area affected by the cancer. The extent of radiation depends on whether a lumpectomy or mastectomy was done and whether or not lymph nodes are involved

51. External beam radiation

52. 3D-CONFORMAL RADIO THERAPY Radiation is given with special machines so that it is aimed better at the area where the tumor was . Treatment was given twice a day for five days.

53. 3D-CONFORMAL RADIO THERAPY

54. POSSIBLE SIDE EFFECTS OF EXTERNAL RADIATION The main side effects of EBRT are swelling and heaviness. Sunburn like skin changes in the treated areas and fatigue.

55. Brachytherapy Intra cavitary Brachytherapy:   This Method Of Brachytherapy Consists Of A Small Balloon Attached To A Thin Tube. The Deflated Balloon Is Inserted Into The Space Left By The Lumpectomy And Is Filled With A Salt Water Solution. (This Can Be Done At The Time Of Lumpectomy Or Within Several Weeks Afterward.) The Balloon And Tube Are Left In Place Throughout Treatment

56. Intracavitary applicator

57. Interstitial Brachytherapy:   In this approach, several small, hollow tubes called catheters are inserted into the breast around the area of the lumpectomy and are left in place for several days. Radioactive pellets are inserted into the catheters for short periods of time each day and then removed. 

58. INTERSTITIAL

59. INTERSTITIAL

60. Surgical Management

61. Surgical Management Involves- Breast Preserving Procedures: - Lumpectomy + Radiation Therapy Mastectomy- 1. Radical Mastectomy 2. Modified Radical Mastectomy 3. Prophylactic Or Total Mastectomy 4. Axillary Dissection

62. Post Mastectomy Care Elevate affected side and distal joint higher than proximal joint. No bp, injection , venepuncture on affected side. Watch for sign and symptoms of oedema on affected arm. Lymphedema can occur any time after axillary node dissection. Flexion and extension of exercises of the hand in the recovery. Abduction and external rotation arm exercise after wound has healed.

63. Assess dressing for drainage. Assess wound drain for amount and colour. Provide privacy when client looks at incision. Care during chemotherapy Care during radiation therapy Psychological concerns

64. Post operative exercises

65. Nursing Diagnosis

66. Body image disturbance related to surgical intervention Anxiety related to unsolved issues regarding dying, prognosis , hospitalization, surgical intervention , recovery. Fear related to serious threat to well being. Ineffective coping related to treatment , prognosis. Sexual dysfunction related to loss of body part , partner’s reaction to loss

67. Chronic sorrow related to diagnosis of cancer , loss of body integrity. risk for spiritual distress: risk factor – fear of diagnosis of cancer . insomnia related to anxiety , pain Risk for infection : risk factor- inadequate immune system social isolation related to hospitalization , lifestyle chances

68. Impaired physical motility related to weakness, pain Chronic pain related to metastatic cancer. Ineffective role performance related change in physical capacity , inability to resume prior role. Impaired skin integrity related to immunological deficit , immobility.

69. Patient Care During Radiation Therapy Education Information about radiation treatment planning Symptom management during radiation therapy Skin reactions Fatigue Psychosocial and family support

70. Patient Care During Chemotherapy Symptom management during chemotherapy Bone marrow depressions Nausea and vomiting Mucositis

71. Neurotoxicity Alopecia Arthralgia and myalgia Hemorrhagic cystitis Behavioral symptoms

72. Palliative Care Life style Patient wish Patient desire Spiritual preparation

73. Rehabilitation Exercise Prosthesis Daily Activities House Hold Work Office Work Physical

74. Fear Anxiety Depression Sexual Body image Problem of un employment Psychological

75. Prosthesis Silicone Breast Prostheses Non-silicone Breast Prostheses Partial Breast Prosthesis Attachable (Contact) Breast Prosthesis

76. Health Education Breast Self-examination Diet Treatment Pregnancy Follow-up

77. Thank You