breast cancer ppt.pptx

breast cancer is a disease which is more common in females. Introduction and definition of breast cancer is explained in slides. Incidence according to american cancer society estimation in united states 2023 is explained here.Types of breast cancer elaborated through images . Stages, pathophysiology, sign and symptoms, essential diagnostic evaluation of breast cancer and TNM classification in detail
described. Medical management includes chemotherapy, neoadjuvant therapy, adjuvant therapy, endocrine therapy, various radiation therapy etc. Pharmacological management described. Surgeries of breast cancer described. Nursing management and post operative management explained .Nursing diagnosis of breast cancer is prioritized.

1.   KING GEORGE’S MEDICAL UNIVERSITY K.G.M.U. COLLEGE OF NURSING BREAST CANCER PRESENTED BY- DIVYA PAL M.Sc. NURSING I YEAR 1 1

2. Introduction Breast cancer begins when healthy cells in the breast ,change and grow out of control, forming a mass or sheet of cells called a tumor . A tumor can be benign or malignant. 2

3. Definition “ Breast Cancer is a disease in which cells in the breast grow out of control.” “Breast cancer is characterized by growth of malignant cells in the mammary glands.” 3

4. Incidence American Cancer Society’s estimates in the united states for 2023 are: About 297,790 new cases of invasive breast cancer will be diagnosed in women. About 55,720 new cases of ductal carcinoma in situ (DCIS) will be diagnosed. About 43,700 women will die from the breast cancer. 4

5. Types of breast cancer Cell type: In situ DCIS- Abnormal cells in duct. Incidence is 28%. Frequently found in combination with invasive cancer. A non-invasive breast cancer , the majority found by mammogram . Due to milk stasis. 5

6. DCIS 6

7. LCIS Solid proliferation of small cells within breast lobules. Incidence is 3%-5% most frequent in menopausal women. 7

8. Cell type-Invasive Ductal -Classified on basis of microscopic appearance as ductal or lobular. Incidence is 85% to 90%.Characterized by stony hardness on palpation. Lobular -As above. Incidence rate is 5% to 10%.Relatively uncommon. Cell type- Inflammatory Applies to distinctive inflamed appearance of skin ,no consistent histologic type. Incidence rate is 1% to 4%. 8

9. Cell type- Other Tubular- Mucinous- Spread from breast to other part of body. Papillary -A lump or thickening of breast tissue Medullary- Cancer of the thyroid gland Sarcoma- Vey rare form of breast cancer <10% of all breast cancers. 9

10. 10

11. Cell type- Paget’s disease of nipple. It is rare, causes eczema- like changes to The skin of the nipple and the area of darker Skin surrounding the nipple (areola). Usually associated with underlying intraductal or invasive carcinoma. Incidence rate is 2%.Presents as scaly , erythematous , periareolar eruption. 11

12. Staging of Breast Cancer Stage I- tumor size> 2 cm. Stage II Stage A No evidence of tumor ,ranges to 5 cm. No Lymph node involvement or 1to3 axillary nodes and internal mammary nodes . No matastasis . Stage -B Tumor size ranging from 2 to >5 cm. No Lymph node involvement ,or 1to 3 axillary node or internal mammary nodes can involve. No metastasis. 12

13. Stage- III Stage A- No evidence of tumor ranging to >5 cm, Lymph node will involve.4 to 9 axillary node or internal mammary nodes. Stage B-Ranging from 2 to >5 cm. No lymph node involvement. 1 to 3 axillary node or internal mammary nodes can involve. No metastasis. Stage C- Any size of tumor . 10 or more axillary nodes or internal mammary lymph node will involve with no metastasis. Stage IV- Any size of tumor . Any type of nodal involvement .No metastasis. 13

14. 14

15. Risk Factors of Breast Cancer Increasing age family history, Genes Radial exposure Dense breast tissue Obesity Alcohol consumption Early menstruation Late menopause Having a first child at an older age Never being pregnant, Hormone therapy to birth control No breastfeed. 15

16. Pathophysiology of Breast Cancer Due to etiological factor Permanent damage to DNA Mutation of genes Activation of growth inducer oncogenes, inhibition of tumor suppressor genes Disrupted proliferation of cells 16

17. Growth of colony Progression of tumor Breast Cancer 17

18. TNM staging system for breast cancer Tumour (T) Tumour describes the size of the tumour (area of cancer). This is a simplified description of the T stage. TX means that the tumour size can't be assessed. Tis (DCIS). DCIS means ductal carcinoma in situ. It is a pre invasive breast cancer. The cancer cells are in breast ducts and have not started to spread into the surrounding breast tissue. 18

19. T1 tumour is 2 centimetres (cm) across or less. T1 is further divided into 4 groups: T1mi tumour is 0.1cm across or less T1a tumour is > 0.1 cm but not more than 0.5 cm 19

20. T1b tumour is > 0.5 cm but not more than 1 cm. T1c tumour is > 1 cm but not more than 2 cm. T2 tumour is > 2 centimetres but no more than 5 centimetres across. T3 tumour is bigger than 5 centimetres across. 20

21. T4 is divided into 4 groups T4a tumour has spread into the chest wall (the structures surrounding and protecting the lungs). T4b tumour has spread into the skin and the breast might be swollen. T4c tumour has spread to both the skin and the chest wall. T4d I nflammatory carcinoma – this is a cancer in which the overlying skin is red, swollen and painful 21

22. Node (N) Node (N) describes whether the cancer has spread to the lymph nodes. Pathological staging if you have surgery Clinical staging if you don't have surgery 22

23. . Pathological staging: Doctors classifies stage by using the tissue the surgeon removes during an operation. This is also called surgical staging. Pathological stage written as ptnm . Clinical staging: Doctor stages after examining looking at test and scan results. Doctors use clinical staging if patient don’t have surgery straight away. Clinical stage written as ctnm . 23

24. Pathological node staging Below is a simplified description using the pathological staging for nodes in breast cancer. Pnx L ymph nodes can't be assessed (for example, if they were previously removed). Pn0 T here are no cancer cells in any nearby nodes or only isolated tumour cells ( itcs ). 24

25. Isolated tumour cells ( itcs ) are small clusters of cancer cells less than 0.2 mm across, or a single tumour cell, or a cluster of fewer than 200 cells in one area of a lymph node. Lymph nodes containing only isolated tumour cells are not counted as positive lymph nodes. 25

26. pN1 is divided into 4 groups pN1mi O ne or more lymph nodes contain areas of cancer cells called micro metastasis that are larger than 0.2mm. Or the nodes contain more than 200 cancer cells but are less than 2mm. pN1a C ancer cells have spread (metastasised) into 1 to 3 lymph nodes and at least one is larger than 2mm. 26

27. pN1b cancer cells in the lymph nodes behind the breastbone (the internal mammary nodes) found with a sentinel node biopsy. pN1c cancer cells in 1 to 3 lymph nodes in the armpit and the lymph nodes behind the breastbone. pN2 N2 is divided into 2 groups: 27

28. Pn2a Cancer cells in 4 to 9 the lymph nodes in the armpit, and at least one is larger than 2 mm. Pn2b Cancer cells in the lymph nodes behind the breast bone (the internal mammary nodes), which have been seen on a scan or felt by the doctor. There is no evidence of cancer in lymph nodes in the armpit. 28

29. pN3 is divided into 3 groups: pN3a cancer cells in 10 or more lymph nodes in the armpit and at least one is larger than 2mm, or there are cancer cells in the nodes below the collarbone. pN3b cancer cells in lymph nodes in the armpit and lymph nodes behind the breastbone. pN3c cancer cells in lymph nodes above the collarbone. 29

30. Clinical node staging Clinical staging means the doctor stages you after examining you and looking at test and scan results. Doctors use clinical staging if you don’t have surgery straight away. You might see your clinical stage written as cTNM . cNX means it is not possible to assess the lymph nodes (for example, if they were previously removed). cN0 means there are no signs of cancer in the lymph nodes following scans and examination. 30

31. cN1 is divided into 2 groups- cN1 means the cancer cells have spread to one or more lymph nodes in the lower and middle part of the armpit. The lymph nodes move a little when they are felt and are not stuck to surrounding tissue. cN1mi means the cancer cells in the lymph nodes are very small and can only be seen under a microscope. These are called micrometastases . They are larger than 0.2mm, but no larger than 2mm. 31

32. cN2 is divided into 2 groups cN2a means the cancer cells in the armpit are stuck together or fixed to other areas of the breast such as the muscle. cN2b means there are cancer cells in the lymph nodes behind the breast bone (the internal mammary nodes). There is no sign of cancer in the lymph nodes in the armpit. 32

33. cN3 is divided into 3 groups cN3a cancer cells are seen in one or more lymph nodes below the collar bone. cN3b cancer cells are seen in one or more lymph nodes around the armpit and breast bone. cN3c cancer cells are seen in one more lymph nodes above the collar bone. 33

34. Metastasis Metastasis (M) describes whether the cancer has spread to a different part of the body. cMo ( i +) means there is no sign of the cancer on physical examination, scans or x-rays. But cancer cells are present in blood, bone marrow, or lymph nodes far away from the breast cancer – the cells are found by laboratory tests . 34

35. Cm1 means the cancer has spread to another part of the body, seen on scans or felt by the doctor. Pm1 means that cancer measuring more than 0.2 mm across has spread to another part of the body. This has been confirmed by examining tissue from a biopsy, or surgery and scans. 35

36. Sign and Symptoms Changes in skin texture Nipple discharge Dimpling Lymph node changes Breast or nipple pain 36

37. Retracted or inverted nipple Changes in skin color , swelling Changes in breast size Lump around color bone or underarm Redness or rash 37

38. 38

39. 39

40. Diagnostic Evaluation History collection- family history , personal history. Physical examination Biological markers CA-15.3 PET scan Ultrasound Biopsy Breast MRI. 40

41. Nipple discharge cytology D uctal lavage 41

42. Multiparameter gene assays Cancer subtyping Routine blood investigations FNAC Needle localization with biopsy Breast biopsy 42

43. Excisional Biopsy 43

44. Stereotactic core needle biopsy 44

45. Mammography 45

46. Medical management Medical oncology Adjuvant therapy: Additional cancer treatment given after the primary treatment to lower the risk that cancer will come back. It may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, biological therapy . 46

47. Chemotherapy Chemotherapy is a drug that uses powerful chemicals to kill fast growing cells in the body. 47

48. HER-2 targeted therapy (Human epidermal growth factor receptor 2) These are a class of medicines used to treat all stages of HER -2 positive breast cancer, from early stage to metastatic ,as well as certain HER-2 low breast cancer. 48

49. Endocrine therapy Also called hormonal therapy or endocrine therapy slows or stops the growth of hormone sensitive tumors by blocking the body’s ability to produce hormones or by interfering the effects of hormones on breast cancer cells. 49

50. Neoadjuvant therapy Neoadjuvant chemotherapy is a chemotherapy that a person with cancer receives before their primary course of treatment. The aim to shrink a cancerous tumor using drugs before moving onto other treatments. Treatment of recurrent or metastatic cancer. 50

51. Radiation oncology Postlumpectomy radiation:- It reduces the risk that cancer will return in the affected breast. A course of radiation will starts between 6 and 12 weeks after lumpectomy surgery. 51

52. Whole breast radiation+/- tumor bed boost A boost to the tumor bed means that an extra dose of radiation is applied that covers the initial tumor site where the cancer is most likely to return. 52

53. Whole breast Hypofractionation+/- tumor bed boost Accelerated partial breast irradiation :- Uses precise radiation beams to kill cancerous cells in a smaller area of the breast (partial breast) versus the whole breast or chest area. Postmastectomy radiation:- This therapy is recommended for patients with more advanced breast cancer or certain high risk pathologic features .PMRT is directed at the chest wall and often includes the regional lymph nodes and drain the breast. 53

54. Palliative radiation of metastatic disease Radiation therapy uses high energy x-rays to treat cancer. Palliative treatment means treatment to shrink a cancer , slow down it’s growth or control symptoms caused by the cancer. 54

55. Adjuvant and Neoadjuvant chemo drugs Anthracyclines such as doxorubicin ( adiramycin ) and epirubicin ( ellence ). Taxanes , such as paclitaxel (Taxol) and docetaxel (Taxotere) 5-fluorouracil (5-FU) or capecitabine (Xeloda) Cyclophosphamide (Cytoxan) Carboplatin ( Paraplatin ) 55

56. Chemo drugs for breast cancer that has spread (metastatic breast cancer) Taxanes : Paclitaxel (Taxol), docetaxel (Taxotere), and albumin-bound paclitaxel (Abraxane) Anthracyclines: Doxorubicin (Adriamycin), liposomal doxorubicin ( Doxil ), and epirubicin ( Ellence ) Platinum agents (Cisplatin, carboplatin) Vinorelbine ( Navelbine ) Capecitabine (Xeloda) Gemcitabine ( Gemzar ) 56

57. Side effects Hair loss Nail changes Mouth sores Loss of appetite or weight changes Nausea and vomiting Diarrhea Fatigue 57

58. Pharmacological Management Kinase inhibitors HER2 (Human epidermal growth factor receptor 2) is a type of protein known as a kinase. Kinases are proteins in cells that normally relay signals (such as telling the cell to grow). Drugs that block kinases are called kinase inhibitors. 58

59. Lapatinib ( Tykerb ) This drug is a pill taken daily. Lapatinib is used to treat advanced breast cancer. It is typically given along with trastuzumab and the chemo drug capecitabine. 59

60. Neratinib ( Nerlynx ) This kinase inhibitor is a pill taken daily. Neratinib is used to treat early-stage breast cancer after a woman has been treated with trastuzumab for one year, and it is usually given for one year. It can also be given along with the chemo drug capecitabine to treat people with metastatic disease, typically after at least 2 other anti-HER2 targeted drugs have been tried . 60

61. Tucatinib ( Tukysa ) This kinase inhibitor is taken as a pill, typically twice a day. Tucatinib is used to treat advanced breast cancer, after at least one other anti-HER2 targeted drug has been tried. It is usually given along with trastuzumab and the chemo drug Capecitabine. 61

62. CDK4/6 inhibitors Palbociclib ( Ibrance ), ribociclib ( Kisqali ), and abemaciclib ( Verzenio ) are drugs that block proteins in the cell called cyclin-dependent kinases (CDKs), particularly CDK4 and CDK6. Blocking these proteins in hormone receptor-positive breast cancer cells helps stop the cells from dividing. This can slow cancer growth. 62

63. Aromatase inhibitor (al) or fulvestrant Given to women with advanced breast cancer who have gone through menopause. 63

64. mTOR inhibitor Everolimus ( Afinitor ) blocks mTOR, a protein in cells that normally helps them grow and divide. Everolimus may also stop tumors from developing new blood vessels, which can help limit their growth. In treating breast cancer it seems to help hormone therapy drugs work better. Everolimus is a pill that is taken once a day. 64

65. PI3K inhibitor Alpelisib ( Piqray ) blocks a form of the PI3K protein in cancer cells, which can help them stop growing. This drug is a pill taken once a day. It can be used along with fulvestrant to treat postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer with a PIK3CA gene mutation that has grown during or after treatment with an aromatase inhibitor . 65

66. Antibody-drug conjugate Sacituzumab govitecan ( Trodelvy ): In the case of this ADC, the monoclonal antibody part attaches to the Trop-2 protein on breast cancer cells and brings the chemo directly to them. (Some breast cancer cells have too much Trop-2, which helps them grow and spread quickly.) 66

67. Targeted therapy for women with BRCA gene mutations Olaparib and talazoparib can be used to treat advanced or metastatic, HER2-negative. 67

68. Surgical Management Modified radical mastectomy It includes removal of breast, preservation of pectoralis muscle, axillary lymph node dissection (ALND). Side effects - Chest wall tightens, Phantom breast sensations, Arm swelling ,Sensory changes 68

69. Breast conservation surgery (lumpectomy) with radiation therapy Wide excision of tumor , sentinel lymph node dissection (SLND) and/or ALND, radiation therapy. Side effects:- Breast soreness, Breast edema , Skin reactions, Arm swelling, Sensory changes in breast and arm ,Fatigue. 69

70. Tissue expansion and breast implants Expander used to slowly stretch tissue, saline gradually injected into reservoir over weeks to months. Insertion of implant under musculofascial layer of chest wall. Side effects:- Discomfort, Chest wall tightness. 70

71. Musculocutaneous flap procedures A musculocutaneous flap (muscle, skin, blood supply) is transposed from latissimus dorsi to transverse rectus abdominis to chest wall. Side effect:- Pain related to two surgical sites and extensive surgery. 71

72. Nursing Management :- Alert patient that extra views do not imply that the patient has breast cancer. Recommended regular screening based on established guidelines. Remind patients do not apply deodorant , cream or powder to breast , nipple or underarms areas on examination day. Advise that some discomfort may be felt from compressing the breast. Patients should have an opportunity to become informed about the benefits , limitations and potential harms associated with regular screening 72

73. Provide psychological support to the patient throughout the diagnostic and treatment process. Tell patient’s that routine screening mammography has been shown to reduce mortality from breast cancer .Procedure takes approximately 15 minutes. Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and depression. 73

74. Involve the patient in planning and treatment. Describe surgical procedures to alleviate fear. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy. Administer I.V. fluids and hyperalimentation as indicated. Help patient identify and use support persons or family or community. Suggest to the patient the psychological interventions may be necessary for anxiety depression, or sexual problems. 74

75. Teach all women the recommended cancer-screening procedures. Documentation Guidelines Response to surgical interventions: Condition of dressing and wound, stability of vital signs, recovery from anesthesia . Presence of complications: Pain, edema , infection, seroma, limited ROM. Knowledge of and intent to comply with adjuvant therapies. Reaction to cancer and body changes. Knowledge of and intent to comply with incision care, postoperative exercises, arm precautions, follow-up care, and early detection methods for recurrence. 75

76. Post Operative management Dressing is removed and the wound is assessed for erythema , hematoma , edema , tenderness, odor and drainage. Report suspected hematoma promptly. Initial dressing may consist of gauze held in place by elastic, tape or clear occlusive dressing wrap. Usually removed within 24 hours. Incision may remain open to air or elastic wrap may be replaced if patient prefers. Suction drain from wound is maintained. 76

77. May have 100 to 200 mL serous to serosanguineous drain- age in the first 24 hours. Report if grossly bloody or excessive in amount. Arm on affected side is observed for edema , erythema, and pain. Patient teaching about drain care, exercises, surgical outcome, and BSE occurs. Female relatives, especially sisters, daughters, and mother, who may need closer breast cancer surveillance are discussed. 77

78. Nursing Diagnosis . Ineffective therapeutic regimen management related to lack of knowledge regarding disease process and post operative care as evidenced by frequent questions about disease and treatment , follow up care. Acute pain related to tumor advancement causing inflammation and compression on nerves and bones as evidence by facial grimacing. Anxiety related to threat of death as evidenced by verbalization of fear or worry. Impaired skin integrity related to effects of radiation as evidenced by damaged epidermal tissue 78

79. Summary:- Breast cancer is the most common malignancy in women and the second most common cause of cancer death. Screening mammogram has significantly changed the presentation and outcomes for patients with breast cancer. Management of patients with breast cancer requires a multidisciplinary approach that includes surgery, medical therapy, and radiation. 79

80. References- 1. Anxiety. (n.d.). Cancer.Net . Retrieved March 16, 2022, from https://www.cancer.net/ coping-with-cancer/managing- emotions/anxiety. 2. Breast cancer - Diagnosis and treatment. (2021, October 16). Mayo Clinic. Retrieved March 19, 2022, from https://www.mayoclinic.org/di seases -conditions/breast- cancer/diagnosis- treatment/drc-20352475 3. www.medicalnewstoday.com/releases/196366.php 4. ABCD: After Breast Cancer Diagnosis, abcdbreastcancersupport.org American Cancer Society, www.cancer.org 5. American Society of Plastic Surgeons (ASPS), www.plasticsurgery.org Cancer Care, Inc., www.cancercare.org 6. Fertile Hope, www.fertilehope.org 7. National Breast Cancer Coalition, www.breastcancerdeadline2020.org 8.Oncology Nursing Society (ONS), www.ons.org 9. Reach to Recovery Program-I Can Cope Program, www.cancer.org/cance 80

81. Recapitulation What is breast Cancer? Explain in detail tnm classification of breast cancer? 81

82. 82