Breast Cancer

Introduction
Breast cancer is a heterogenous disease that encompasses a number of distinct biological
characteristics and clinical behaviour. It can start in one or both breasts. It is a most common
malignancy among women but men can get breast cancer too. It is second only to lung cancer as the
leading cause of death from cancer in women. Breast cancer is often curable, particularly if
diagnosed at an early stage. This requires early detection and a knowledge and awareness of all type
of the disease, including the rarer forms of breast cancer.

Definition
Breast cancer is defined as malignant neoplasm of the breast arising from the epithelial lining of the
lobule, ducts and the nipple.
It begins in the breast tissue and may start in the duct or lobe of the breast. When the “controls” in
breast cells are not working properly, they divide continually and a lump or tumor is formed.

Incidence
Approximately 183,000 women are diagnosed with invasive breast cancer each year and nearly
41,000 women die of the disease. In the United States more than 230,480 new cases of invasive
breast cancer and more than 57,650 cases of in situ breast cancer are diagnosed annually.1 About
2140 of those new cases are diagnosed in men. Approximately 39,920 deaths (39,510 women and
410 men) occur each year related to breast cancer.
Breast cancer is the second leading cause of cancer death in women. (only lung cancer kills more
women each year)

Related Anatomy and Physiology

Breasts:
The breasts or mammary glands are accessory glands of the female reproductive system. They exist
also in the male, but in only a rudimentary form.
>Structure
The mammary glands or breasts consist of varying amounts of glandular tissue, responsible for milk
production, supported by fatty tissue and fibrous connective tissue that anchor the breast to the chest
wall.
Each breast contains about 20 lobes, each of which contains a number of glandular structures called
lobules, where milk is produced. Lobules open into tiny lactiferous ducts, which drain milk toward
the nipple. Supporting fatty and connective tissues run through the breast, surrounding the lobules,
and the breast itself is covered in subcutaneous fat. In the lactating breast, glandular tissue
proliferates (hyperplasia) to support milk production, and recedes again after lactation stops.
The nipple- This is a small conical eminence at the center of the breast surrounded by a pigmented
area, the areola. On the surface of the areola are numerous sebaceous glands (Montgomery’s
tubercles), which lubricate the nipple during lactation.
 >Blood supply, lymph drainage and nerve supply
Arterial supply: The breasts are supplied with blood
from the thoracic branches of the axillary arteries and
from the internal mammary and intercostal arteries.
Venous drainage: This is formed by an anastomotic
circle round the base of the nipple from which
branches carry the venous blood to the
circumference, and end in the axillary and mammary
veins.
Lymph drainage: This is mainly into the superficial
axillary lymph vessels and nodes. Lymph may drain
through the internal mammary nodes if the
superficial route is obstructed.
Nerve supply: The breasts are supplied by branches from the 4th, 5th and 6th thoracic nerves, which
contain sympathetic fibres.

Function:
In the female, the breasts are small and immature until puberty. Thereafter they grow and develop
under the influence of estrogen and progesterone. During pregnancy these hormones stimulate
further growth. After the baby is born the hormone prolactin from the anterior pituitary stimulates the
production of milk, and oxytocin from the posterior pituitary stimulates the release of milk in
response to the stimulation of the nipple by the sucking baby, by a positive feedback mechanism.

Etiology and Risk Factors

Multiple factors are associated with an increased risk of developing breast cancer, including
increasing age, family history, exposure to female reproductive hormones (both endogenous and
exogenous), dietary factors, benign breast disease, and environmental factors. The majority of these
factors convey a small to moderate increase in risk for any individual woman.
>Risk factors for women:
-Age: The risk factors most associated with breast cancer include female gender and advancing age.
Women are at far greater risk than men, with 99% of breast cancers occurring in women. Increasing
age also increases the risk of developing breast cancer. The incidence of breast cancer in women
under 25 years of age is very low and increases gradually until age 60. After age 60, the incidence
increases dramatically.

-Familial Factors: Family history of breast cancer is an important risk factor, especially if the
involved family member also had ovarian cancer, was premenopausal, had bilateral breast cancer, or
is a first degree relative (i.e., mother, sister, daughter). Having any first degree relative with breast
cancer increases a woman’s risk of breast cancer 1.5 to 3 times, depending on age. A woman who has
multiple family members diagnosed with early-onset breast cancer is at a much higher risk of
developing the disease.
-Gene changes:
Genes control how our cells function. They are made up of a chemical called DNA, which comes
from both our parents. DNA affects more than just how we look. Normal cells have genes called
proto-oncogenes, which help control when the cells grow, divide to make new cells. If a proto-
oncogene is mutated (changes) in a certain way, it becomes an oncogene. Cells that have these
mutated oncogenes can become cancer.
Inherited predisposition: The identification of the two tumor suppressor genes BRCA1 and
BRCA2(BRCA stands for BReast CAncer) has provided new insights into the understanding of
breast cancer genetics. When a woman has a mutation in either of these genes, she faces a markedly
increased lifetime risk of developing breast cancer. The possibility of a mutation in either BRCA1 or
BRCA2 should be considered when breast cancer is diagnosed at a young age (i.e., less than 45 to
55), when multiple relatives are affected, when there is a history of other cancers in the family
(particularly ovarian cancer), or any combination of these factors. Both BRCA1 and BRCA2 are
inherited in an autosomal dominant manner and can be passed to offspring through either maternal or
paternal lineage. The BRCA1 gene, located on chromosome 17, is a tumor suppressor gene that
inhibits tumor development when functioning normally. BRCA2 is located on chromosome 13 and is
an even larger gene than BRCA1. In addition to BRCA gene mutations, many other abnormal genes
have been identified that increase a person’s risk of developing breast cancer. These include the
tumor suppressor gene p53 (which inhibits tumor development when functioning normally), ATM
(which helps to repair damaged deoxyribonucleic acid [DNA]), and CHEK2 (which stops tumor
growth). Breast cancer is also observed as part of other familial syndromes, including Li-Fraumeni
syndrome, Cowden syndrome, Muir syndrome, and ataxia-telangiectasia.
-Hormonal Factors: The development of breast cancer in many women appears to be related to
female reproductive hormones. Epidemiologic studies have consistently identified a number of breast
cancer risk factors, each of which is associated with increased exposure to endogenous estrogens.
Early age at menarche, nulliparity or late age at first full-term pregnancy, and late age at menopause
increase the risk of developing breast cancer. In postmenopausal women, obesity and
postmenopausal hormone therapy, both of which are positively correlated with plasma estrogen
levels and plasma estradiol levels, are associated with increased breast cancer risk. Furthermore, in
utero exposure to high concentrations of estrogen may also increase breast cancer risk.
The relationship between pregnancy and breast cancer risk appears more complicated. Age at first
full-term pregnancy clearly influences breast cancer risk. Based on epidemiologic studies, women
whose first full-term pregnancy occurs after age 30 have a two- to fivefold increase in breast cancer
risk in comparison with women who have a first full-term pregnancy before approximately age 18.
During pregnancy, mammary cells differentiate into mature breast cells prepared for lactation. After
this differentiation, these cells have a longer cell cycle, allowing more time for DNA repair in G1.
Breast cancer risk increases transiently after a pregnancy.
-Benign Breast Disease with Atypical epithelial hyperplasia: Atypical changes in breast biopsy
increase the risk of breast cancer.

-Dense breast tissue: Mammograms harder to read and interpret. Dense tissue may be associated
with more aggressive tumors.
-Weight gain and obesity after menopause: Fat cells store estrogen, which increases the likelihood
of developing breast cancer.
-Exposure to ionizing radiation: Radiation damages DNA (e.g., prior treatment for Hodgkin’s
lymphoma).
-Alcohol consumption: Women who drink ≥1 alcoholic beverage per day have an increased risk of
breast cancer.
-Physical inactivity: Breast cancer risk is decreased in physically active women.
>Risk Factors for men: Predisposing risk factors for breast cancer in men include
hyperestrogenism, a family history of breast cancer, and radiation exposure. Men in BRCA-positive
families may consider genetic testing. Men with an abnormal BRCA gene also have an increased risk
of developing prostate cancer.

Types of Breast Cancer

Types Frequency of Occurrence
1.Noninvasive ductal carcinoma 20%
-Ductal carcinoma in situ
2.Invasive
i>Invasive ductal carcinoma 70-75%
-Medullary
-Tubular
-Colloid(mucinous)
iii>special types of invasive:
-Triple-negative breast cancer 15%
-Inflammatory breast cancer 1-5%
ii>Invasive lobular carcinoma 5-10%
3.Less common types:
-Paget disease 1-3%
-Angiosarcoma 1%
-Phyllodes tumor
1.Noninvasive Breast Cancer: An estimated 20% of all diagnosed breast cancers are noninvasive.
These intraductal cancers include ductal carcinoma in situ (DCIS) and lobular carcinoma in situ
(LCIS). In situ means within the ducts.
i. DCIS tends to be unilateral and it starts in a milk duct which has not grown into the rest of the
breast tissue. It is also called intraductal carcinoma or stage 0 breast cancer. This means the cells that
line the ducts have changed to cancer cells but they have not spread through the walls of the ducts
into the nearby breast tissue.
ii. LCIS: The term lobular carcinoma in situ is somewhat misleading. Although LCIS is a risk factor
for developing breast cancer, it is not known to be a premalignant lesion.
2.Invasive Breast Cancer: The term invasive or infiltrating breast cancer is used to describe any
type of breast cancer that has spread (invaded) into the surrounding breast tissue. It starts in the milk
duct and then breaks through the wall of the duct and spread (invaded) into the surrounding breast
tissue.
The most common types are invasive ductal carcinoma and invasive lobular carcinoma.
i. Invasive ductal Carcinoma (IDC): This is the most common type of breast cancer. About 8 in 10
invasive breast cancers are invasive (or infiltrating) ductal carcinoma. It starts in the cells that line a
milk duct and grows into the nearby breast tissues. It has ability to spread (metastasize) to other parts
of the body through the lymph system and blood stream.
ii. Invasive lobular carcinoma (ILC): It starts in the breast glands that make milk (lobules). It has
also ability to metastasize to other parts of the body. It is harder to detect on physical exam or
mammograms, than invasive ductal carcinoma and compared to other kinds of invasive carcinoma, it
is more likely to affect both breasts.
Other types of invasive (infiltrating) ductal carcinoma include medullary carcinoma, which accounts
for 15% of all breast cancers. It most frequently occurs in women in their late 40s and 50s,
manifesting with cells that resemble the medulla of the brain. Tubular carcinoma accounts for about
2% of all breast cancers. This type of breast cancer is usually found in women over 50. It has an
excellent prognosis. Colloid (mucinous) carcinoma accounts for about 1% to 2% of all breast cancer.
These tumors, which produce mucus, usually have a favorable prognosis.
iii. Special types of invasive breast cancers: Some invasive breast cancers have special features or
develop in different ways that influence their treatment and outlook. These cancers are less common
but can be more serious than other types of breast cancer.
-Triple-negative breast cancer: Triple-negative breast cancer is an aggressive type of invasive
breast cancer in which the cancer cells don’t have estrogen or progesterone receptors (ER or PR) and
also don’t make any or too much of the protein called HER2. (The cells test "negative" on all 3 tests.)
It accounts for about 15% of all breast cancers and can be a difficult cancer to treat.
-Inflammatory breast cancer: Inflammatory breast cancer is an aggressive type of invasive breast
cancer in which cancer cells block lymph vessels in the skin, causes symptoms of breast
inflammation like swelling and redness. The breast is looking "inflamed." It is rare and accounts for
about 1% to 5% of all breast cancers.
-IBC doesn’t look like a typical breast cancer. It often does not cause a breast lump. And it might not
show up on a mammogram. This makes it harder to diagnose.
-IBC tends to occur in younger women (younger than 40 years old) and who are overweight or
obese.
Sign and symptoms: Signs and symptoms of IBC develop very quickly (within 3 to 6 months).
These are-
-Swelling in the breast
-Redness involving more than one third of the breast
-Pitting or thickening of the skin of the breast so that it may look and feel like an orange peel
-A retracted or inverted nipple
-One breast looking larger than the other because of swelling
-One breast feeling warmer and heavier than the other.
-A breast may be tender, itchy or painful
-Swelling of the lymph nodes under the arms or near the collarbone
3.Less common types of breast cancer: There are other types of breast cancers that start to grow in
other types of cells in the breast. These cancers are much less common, and sometimes need different
types of treatment.
-Paget disease of the breast: Paget’s disease is a rare breast malignancy characterized by a
persistent lesion of the nipple and areola with or without a mass. (This is different from Paget’s
disease of the bone) Most women with Paget’s disease have underlying ductal carcinoma. Only in
rare cases is the cancer confined to the nipple itself. Itching, burning, bloody nipple discharge with
superficial skin erosion and ulceration may be present. Diagnosis of Paget’s disease is confirmed by
pathologic examination of the lesion. Nipple changes are often diagnosed as an infection or
dermatitis, which can lead to treatment delay.
-Angiosarcoma: Sarcomas of the breast are rare making up less than 1% of all breast cancers.
Angiosarcoma starts in cells that line blood vessels or lymph vessels. It can involve the breast tissue
or the skin of the breast. Some may be related to prior radiation therapy in that area. It can happen 8-
10 years after getting radiation treatment to the breast.
Angiosarcoma can cause skin changes like purple colored nodules and/or a lump in the breast. It can
occur in the affected arms of women with lymphedema (swelling that can develop after treatment or
surgery)
-Phyllodes tumor: Phyllodes tumor are rare breast tumors. They develop in the connective
tissue(stroma) of the breast, not the ducts or glands. Most phyllodes tumors are benign and only a
small number are malignant. Women with Li-Fraumeni syndrome ((a rare, inherited genetic
condition) have an increased risk for phyllodes tumors.
They are often divided into 3 groups, based on how they look under a microscope-
1.Benign (Non-cancerous): These tumors are account for more than half of all phyllodes tumors.
These tumors are the least likely to grow quickly or to spread.
2.Borderline: These tumors have features in between benign and malignant.
3.Malignant: These tumors account for about 1 in 4 phyllodes tumor. These tend to grow the fastest
and are the most likely to spread or to come back after treatment.

Breast Cancer biological classification based on Protein HER-2(Human

Epidermal Growth Factor Receptor 2)& ER(Estrogen Receptor)
1.Luminal Cancers → ER(+), HER-2(-) [Peaks later in life]
2.HER -2 Cancers→ ER(+/-), HER-2(Overexpression) [Plateau in middle age]
3.Tripple negative Breast Cancer→ ER(-), HER-2(-), PR(-) [Plateau in middle age]
Where PR is Progesterone Receptor

Pathophysiology

How Breast Cancer spread?

Primary Site-The mammary gland, situated on the anterior chest wall, is composed of glandular
tissue within a dense fibroareolar stroma. The glandular tissue consists of approximately 20 lobes,
each of which terminates in a separate excretory duct in the nipple.
Regional Lymph Nodes-The breast lymphatics drain by way of three major routes: axillary,
transpectoral, and internal mammary. Intramammary lymph nodes are considered with, and coded as,
axillary lymph nodes for staging purposes; metastasis to any other lymph node is considered distant
(M1), including supraclavicular, cervical, or contralateral internal mammary. The regional lymph
nodes are presented here:
1. Axillary (ipsilateral): interpectoral (Rotter's) nodes and lymph nodes along the axillary vein and its
tributaries that may be (but are not required to be) divided into the following levels:
a. Level I (low axilla): lymph nodes lateral to the lateral border of pectoralis minor muscle
b. Level II (midaxilla): lymph nodes between the medial and lateral borders of the pectoralis minor
muscle and the interpectoral (Rotter's) lymph nodes
c. Level III (apical axilla): lymph nodes medial to the medial margin of the pectoralis minor muscle
including those designated as subclavicular, infraclavicular, or apical Note: Intramammary lymph
nodes are coded as axillary lymph nodes.
2. Internal mammary (ipsilateral): lymph nodes in the intercostal spaces along the edge of the
sternum in the endothoracic fascia.
Any other lymph node metastasis is coded as a distant metastasis (M1), including supraclavicular,
cervical, or contralateral internal mammary lymph nodes.
Metastatic Sites- All distant visceral sites are potential sites of metastasis. The four major sites of
involvement are bone, lung, brain, and liver, but this widely metastasizing disease has been found in
many other sites.

Clinical Manifestations
-Usually detected as a lump or thickening in the breast
-If palpable, breast cancer is characteristically hard and may be irregularly shaped, poorly delineated,
nonmobile, and nontender.
-A small percentage of breast cancers cause nipple discharge. The discharge is usually unilateral and
may be clear or bloody. Peau d’orange may occur due to plugging of the dermal lymphatics.
-Dimpling of the skin over the breast
-Nipple retraction due to fibrosis of lactiferous ducts and suspensory ligaments.
-Eczematous rash over the nipple
Site of Breast Cancer Recurrence, Metastasis with respected to clinical manifestations:

Site Clinical Manifestations

Local Recurrence Firm, discrete nodules, occasionally pruritic,
Skin, Chest wall usually painless, commonly in or near a scar
Regional recurrence Enlarged nodes in axilla or supraclavicular area,
Lymph nodes usually nontender
Distant Metastasis Localized pain of gradually increasing intensity,
Skeletal percussion tenderness at involved sites,
 pathologic fracture caused by involvement of
bone cortex.
Spinal cord Progressive back pain, localized and radiating.
Change in bladder or bowel function. Loss of
sensation in lower extremities
Brain Headache described as “different,” unilateral
sensory loss, focal muscular weakness,
hemiparesis, incoordination (ataxia), nausea and
vomiting unrelated to medication, cognitive
changes.
Pulmonary (including lung nodules and pleural Shortness of breath, tachypnea, nonproductive
effusions) cough (not present in all patients).
Liver Abdominal distention. Right lower quadrant
abdominal pain sometimes with radiation to
scapular area. Nausea and vomiting, anorexia,
weight loss. Weakness and fatigue.
Hepatomegaly, ascites, jaundice. Peripheral
edema. Elevated liver enzymes
Bone marrow Anemia, infection, increased bleeding, bruising,
petechiae. Weakness, fatigue, mild confusion,
light-headedness. Dyspnea.
Assessment and Diagnostic Findings
Breast Cancer Screening Guidelines Screening guidelines for the early detection of breast cancer
include the following:
-Yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. A
controversial recommended change is that women at normal risk for breast cancer should begin
annual screening at age 50 and stop screening at age 75.
-Clinical breast examination (CBE) preferably at least every 3 years for women in their 20s and 30s,
and every year for women beginning at age 40.
-Women should report any breast changes promptly to their health care provider. Breast self-
examination (BSE) is an option for women starting at age 20.
-Women at increased risk (family history, genetic link, past breast cancer) should talk with their
health care provider about the benefits and limitations of starting mammography screening earlier,
having additional tests (e.g., breast ultrasound or magnetic resonance imaging [MRI]), or having
more frequent examinations.
Diagnostic Radiologic Studies. Several techniques can be used to screen for breast disease or to
help diagnose a suspicious physical finding-
• Mammography: It is a method used to visualize the breast’s internal structure using x-rays.
This generally well-tolerated procedure can detect suspicious lumps that cannot be felt.
Mammography has significantly improved the early and accurate detection of breast
malignancies. Improved imaging technology has also reduced the radiation dose from
mammography.
Digital mammography is a technique in which x-ray images are digitally coded into
a computer. It is not clear whether mammogram interpretation has improved with the
 aid of a computer. The associated costs of using computer-aided detection may also
outweigh the benefits.
Three-dimensional (3D) mammography, a new type of mammogram that produces
a 3D image of the breast, provides a clearer view of overlapping breast tissue
structures. 3-D images help to accurately detect and diagnose breast cancer.
• Ultrasound: If the clinical findings are suspicious and the mammogram is normal, an
ultrasound or MRI may be used. The somo-v ABUS is an ultrasound device, capturing
multiple images in 3D for breast cancer screening use in women with dense breasts. This
device is used along with standard mammography in women with a negative mammogram
and no breast cancer symptoms.
• MRI: It is recommended as a sensitive screening tool for women who are at high risk for
breast cancer, whose mammography or ultrasound is suspicious for malignancy, or who have
previously had an occult breast cancer detected by mammogram.
• Biopsies: A definitive diagnosis of a suspicious area is made by analyzing biopsied tissue.
Biopsy techniques include fine needle aspiration (FNA), core (core needle), vacuum-assisted,
and surgical biopsies. FNA biopsy is performed by inserting a needle into a lesion to sample
fluid from a breast cyst, remove cells from intercellular spaces, or sample cells from a solid
mass. Before the procedure, the breast area is first locally anesthetized. Then the needle is
placed into the breast, and fluid and cells are aspirated into a syringe. Three or four passes are
usually made. If the results are negative with a suspicious lesion, an additional biopsy may be
necessary. Inform patients that biopsy results are usually available in 1 to 3 days. A core (core
needle) biopsy involves removing small samples of breast tissue using a hollow “core”
needle. For palpable lesions, this is accomplished by fixing the lesion with one hand and
performing a needle biopsy with the other. In the case of nonpalpable lesions, stereotactic
mammography, ultrasound, or MRI image guidance is used.
In addition to radiologic and biopsy studies used to diagnose breast cancer other tests are used to
predict the risk of local or systemic recurrence. These tests include axillary lymph node status,
tumor size, estrogen and progesterone receptor status, cell proliferative indices, and genomic
assays.

• Axillary lymph node involvement is one of the most important prognostic factors in breast
cancer. Axillary lymph nodes are often examined to determine if cancer has spread to the
axilla on the side of the breast cancer. The more nodes involved, the greater the risk of
recurrence. Lymphatic mapping and sentinel lymph node dissection (SLND) help the surgeon
identify the lymph node(s) that drain first from the tumor site (sentinel node). An SLND is
less invasive than an axillary lymph node dissection (ALND). In SLND a radioisotope and/or
blue dye is injected into the affected breast, and intraoperatively it is determined in which
sentinel lymph nodes (SLNs) the radioisotope or dye is located. A local incision is made in
the axilla, and the surgeon dissects the blue stained or radioactive SLNs. Generally, with an
SLND, one to four axillary lymph nodes are removed. The nodes may be sent for pathologic
analysis. If the SLNs are negative, no further axillary surgery is required. If the SLNs are
positive, a complete axillary dissection may be done, depending on the patient’s clinical
situation. SLND is associated with lower morbidity rates and greater accuracy compared with
complete ALND.
• Tumor size is a prognostic variable: the larger the tumor, the poorer the prognosis. The wide
variety of biologic types of breast cancer explains the variability of disease behavior. In
 general, the more well differentiated (like the original cell type) the tumor, the less aggressive
it is. The cells of poorly differentiated (unlike the original cell type) tumors appear
morphologically disorganized, and they are more aggressive. Estrogen and progesterone
receptor status is another diagnostic test useful for decisions about both treatment and
prognosis.
Receptor-positive tumors (1) commonly show histologic evidence of being well
differentiated, (2) frequently have a diploid (more normal) DNA content and low proliferative
indices, (3) have a lower chance for recurrence, and (4) are frequently hormone dependent
and responsive to hormone therapy.
Receptor-negative tumors (1) are often poorly differentiated histologically, (2) have a high
incidence of aneuploidy (abnormally high or low DNA content) and higher proliferative
indices, (3) frequently recur, and (4) are usually unresponsive to hormone therapy.
• Marker HER-2: Overexpression of this receptor has been associated with unusually
aggressive tumor growth, a greater risk for recurrence, and a poorer prognosis in breast
cancer. A patient whose breast cancer tests negative for all three receptors (estrogen,
progesterone, and HER-2) has triple negative breast cancer.
• Oncotype DX and MammaPrint: These tests are typically reserved for patients who (1)
have early-stage breast cancer with no to few lymph nodes involved; and (2), in the case of
Oncotype DX, have estrogen receptor–positive breast cancer that can be treated with
hormone therapy.
• Cancer markers for breast cancer include CA 15-3 and CA 27-29. These proteins are
produced by the MUC1 gene. Breast cancer cells shed copies of these proteins into the
bloodstream. These markers are not specific or sensitive enough to be used as a screening
tool to detect early breast cancer.

Staging of Breast Cancer

The staging system most often used for breast cancer is TNM classification. The most recent AJCC
system, effective January 2018, has both clinical and pathologic staging systems for breast cancer:
• The pathologic stage (also called surgery stage) is determined by examining tissue
removed during an operation.
• If the surgery is not possible, the cancer will be given a clinical stage instead. This is based
on the results of a physical exam, biopsy and imaging tests. The clinical stage is used to help
plan treatment.
In both staging systems, 7 key pieces of information are used:
• The extent (size) of the tumor (T)
• The spread to nearby lymph nodes (N)
• The spread (metastasis) to distant sites (M)
• Estrogen Receptor (ER) status (cancer have the protein called an estrogen receptor)
• Progesterone Receptor (PR) status (cancer have the protein called progesterone receptor)
• HER2 status (cancer have too much protein called HER2)
• Grade of the cancer (G)

Prognosis
Several features of breast tumors contribute to the prognosis. Generally, the smaller the tumor, the
better the prognosis. Carcinoma of the breast is not a pathologic entity that develops overnight. It
starts with a genetic alteration in a single cell. It can take about 16 doubling times for a carcinoma to
become 1 cm or larger, at which point it becomes clinically apparent. The prognosis also depends on
whether the cancer has spread. For example, the overall 5-year survival rate is greater than 98%
when the tumor is confined to the breast (ACS, 2002). When the cancer cells have spread to the
regional lymph nodes, however, the overall 5-year survival rate falls to 76%. The 5-year survival rate
for women diagnosed with metastatic disease is 16%. At diagnosis, about 37% of patients have
evidence of regional or distant spread or metastasis.

Prevention
-Keep weight in check
-Be physically active
-Eat fruits and vegetables
-Don’t smoke
-Breastfeed the baby
-Avoid birth control pills

-Avoid hormonal therapy for menopause

-Breast Self-examination: This is the way that can help in identify changes in breasts such as lumps,
thickening etc. A practice of BSE on monthly basis is very important for early detection of cancer.
When to conduct BSE:
-Once a month by all women above 20 years of age
-Should be conducted on fixed date every month
-Better to conduct one week after menstrual cycle
Pattern: circling, massaging motion and follow a clock pattern or wedge pattern or sweeping motion
(outer part to towards nipple)
1.Clock pattern:
-Visualize breast as face of clock, place left hand behind head and examine left breast with right hand
-Place right hand at 12 ‘o’ clock at very top of the breast
-Place pads of three middle fingers firmly on breast in slight circling massaging motion
-Move hands down to 1 ‘o’ clock, then 2 ‘o’ clock until return to 12 ‘o’ clock
-Continue same pattern, moving hand in similar circles toward nipple
2.Wedge pattern:
-Visualize breast as a circle divided into wedges like piece of pie
-place left hand behind head and examine left breast by right hand
- Place pads of three middle fingers firmly on breast in slight circling massaging motion
-Start at the top of breast about half inch below collarbone and slide fingers in toward nipple
-Examine breast tissue in entire wedge
3. Sweeping pattern:
- place left hand behind head and examine left breast by right hand
-Sweep three middle fingers from collarbone to nipple
-Clockwise around breast, sweep fingers outside to inside toward nipple
Steps:
1.Inspection on mirror:
-Stand and face mirror with arms relaxed at sides or arms resting on hips, then turn to right and left
for side view look
-Bend forward form waist
-Stand straight with arms raised over head and move arms slowly up and down at sides.
Sitting or standing position: Do upright BSE in shower, soapy hands glide more easily over wet
area
2.Palpation:
Lying Position:
-To examine left breast, place pillow under right shoulder and place right hand behind head. This
position evenly distributes breast tissues.
-Examine in clock pattern, check for abnormalities

.Collaborative Management

>Medical Management
-Chemotherapy:
Chemotherapy is administered to eradicate the micro metastatic spread of the disease. Although
chemotherapy is generally initiated after breast surgery, no single standard exists for the sequencing
of systemic chemotherapy and radiation therapy. In some patients, chemotherapy is given
preoperatively. Preoperative (neoadjuvant) chemotherapy may decrease the size of the primary
tumor, with the goal of less extensive surgery. Chemotherapy regimens for breast cancer combine
several agents to increase tumor cell destruction and to minimize medication resistance. The use of
combinations of drugs is usually superior to the use of a single drug. The benefit of combination
treatment results from the use of drugs that have different mechanisms of action and work at different
parts of the cell cycle. The more common combination-therapy protocols are (1) CMF—
cyclophosphamide (Cytoxan), methotrexate, and 5-fluorouracil (5-FU); (2) AC—doxorubicin
(Adriamycin) and cyclophosphamide, with or without the addition of a taxane such as paclitaxel
(Taxol) or docetaxel (Taxotere); or (3) CEF or CAF— cyclophosphamide, epirubicin (Ellence) or
doxorubicin (Adriamycin), and 5-FU
Because healthy cells are also affected by chemotherapy, a variety of side effects accompany this
treatment modality. The incidence and severity of common side effects are influenced by the specific
drug combination, drug schedule, and dosage. The most common side effects involve rapidly
dividing cells in the gastrointestinal tract (nausea, anorexia, weight loss), bone marrow (anemia), and
hair follicles (alopecia [hair loss]). Cognitive changes during and after treatment, especially with
chemotherapy, have been reported in patients with cancer. This phenomenon, called “chemobrain,”
may affect up to 83% of breast cancer survivors.27 These changes include difficulties in
concentration, memory, focus, and attention. It is not clear if chemobrain is related to specific cancer
treatments or is an overall systemic reaction.
Other types of drug therapy of breast cancer are Hormonal therapy and Biologic and targeted therapy.
They are described in table below-

-Estrogen Receptor Blockers

Tamoxifen has been the hormonal agent of choice in estrogen receptor–positive women with all
stages of breast cancer over the past 30 years. It is commonly used in early-stage or advanced breast
cancer and to treat recurrent disease.
DRUG ALERT: Tamoxifen (Nolvadex)
• Irregular vaginal bleeding or spotting may occur.
• Decreased visual acuity, corneal opacity, and retinopathy can occur in women receiving high doses
(240-320 mg/day for >17 mo). These problems may be irreversible.
• Instruct patient to immediately report decreased visual acuity.
• Monitor for signs of deep vein thrombosis, pulmonary embolism, and stroke, including shortness of
breath, leg cramps, and weakness.
-Aromatase Inhibitors
Aromatase inhibitor drugs interfere with the enzyme aromatase, which is needed for the synthesis of
estrogen. These drugs, including anastrozole, letrozole (Femara), and exemestane (Aromasin), are
used in the treatment of breast cancer in postmenopausal women. Aromatase inhibitors do not block
the production of estrogen by the ovaries. Thus they are of little benefit and may be harmful in
premenopausal women.
- Estrogen Receptor Modulator and Others
Raloxifene (Evista) is a selective estrogen receptor modulator that produces both estrogen-agonistic
effects on bone and estrogen-antagonistic effects on breast tissue.
- Biologic and Targeted Therapy
Trastuzumab (Herceptin) is a monoclonal antibody to HER-2. After the antibody attaches to the
antigen, it is taken into the cells and eventually kills them.20 It can be used alone or in combination
with chemotherapy agents such as docetaxel or paclitaxel to treat patients whose tumors overexpress
HER-2. Additional genetic testing (e.g., SPoT-Light test) may offer information on which patients are
good candidates for treatment with trastuzumab.
DRUG ALERT: Trastuzumab (Herceptin)
• Use with caution in women with preexisting heart disease.
• Monitor for signs of ventricular dysfunction and heart failure.
-Pertuzumab (Perjeta) is a new anti-HER-2 therapy that is used for patients who have not received
prior treatment for metastatic breast cancer with an anti-HER-2 agent or chemotherapy. Pertuzumab
is combined with trastuzumab and docetaxel.
-Lapatinib (Tykerb) works inside the cell by blocking the function of the HER-2 protein. It may be
used in combination with capecitabine for patients with advanced metastatic disease who are HER-2
positive. The combination treatment is indicated for women who have become resistant to other
cancer drugs. Advanced breast cancer in postmenopausal women who are estrogen and progesterone
receptor positive and HER-2 positive may be treated with lapatinib in combination with letrozole.
-Everolimus (Afinitor) is used in combination with exemestane to treat postmenopausal women
with advanced hormone receptor positive, HER-2-negative breast cancer. The drug combination is
intended for use in women with recurrence or progression of their cancer after treatment with
letrozole or anastrozole.

>Surgical Management
1.Breast-Conserving Surgery.: Breast-conserving surgery (also called lumpectomy or partial
mastectomy) usually involves removal of the entire tumor along with a margin of normal
surrounding tissue. After surgery, radiation therapy is delivered to the entire breast, ending with a
boost to tumor bed. If evidence exists that the risk for recurrence is high, chemotherapy may be
administered before radiation therapy.
Contraindications to breast-conserving surgery include the following: breast size is too small in
relation to the tumor size to yield an acceptable cosmetic result, masses and calcifications are
multifocal (within the same breast quadrant), masses are multicentric (in more than one quadrant),
and diffuse calcifications occur in more than one quadrant.

2.Axillary Lymph Node Dissection: Axillary lymph node dissection (ALND) on the same side as
the breast cancer is often performed when breast-conserving surgery is done. A typical ALND
generally involves the removal of 12 to 20 nodes. Recently, sentinel lymph node dissection (SLND)
has become the standard of care, with ALND reserved for patients when clinically indicated
(evidence of disease in the axilla). Examination of the lymph nodes provides prognostic information
and helps determine further treatment (chemotherapy, hormone therapy, or both).
3.Modified Radical Mastectomy: A modified radical mastectomy includes removal of the breast
and axillary lymph nodes, but it preserves the pectoralis major muscle. This surgery would be
selected over breast-conserving surgery if the tumor were too large to excise with good margins and
attain a reasonable cosmetic result. Some patients may select this surgical procedure over
lumpectomy when presented with a choice. When a modified radical mastectomy is performed, the
patient has the option of breast reconstruction.
Postmastectomy Pain Syndrome- Postmastectomy pain syndrome can occur in patients after a
mastectomy or an axillary node dissection. Common symptoms include chest and upper arm pain,
tingling down the arm, numbness, shooting or pricking pain, and unbearable itching that persist
beyond the normal 3-month healing time. The most common theory for the onset of this syndrome is
injury to intercostobrachial nerves, which are sensory nerves that exit the chest wall muscles and
provide sensation to the shoulder and the upper arm.
Treatments include nonsteroidal anti-inflammatory drugs, antidepressants, topical lidocaine patches,
EMLA (local anesthetics: lidocaine and prilocaine), and antiseizure drugs (e.g., gabapentin
[Neurontin]). Other possible treatment modalities include imagery, biofeedback, physical therapy to
prevent “frozen shoulder” syndrome as a result of inadequate movement, and psychologic counseling
with a therapist trained in the management of chronic pain syndromes.

-Radiation Therapy: Radiation therapy is one form of adjuvant (additional) therapy that can be
used after surgery. Radiation therapy may be used for breast cancer as treatment to (1) prevent local
breast cancer recurrences after breast-conserving surgery; (2) prevent local and nodal recurrences
after mastectomy; or (3) relieve pain caused by local, regional, or distant recurrence.
>Primary Radiation Therapy: When radiation therapy is a primary treatment, it is usually
performed after excision of the breast mass. The decision to use radiation therapy after mastectomy
is based on the probability that local residual cancer cells are present. The possible presence of
residual cells is related to tumor size and biology and number of involved lymph nodes. In traditional
whole breast (and regional lymph nodes in some cases) radiation treatment, the area is radiated 5
days per week over the course of about 5 to 7 weeks. An external beam of radiation is used to deliver
an approximate total dose of 45 to 50 Gy (4500 to 5000 cGy or rads). A “boost” is a dose of radiation
delivered to the area in which the original tumor was located. It can be given by external beam and
adds five to eight more treatments to the total number given.
Complications: Fatigue, skin changes, and breast edema may be temporary side effects of external
beam radiation therapy. Radiation of the axilla and/or supraclavicular nodes may be indicated when
lymph nodes are involved to decrease the risk of axillary recurrence. Radiating a localized area will
not prevent distant metastasis. Chemotherapy may be used in select cases (e.g., local recurrence after
mastectomy).
Post radiation Nursing Management:
Self-care instructions for patients receiving radiation are based on maintaining skin integrity during
and after radiation therapy:
• Use mild soap with minimal rubbing.
• Avoid perfumed soaps or deodorants.
• Use hydrophilic lotions (Lubriderm, Eucerin, Aquaphor) for dryness.
• Use a nondrying, antipruritic soap (Aveeno) if itching occurs.
• Avoid tight clothes, underwire bras, excessive temperatures, and ultraviolet light. Patients may note
increased redness and, rarely, skin break down at the booster site (tissue site that received
concentrated radiation).
Important aspects of follow-up care include teaching patients to minimize exposure of the treated
area to the sun for 1 year and reassurance that minor twinges and shooting pain in the breast are
normal reactions after radiation treatment.

-Brachytherapy: Brachytherapy (internal radiation) is used for partial-breast radiation as an

alternative to traditional external radiation treatment for early-stage breast cancer. Radiation is
delivered directly into the cavity left after a tumor is surgically removed by a lumpectomy. This
approach is a minimally invasive way to deliver radiation. Because the radiation is concentrated and
focused on the area with the highest risk for tumor recurrence, internal radiation only requires 5 days.
Traditional external radiation treatments can take 5 to 7 weeks. Internal radiation therapy is primarily
delivered using a multi catheter method or balloon-catheter system.
In the multi catheter method (e.g., SAVI) many very small catheters are placed in the breast at the
site of the tumor. The SAVI is inserted through a small incision, and the catheter bundle expands
uniformly. The ends of the catheters stick out through little holes in the skin. Small radioactive seeds
are placed in the catheters. The seeds are left in place just long enough to deliver the radiation dose
(e.g., 5 to 10 minutes). The tiny radioactive seeds are inserted only during treatment and then
removed. The radiation does not remain in the body between treatments or after the final treatment is
over.
In the balloon-catheter system, the balloon is placed where the tumor is located. The balloon is
filled with fluid to keep it in place. Radioactive seeds are inserted. Radiation is emitted by a tiny
radioactive seed attached by a wire on the way to an after loader, a computer-controlled machine.
The seed travels through the Mammo Site applicator into the inflated balloon. As with the multi
catheter system, the radiation does not remain in the body between treatments or after the final
treatment is over. Once the final session is completed, the balloon is deflated and the system is
removed. Internal radiation may also be used as a boost therapy in conjunction with external
radiation. The long-term effectiveness and safety of brachytherapy is currently under investigation.
-Palliative Radiation Therapy: In addition to reducing the primary tumor mass with a
resultant decrease in pain, radiation therapy is also used to treat symptomatic metastatic lesions in
such sites as bone, soft tissue organs, brain, and chest. Radiation therapy often relieves pain and is
successful in controlling recurrent or metastatic disease.

>Nursing Management:
Assessment:
Subjective Data
-Important Health Information
Past health history: Benign breast disease with atypical changes; previous unilateral breast cancer;
menstrual history (early menarche with late menopause); pregnancy history (nulliparity or first full-
term pregnancy after age 30); previous endometrial, ovarian, or colon cancer; hyperestrogenism and
testicular atrophy (in men)
Medications: Hormones, especially as postmenopausal hormone therapy and in oral contraceptives,
infertility treatments
Surgery or other treatments: Exposure to therapeutic radiation (e.g., Hodgkin’s lymphoma or thyroid
radiation)
-Functional Health Patterns
Health perception–health management: Family history of breast cancer (especially mother or sister,
young age at diagnosis); history of abnormal mammogram or atypical prior biopsy; palpable change
found on BSE; frequent alcohol use
Nutritional-metabolic: Obesity; unexplained severe weight loss (possible indicator of metastasis)
Cognitive-perceptual: Changes in cognition, headache, bone pain (possible indicators of metastasis)
Sexuality-reproductive: Unilateral nipple discharge (clear, milky, or bloody); change in breast
contour, size, or symmetry Coping–stress tolerance: Psychologic stress Self-perception–self-concept:
Anxiety regarding threat to self-esteem
Physical activity: Level of usual activity
Objective Data
-General
Axillary and supraclavicular lymphadenopathy
-Integumentary
Hard, irregular, nonmobile breast lump most often in upper, outer sector, possibly fixated to fascia or
chest wall; thickening of breast; nipple inversion or retraction, erosion; edema (“peau d’orange”),
erythema, induration, infiltration, or dimpling (in later stages); firm, discrete nodules at mastectomy
site (possible indicator of local recurrence); peripheral edema (possible indicator of metastasis)
-Respiratory
Pleural effusions (possible indicator of metastasis)
-Gastrointestinal
Hepatomegaly, jaundice; ascites (possible indicators of liver metastasis) Possible Diagnostic
Findings Finding of mass or change in tissue on breast examination; abnormal mammogram,
ultrasound, or breast MRI; positive results of FNA or surgical biopsy or similar results with a needle
biopsy.
Nursing Diagnosis
>PREOPERATIVE NURSING DIAGNOSES
Based on the health history and other assessment data, the patient’s major preoperative nursing
diagnoses may include the following:
• Deficient knowledge about breast cancer and treatment options
• Anxiety related to cancer diagnosis
• Fear related to specific treatments, body image changes, or possible death
• Risk for ineffective coping (individual or family) related to the diagnosis of breast cancer and
related treatment options • Decisional conflict related to treatment options
>POSTOPERATIVE NURSING DIAGNOSES
Based on the health history and other assessment data, the patient’s major postoperative nursing
diagnoses may include the following:
• Acute pain related to surgical procedure
• Impaired skin integrity due to surgical incision
• Risk for infection related to surgical incision and presence of surgical drain
• Disturbed body image related to loss or alteration of the breast related to the surgical procedure
• Risk for impaired adjustment related to the diagnosis of cancer, surgical treatment, and fear of death
• Self-care deficit related to partial immobility of upper extremity on operative side
• Disturbed sensory perception (kinesthesia) related to sensations in affected arm, breast, or chest
wall
• Risk for sexual dysfunction related to loss of body part, change in self-image, and fear of partner’s
responses
• Deficient knowledge: drain management after breast surgery
• Deficient knowledge: arm exercises to regain mobility of affected extremity
• Deficient knowledge: hand and arm care after an axillary lymph node dissection
Planning and Goals
The major goals for the patient may include increased knowledge about the disease and its treatment;
reduction of preoperative and postoperative fears, anxiety, and emotional stress; improvement of
decision-making ability; pain management; maintenance of skin integrity; improved self-concept;
improved sexual function; and the absence of complications.

Preoperative Nursing Interventions

-EXPLAINING BREAST CANCER AND TREATMENT OPTIONS
The patient confronting the diagnosis of breast cancer reacts with fear, dread, and anxiety. In view of
the usually overwhelming emotional reactions to the diagnosis, the patient must be given time to
absorb the significance of the diagnosis and any information that will help her to evaluate treatment
options. The nurse caring for the woman who has just received a diagnosis of breast cancer needs to
be knowledgeable about current treatment options and able to discuss them with the patient. The
nurse should be aware of the information that has been given to the patient by the physician.
-REDUCING FEAR AND ANXIETY AND IMPROVING COPING ABILITY
The patient’s emotional preparation begins when the tentative diagnosis of cancer is made. Patients
who have lost close relatives to breast cancer (or any cancer) may have difficulty coping with the
possible diagnosis of breast cancer because memories of loss and death can emerge during their own
crisis. The nurse provides anticipatory teaching and counseling at each stage of the process and
identifies the sensations that can be expected during additional diagnostic procedures. The nurse also
discusses the implications of each treatment option and how it may affect various aspects of the
patient’s treatment course and lifestyle. The patient is introduced to other members of the oncology
team (eg, radiation oncologist, medical oncologist, oncology nurse, and social worker) and is
acquainted with the role of each in her care. After the treatment plan has been established, the nurse
needs to promote preoperative physical, psychological, social, and nutritional well-being. The patient
usually prefers to be active in her care and decision making. Some women find it helpful and
reassuring to talk to a breast cancer survivor, someone who has completed treatment and has been
trained as a volunteer to talk with newly diagnosed patients.
-PROMOTING DECISION-MAKING ABILITY
At times, a patient may demonstrate behavior that indicates she cannot make a decision about
treatment. Careful guidance and supportive counseling are the interventions the nurse can use to help
such a patient.
Postoperative Nursing Interventions
-RELIEVING PAIN AND DISCOMFORT
Ongoing nursing assessment of pain and discomfort is important because patients experience
differing degrees of pain intensity. Some women may have more generalized pain and discomfort of
the chest wall, affected breast, or affected arm. Moderate elevation of the involved extremity is one
means of relieving pain because it decreases tension on the surgical incision, promotes circulation,
and prevents venous congestion in the affected extremity. Intravenous or intramuscular opioid
analgesic agents are another method to manage pain in the initial postoperative phase. After the
patient is taking fluids and food and the anesthesia has cleared sufficiently (usually by the next
morning), oral analgesic agents can be effective in relieving pain.
-MAINTAINING SKIN INTEGRITY AND PREVENTING INFECTION
In the immediate postoperative period, the patient will have a snug but not tight dressing or a surgical
bra packed with gauze over the surgical site and one or more drainage tubes in place. A particular
concern is preventing fluid from accumulating under the chest wall incision or in the axilla by
maintaining the patency of the surgical drains. The dressings and drains should be inspected for
bleeding and the extent of drainage monitored regularly.
-PROMOTING POSITIVE BODY IMAGE
During teaching sessions, the nurse can address the patient’s perception of the body image changes
and physical alteration of the breast. Patients may initially be uncomfortable looking at the surgical
incision. No matter how prepared a patient may be, the view of her incision and absence of her breast
is often difficult for her. Exploring this sensitive area must be a careful nursing action, and cues
provided by the patient must be respected and sensitively handled. Privacy is a consideration when
assisting the woman to view her incision fully for the first time and allows the patient to express her
feelings safely to the nurse.
-PROMOTING POSITIVE ADJUSTMENT AND COPING
Ongoing assessment of the patient’s concerns related to the diagnosis of cancer, the consequences of
surgical treatment, and fear of death is important in determining her progress in adjusting and the
effectiveness of her coping strategies. Assisting the patient in identifying and mobilizing her support
systems is important.
-PROMOTING PARTICIPATION IN CARE
Ambulation is encouraged when the patient is free of post anesthesia nausea and is tolerating fluids.
The nurse supports the patient on the nonoperative side. Exercises (hand, shoulder, arm, and
respiratory) are initiated on the second postoperative day, although instruction occurs on the first
postoperative day. The goals of the exercise regimen are to increase circulation and muscle strength,
prevent joint stiffness and contractures, and restore full range of motion. Hand exercises are also
important for the same reasons.

>Post mastectomy exercises: Post mastectomy exercises are exercises that are done after
mastectomy surgeries i.e. removal of breast.
GENERAL GUIDELINES-
• Wear comfortable loose clothing during exercise
• Do exercise slowly, until you feel gentle stretch not pain
• May feel tightness in chest and armpit after surgery, but its normal and decrease on doing
exercise
• Many women may feel burning, tingling, numbness on back of arm or on chest wall. This
may increase after surgery, but keep doing exercises
• Exercise after a warm shower, when our muscles are warm and relaxed
• Breathe deeply and often as you do exercise
• Do not bounce, or make any quick, jerky movements while stretching
 • Contact doctor if unusual pain or swelling is seen
• Don't exercise too much in early weeks
• Do each exercise 5-7 times
• Do exercise twice a day
INSTRUCTIONS TO BE GIVEN-
• Begin exercise the day after surgery

• Plan to take your pain medication 20-30 min before exercise.

• Do exercise2 times a day
• Try to do daily and do not forget
EXERCISES-
Exercises are divided into 3 stages based on the post mastectomy period-
• Right after surgery (First 1 to 7 days)
• First stage of healing (First 6 weeks after surgery)
• Second stage of healing (From about 6 weeks after surgery)
1.RIGHT AFTER SURGERY (1 to 7 days)-
These are gentle exercises done after first week of surgery or while drain is still in place.
A.DEEP BREATHING
Deep breathing is an important part of your recovery and helps to expand your chest wall. It helps
with relaxation and can remind you to fill your lungs completely.
Steps-
1. Try lying on your back or sitting and then take a slow, deep breath through your nose.
Breathe in as much air as you can while trying to expand your chest and stomach like a
balloon.
2. Do not tense your shoulders or neck.
3. Relax and breathe out slowly and completely.
4. Repeat 4 or 5 times.
B.PUMP IT UP
This exercise helps reduce swelling after surgery by using your muscles as a pump to improve the
circulation in your affected arm (on the same side as your surgery).Steps-
 1. Try lying on your unaffected side with your affected arm straight out, above the level of
your heart (use pillows if you need to) or sit in a chair with good back support with your arm
supported by pillows.
2. Slowly open and close your hand. Repeat 15 to 25 times.
3. Then slowly bend and straighten your elbow. Repeat
15 to 25 times.
C.BALL SQEEZING-
1. While standing, sitting, or lying down, hold a rubber
ball in your hand on the treated side.
2. Keep your arm slightly bent with your palm toward the
ceiling. Lift your hand higher than your heart. Squeeze
and relax the ball.
3. Repeat 10 times.
D.BRUSHING AND COMBING OF THE AFFECTED
SIDE- Daily brushing and combing helps in early healing.
E.SHOULDER SHRUGS AND CIRCLES
This exercise can be done sitting or standing.
Steps-

1. Lift both shoulders up towards your ears. Keep your chin tucked in slightly. Hold for 5 to 10
seconds, and then slowly drop them down and relax. Repeat 5 to 10 times.
2. Gently rotate both shoulders forward and up, and then slowly back and down, making a
circle. Keep your chin tucked in slightly. Switch and repeat in the opposite direction.
3. Repeat 5 to 10 times in each direction.

F.ARM LIFT: This exercise can be done sitting or standing.

Steps 1. Clasp your hands together in front of your chest. Point your elbows out.
2. Slowly lift your arms upwards until you feel a gentle stretch.
3. Hold for 1 to 2 seconds, and then slowly return to the start position.
4. Repeat 5 to 10 times.
G.SHOULDER BLADE SQUEEZE
This exercise helps improve movement in your shoulder and your posture.
Steps-
1. Sit in a chair facing straight ahead without resting your back on the chair, or stand up. Your
arms should be at your side with your elbows straight and your palms facing your sides.
2. Open your chest, gently squeeze your shoulder blades together and down and rotate your
thumbs so your palms face forward.
3. Hold for 5 to 10 seconds and practice your deep breathing while holding this posture.
Relax and return to the start position.
4. Repeat 5 to 10 times.
Rope turning- Tie a light rope to a doorknob. Stand facing the door. Take the free end of the
rope in the hand on the side of surgery. Place the other hand on
the hip. With the rope-holding arm extended and held away
from the body (nearly parallel with the floor), turn the rope,
making as wide swings as possible. Begin slowly at first; speed
up later.
2.FIRST STAGE OF HEALING (First 6 weeks)
1. Once the drain has been removed, you should try to get back
full control of your shoulder.
2. Begin with these easy exercises, and then move on to the
more advanced exercises once you feel stronger.
3. By the end of this stage, you should have full movement of your affected arm and shoulder.
4. But listen to your body. You shouldn't feel worse after the exercises.
A.WAND EXERCISE (2 POSITIONS)
This exercise helps improve the forward movement of your shoulder.
You will need a "wand" to do this exercise - try a broom handle, stick or a cane.
You may feel a gentle pull but not any pain or pinching during these exercises.
If you do, stop the movement before the point of pain or pinching.
Steps-
 1. Lie on your back with your knees bent. Hold your wand with both hands (your palms
should be facing down), and your hands should be shoulder-width apart.
2. Lift the wand over your head as far as you can until you feel a stretch. Your unaffected arm
will help lift the wand.
3. Hold for 1 to 2 seconds. Lower arms.
Repeat 5 to 10 times.

B. WINGING IT
This exercise helps improve movement in the front of
your chest and shoulder.
It may take several weeks of regular exercise before your
elbows get close to the floor.
If you feel pain or pinching in your shoulder, place a
small pillow behind your head, above (not under) your
affected shoulder.
Steps-

1. Lie on your back with your knees bent. Touch your

fingertips to your ears with
your elbows pointed to the
ceiling. (If you can't comfortably put
your hands at your ears, place your
fingers on your forehead, palms facing
each other.)
2. Move your elbows apart and down to
the bed (or floor).Hold for 1 to 2
seconds.
3. Repeat 5 to 10 times.

C.WALL CLIMBING (2 POSITIONS)

Wall hand climbing-. Stand facing the wall with feet apart and toes as close to the wall as possible.
With elbows slightly bent, place the palms of the hand on the wall at shoulder level. By flexing the
fingers, work the hands up the wall until arms are fully extended. Then reverse the process, working
the hands down to the starting point.

Exercise helps increase movement in your shoulder. Try to reach a little higher on the wall each day.
This exercise can be done in 2 directions - facing the wall or your affected side to the wall.
Steps-
1. Stand facing the wall, about 5 cm (2 inches) away. Place both your hands on the wall at shoulder
level.
2. Use your fingers to climb up or slide as high as you can go until you feel a stretch.
3. Return to start position.
4. Repeat 5 to 10 times.
D. SIDE WALL STRETCH-
Steps-
1. Stand with your affected side to the wall, about 2 feet from the wall so you can touch the wall with
your fingertips.
2. Walk your fingers up the wall as you do in facing the wall. Do not rotate your body towards the
wall. Keep your torso facing forward even if it means you can't go up as high.
3. Lower and repeat 5 to 10 times.

1. Pulley tugging- Toss a light rope over a shower

curtain rod or doorway curtain rod. Stand as nearly
under the rope as possible. Grasp an end in each
hand. Extend the arms straight and away from the
body. Pull the left arm up by tugging down with the
right arm, then the right arm up and the left down in
a see-sawing motion.

E.SNOW ANGELS
This exercise can be done lying down on the floor or on a
bed.
Steps-
1. Lie on your back and extend your arms out at your sides.
2. Move them up over your head, eventually touching your fingers, and then back down to your
thighs (as if you're making an angel in the snow).
3. Repeat 3 to 5 times.
Once you're getting better movement in your shoulder, try these more advanced stretches.

F.SIDE BENDS
This exercise helps improve movement on both sides of your body.
Steps-
1. Sit in a chair and clasp your hands together in your lap.
2. Slowly lift your arms over your head. Bend your elbows slightly.
3. When your arms are above your head, bend at your waist and move your body to the right. Hold 1
to 2 seconds. Use your right hand to gently pull your left arm a little further to the right. Keep
yourself firmly planted on the chair. Take a deep breath in and out.
4. Return to the center and then bend to the left, using your left hand to pull your right arm further.
5. Repeat 5 to 10 times on each side.

3.SECOND STAGE OF HEALING (From 6 weeks)

From about 6 weeks after surgery, as you feel stronger, you can gradually start doing strengthening
and general conditioning exercises.
For some women, this means getting back to their old exercise routine, but for others it may mean
trying out some new activities.
Talk to your doctor or another member of your healthcare team about starting a specific
strengthening program or aerobic exercise, and ask if there are any special precautions you should
take.
If you have pain, your shoulder is tight or if your hand or arm begins to swell, talk to your doctor or
another member of your healthcare team.
A.STRENGTHENING
Slowly getting back to household chores, gardening or hard work are some ways you can keep
building your strength.
Within 4 to 6 weeks after surgery, you can start doing your strengthening exercises with light weights
(500 g to 1 kg or 1 to 2 lbs.).
If you don't have any light weights, you can use an unopened juice bottle or a plastic bottle filled
with water.
Check with your doctor or physiotherapist to decide what weight is best for you.
They can also suggest strengthening exercises for the upper body that are suitable for you.
But it is important to build up slowly.
B.REGULAR AEROBIC EXERCISE
➢ It is any exercise that gets your heart and lungs working hard, improves your general physical
condition.
➢ It can help with your recovery and has many benefits. It can:
➢ help improve your cardiovascular fitness - how well your heart, lungs and blood vessels bring
oxygen to your muscles, so that you can do physical work for longer periods of time
➢ help you maintain a healthy body weight
➢ help you feel better, which may reduce stress and anxiety
➢ Help you as you face the challenges of life after cancer. Brisk walking, swimming, running,
cycling, and dancing are all examples of aerobic exercises..
-MANAGING POSTOPERATIVE SENSATIONS
Because nerves in the skin are cut during breast surgery, patients experience a variety of sensations.
Common sensations are tightness, pulling, burning, and tingling along the chest wall, in the axilla,
and along the inside aspect of the upper arm. Explaining to the patient that this is a normal part of
healing helps to reassure her that these sensations are not indicative of a problem. Performing the
exercises may decrease the sensations.
-MONITORING AND MANAGING POTENTIAL COMPLICATIONS
>Lymphedema: Lymphedema can occur any time after an axillary lymph node dissection.
Lymphedema results if functioning lymphatic channels are inadequate to ensure a return flow of
lymph fluid to the general circulation. After removal of axillary nodes, collateral or auxiliary
circulation must take over their function. The patient may experience heaviness, pain, impaired
motor function in the arm, and numbness and paresthesia of the fingers. Fever and a red, painful rash
may also be present with infection of the affected arm. These symptoms may indicate the beginning
or worsening of lymphedema. Lymphedema occurs in about 10% to 20% of patients who undergo an
axillary dissection. Risk factors for lymphedema are increasing age, obesity, presence of extensive
axillary disease, radiation treatment, and injury or infection to the extremity. Patients should care of
the hand and arm to prevent injury to the affected extremity because lymphedema is subsequently
associated with a trauma of some type.
> Hematoma Formation: Hematoma formation may occur after either mastectomy or breast
conservation. The nurse monitors the surgical site for excessive swelling and monitors the drainage
device, if present. Gross swelling or output from the drain may indicate hematoma formation, and the
surgeon should be notified promptly. Depending on the surgeon’s assessment, an Ace wrap may be
applied for compression of the surgical site along with ice packs for 24 hours, or the patient may be
returned to surgery to identify the source of bleeding.
> Infection: Infection follows breast surgery in about 1 in 100 patients. Infection can occur for a
variety of reasons, including concurrent conditions (diabetes, immune disorders, advanced age) and
exposure to pathogens. In addition, cellulitis may occur after breast surgery. Both preoperatively and
before discharge, patients are taught to monitor for signs and symptoms of infection (redness, foul-
smelling drainage, temperature greater than 100.4°F) and to contact the surgeon or nurse for
evaluation. Treatment consists of oral or intravenous antibiotics for 1 or 2 weeks, depending on the
severity of the infection.
Evaluation
>EXPECTED PREOPERATIVE PATIENT OUTCOMES: Expected preoperative patient
outcomes may include:
1. Exhibits knowledge about diagnosis and treatment options
2. Verbalizes willingness to deal with anxiety and fears related to the diagnosis and the effects of
surgery on self-image and sexual functioning
3. Demonstrates ability to cope with diagnosis and treatment
4. Demonstrates ability to make decisions regarding treatment options in timely fashion
>EXPECTED POSTOPERATIVE PATIENT OUTCOMES: Expected postoperative patient
outcomes may include:
1. Reports that pain has decreased and states pain and discomfort management strategies are
effective.
2.Exhibits clean, dry, and intact surgical incisions without signs of inflammation or infection
3. Lists the signs and symptoms of infection to be reported to the nurse or surgeon
4. Verbalizes feelings regarding change in body image
5. Participates actively in self-care activities and exercises as prescribed
6. Recognizes that postoperative sensations are normal and identifies management strategies
7. Experiences no complications a. Identifies signs and symptoms of reportable complications (ie,
redness, heat, pain, edema) b. Describes side effects of chemotherapy and strategies to cope with
possible side effects c. Explains how to contact appropriate health care providers in case of
complications.
MALE BREAST CANCER
Cancer of the male breast accounts for 1% of all breast cancers; about 1,500 new cases of breast
cancer and 400 deaths due to breast cancer occur annually (ACS, 2002b). Symptoms can include a
painless lump beneath the areola, nipple retraction, nipple discharge, or skin ulceration. Diagnostic
tests and treatment modalities are similar to those used for women. The average age of the patient at
the time of diagnosis is 60 years, but it can occur in younger men, especially if there is a genetic link
to the disease, because there may be a relationship to BRCA-2 in men with breast cancer. Risk
factors may include a history of mumps orchitis, radiation exposure, and Klinefelter’s syndrome (a
chromosomal condition reflecting decreased testosterone levels). Detection usually occurs well into
the disease because cancer of the breast is not a common concern among men. Therefore, treatment
generally consists of a modified radical mastectomy. If the pectoralis muscles are involved, a radical
mastectomy is indicated. Radiation therapy may be used postoperatively. Prognosis varies depending
on the stage of disease at diagnosis. Bone and soft tissue are the most common sites of advanced
disease and metastasis. Orchiectomy (removal of the testes), adrenalectomy (removal of the adrenal
gland), and hypophysectomy (removal of the pituitary gland) may be used in advanced disease, but
antihormonal agents are preferable because they are less invasive and disfiguring.

Conclusion
Cancer prevention and screening can prevent many cancers and detect precancerous or early-stage
cancers, significantly reducing morbidity and mortality. Developing an appropriate cancer screening
and, if appropriate prevention plan, should be part of routine preventive care medicine. Cancer
prevention strategies are available for women who have the BRCA1 and/or BRCA2 mutation or
other high-risk features.

Research Input
1.Acute menopausal symptoms during adjuvant systemic treatment for breast cancer.
Study Sample and Design: The sample in this case-control study comprised two groups of women
ranging from 50 to 64 years of age: 200 women undergoing treatment for breast cancer with
tamoxifen or chemotherapy and a control group of 200 women who had undergone breast screening
and had no diagnosis of breast cancer. A self-report questionnaire addressed general health and
menstrual history, breast cancer treatment and associated symptoms, and menopause and menopausal
symptoms.
Findings: Women with breast cancer were more likely than those without cancer to report that they
were currently experiencing menopause symptoms (p = 0.04) and were more likely to have a greater
severity of symptoms as assessed by the Greene Climacteric Scale. Women who were receiving
adjuvant systematic treatment for breast cancer perceived their menopause symptoms as a significant
source of distress, with hot flushes second to tiredness as a side effect attributed to cancer treatment.
Women receiving chemotherapy were more likely to report tiredness, and women receiving
tamoxifen were more likely to report hot flushes. The group undergoing treatment and the control
group differed on four specific symptoms: tiredness, hot flushes, night sweats, and headaches. The
women undergoing breast cancer treatment reported more severe tiredness, hot flushes, and night
sweats than the control group. The control group experienced more severe headaches.
2.The evolving meaning of cancer for long-term survivors of breast cancer.
Study Sample and Design: A descriptive qualitative study was conducted to explore the experience
of long-term survivors of breast cancer. The sample comprised eight women whose survival
following treatment for breast cancer ranged from 5.5 to 29. Their ages at the time of the study
ranged from 65 to 77 years. Four of the women had lumpectomy with radiation and chemotherapy,
and one had lumpectomy with radiation only as her treatment. Three women had undergone
mastectomy and one of them had received oral chemotherapy. Two of the women had positive
axillary lymph nodes, and they had lumpectomy combined with radiation and chemotherapy.
Interviews lasting 60 to 90 minutes were conducted with the women in their homes; three life history
interviews were conducted with each woman and audiotaped.
Findings: Three meanings of cancer emerged from the data: cancer as sickness and death, cancer as
an obstacle, and cancer as transforming. Cancer as sickness and death was the initial perspective of
the women at the time of diagnosis and during the early phases of their treatment. Cancer as obstacle
reflected the women’s perspective that breast cancer was an obstacle that was intrusive or in the way
of their life path that they had to deal with before moving on. Cancer as transforming described the
change in women’s outlooks about life and their own strength as they put their diagnosis in
perspective. They viewed their cancer treatment as past and moved on to renewing their interactions
with their surroundings
 BIBLIOGRAPHY
• Brunner & Suddarth's, Textbook of Medical-Surgical Nursing. Wolters Kluwer (India)
Pvt.Ltd. New Delhi: 12" ed. 2011, Vol. II. Page no 1446- 1482
• Chintamani, Lewis's MEDICAL SURGICAL NURSING, Elsevier, Pondicherry; 1st ed. 2011,
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• Black J.M, Hawks J.H. Medical Surgical Nursing, 8th edition, New Delhi, ELSEVIER. Page
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• American Cancer Society. (2022). Breast Cancer facts and figures. Atlanta: American Cancer
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• www.cancer.org/cancer/acs-medical-content-and-news-staff.html
• www.cancer.org/cancer/breast-cancer/understanding-a-breast-cancer-diagnosis/breast-cancer-
her2-status.html
 CLASS PRESENTATION
ON
BREAST CANCER

SUBMITTED TO SUBMITTED BY
Mrs. Aparna Saha Tamalika Ghosal
Senior Lecturer M.Sc. Nursing 1st year
W.B.G.C.O.N W.B.G.C.O.N
IPGME&R, SSKM Hospital IPGME&R, SSKM Hospital