Breast cancer

Introduction :-

• Breast cancer is the cancer that forms in the cells of the breast.
• After skin cancer breast cancer is the most common cancer diagnosed in the women.

Definition :-

• "Breast cancer is a disease that occur when cells in breast tissue change or mutate and keep reproducing, these abnormal cells usually cluster together to form a tumor."
• A tumor is cancerous or malignant when these abnormal cells invade other parts of the breast.

Types :-

1. Ductal carcinoma in situ :- DCTS is a non-invasive condition.The cancer cells are confined to the ducts in the breast have not invade.
2. Lobular carcinoma in situ :- Lobular carcinoma in situ is cancer that grows in the milk producing glands of the breast , have not invade.
3. Invasive ductal carcinoma :- IDC is the most common type.This type of breast cancer begins in the breast milk duct and then invade nearby tissue in the breast.
4. Invasive Lobular carcinoma :- ILC first develops in breast lobules then invade near by tissue.

Etiology :-

• Breast cancer is caused by a genetic mutation in the DNA of breast cell.
• Inherited mutated genes known are breast cancer Gene 1 (BRCA 1), Breast cancer gene 2 (BRCA 2).

Risk factor :-

• Gender and Age :- the risk begin after 40 year in women.
• family history.
• Inherited genes :- the most well known gene mutation -BRCA 1,BRCA 2.
• Radiation therapy.
• Obesity.
• Beginning period at a younger age (before age 12).
• Beginning menopause at an older age.
• Have never been pregnant.
• Post menopausal hormone therapy (estrogen and progesterone).
• Alcohol Consumption.

Incidence :-

1. Most common malignancy in women.
2. Only 1% breast cancer occur in men.
3. 1/8 post menopausal women or at rest.
4. Occurrence of breast cancer according to the location.

Pathophysiology :-

• Majority of the breast cancer are adenocarcinomas.They are classified as ductal or lobular.

1. Intraductal.
2. Intralobular ( lobe or part or portion of an organ). 
3. Invasive ductal.
4. Invasive lobular.

Stages :-

• Stage 1 :-

1. tumor less than 2 cm.
2. Confined to breast.
3. No positive symptoms.
4. No metastasis present.

• Stage 2 :- Tumors less then 2cm with positive lymph-node.No metastasis evident. or tumor 2-5cm with or without positive lymphnode not metastasis evident or tumor greater then 5cm with lymphnodes ,not metastasis evident.
• Stage 3 :- Tumor >5cm with positive lymphnode,no metastasis present.
• Stage 4 :- Any distend metastasis to brain,lung,liver,or bone with or without positive lymphnode.

Sign and symptoms :-

• A breast lumps or tissue thickning that feel different than surrounding tissue.
• Breast pain.
• Red,pitted skin over entire breast.
• Swelling in all or part of breast.
• A nipple discharge other than breast milk.
• Blood discharge from nipple.
• A sudden change in the shape and size of breast.
• Inverted nipple.
• A lump or swelling in the arm.
• Peeling,scaling, or blaking of skin on nipple.  

Diagnostic evaluation:-

• Mammography :- It is the process of using low energy X-ray to examine the breast for diagnosis.during the procedure the breast is compressed using a dedicated mammogra[hy unit.Parallel plate compression evens out the thickness of breast tissue to increase image quality by reducing the thickness of tissue that X-ray penetrate.
• Breast biopsy :-During this test doctor will remove a tissue sample from the suspicious area to have it tested.The doctor uses a needle to take the tissue sample.then send to laboratory to test the sample.
• Ultrasound :- A breast ultra sound uses sound waves to create a picture of the tissue deep in the breast.A ultrasound distinguish between a solid mass or tumor.
• Breast self examination :- Breast self exam or regularly examining your breast on your own.there are following steps :-(done before warm bath)  

1. Step 1 :-Begin by looking at ypur breast in the mirror with your shoulders straight an arms on your hips.(breast that are their usual size,shape and color) (Dimpling ,bulging of skin,redness,rashes or swelling ,a nipple that has changed position or an inverted nipple)
2. Step 2 :-Now raise your arm and look for the same changes.
3. Step 3 :- While you are at the mirror look for any sign of fluid come out of one or both nipples.(this could be a watery,milky or yellow fluid or blood).
4. Step 4 :- Next fell your breast while lying down using your right hand to feel your left breast and then let hand to feel right breast.use a firm,smooth  touch with the first few fingers pads of your hand,keeping the fingers flat and together.Use a circular motion about the size of a qurter.
5. Finally feel breast while you are standing or sitting.

Management :-

Surgical management :-

• Lympectomy :-This procedure remove the tumor and surrounding tissue.
• Mastectomy :- In this procedure a surgeon remove an entire breast.
• Sentinal node biopsy :- This surgery remove a few of the lymph node.
• Contralateral prophylactic mastectomy :- Even though breast cancer may be present in only one breast this surgery remove healthy breast to reduce risk of developing breast cancer again.

Medical management :-

• Medication used after and in addition to surgery are adjuvant therapy.
• Hormone blocking therapy :- some breast cancers require estrogen to continue growing.they can be identified by the presence of estrogen receptors (ER+) and progesterone receptors (PR+) on their surface.these ER+ cancer can be treated with drugs that either block the receptors. Example :- Tamoxifen , Toremifene (Prvent estrogen from binding to estrogen receptors),Aromatase Inhibitor (stop estrogen production).
• Chemotherapy :- The chemotherapy medication are administered in combinations.Usually for periods of 3-6month. Example:- Cyclophosphamide with Doxorubin.
• Radiation therapy :-Radiation is given after surgery to the region of the tumor bed and regional lymphnode to destroy microscopic tumor cells.Radiation therapy can be delivered as external beam radiotherapy or as Brachytherapy (internal radiotherapy).

Nursing management :-

Pre-operative Nursing care :-

1. Knowledge deficit about breast cancer and treatment.
2. Anxiety related cancer diagnosis.
3. Fear related specific treatment ,body images change or possible death.
4. Decisional conflict related treatment option.
5. Risk for ineffective copping related diagnosis of breast cancer.

Post -operative nursing diagnosis :-

1. Pain related to surgical incision and manifestation of tissue.
2. Impaired skin integrity due to surgical incision.
3. Risk for infection related presence of surgical drain.
4. Body image disturbance related loss or alteration of the breast related surgical procedure.
5. risk for sexual dysfunction related loss of body part ,change in self image.
6. Self care deficit related partial immobility of upper extremity on operative side.