BREAST CANCER
1
What is breast cancer?
 Breast cancer begins in the breast tissue.
 Inside the breasts are glands that produce
and release milk after a woman has a baby.
 The glands that make the milk are called
lobules
 Tiny tubes that carry the milk from the
lobules to the nipple are called ducts.
 Fatty tissue, connective tissue, blood and
lymphatic vessels surrounding the ducts and
lobules, is called Stroma.
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Cont …..
 Breasts consist mainly
of
fatty
tissue
interspersed
with
connective tissue
 There are also less
visible parts
lobes
ducts
lymph nodes
3
Cont…
Lymph is a clear fluid that contains immune
system cells and tissue waste products.
The fluid is carried in lymph vessels that lead
to small, pea-sized collections of tissue called
lymph nodes.
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Cont…
Most of the lymph vessels of the breast drain into:
 Auxiliary nodes :- under the arm
 Supraclavicular and infraclavicular lymph
nodes :- around the collar bone
 Internal mammary lymph nodes :- inside the
chest near the breast bone
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6
Cont…
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Cont…
Benign Tumors
 Not cancerous.
 Benign breast tumors are abnormal growths,
but they do not spread outside of the breast and
they are not life threatening
8
Cont…
 Most lumps are caused by the combination of
cysts and fibrosis
 Cysts are fluid-filled sacs.
 Fibrosis is the formation of scar - like tissue.
 These changes can cause breast swelling and
pain.
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Cont…
Breast cancer
 A malignant (cancerous) tumor that starts in the
cells of the breast.
It is found mostly in women, but men can get
breast cancer, too.
Non - Invasive
 Pre – Cancerous
 Still in its original
position
 Eventually develops
into invasive breast
cancer
Invasive
Cancerous
 Malignant
 Spreads to other
organs (metastasis)
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12
Cont….
Types of breast cancer
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Cont….
Ductal carcinoma In situ
 Carcinoma confound in
in milk duct : Non invasive
(pre cancer)
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Invasive ductal carcinoma
 Cancer arises in the lining of the ducts 
Grows /invades the breast tissues Spreads to
lymph nodes and other organs
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Inflammatory breast cancer (IBC)
 Uncommon (1% to 3% of all breast cancers)
 Invasive Brest Cancer.
 No lump or tumor.
 Mistaken for infection in its early stages.
 IBC makes the skin of the breast look red and
feel warm.
 It also may make the skin look thick and
pitted and may have an orange peel feel.
 The breast may get bigger, hard, tender, or
itchy
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Cont….
Normal breast vs Inflammatory Breast
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Lobular carcinoma in situ (LCIS)



Non – Invasive.
Contained in the lobules and does not
spread to the tissues of the breast.
May become malignant Milk producing
lobules
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Invasive (infiltrating) lobular carcinoma
(ILC)
 Formed in the lobules.
 Grows through the wall of the lobules.
 Spreads
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Cont….
Breast Sarcoma
 Rare breast cancer
 It arises from the connective tissue or
stroma of breast
 E.g Angiosarcoma of breast.
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Causes of breast cancer
 The cause of most breast cancers is unknown.
 Most likely cause is related to changes in the
genetic material (DNA) in our cells.
 DNA changes are often related to our lifestyle,
but some can be due to age and other factors.
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Breast cancer risk factors
 Risk factors are anything that can increase or
decrease a person’s chance of getting a
disease, such as cancer.
There are many known risk factors for breast
cancer. Some of these cannot be changed, but
some can…
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Cont….
Gender
 Being a woman is the main risk factor for developing
breast cancer
 Breast cancer is 100 times more common in women
than men.
 Male br ca is rare it accounts only 1 % of all br ca.
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Cont…
Aging
 Breast cancer risk increases as a woman gets
older
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Cont….
Genetic risk factors
 About 5% to 10% of breast cancer cases are
thought to be hereditary, caused by gene
changes (mutations) inherited from a parent.
 Inherited mutations in BRCA1 or BRCA2 are
the most common cause of hereditary breast
cancer.
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Cont…
 The gene most commonly affected in heridatary
breast cancer is
 BReast CAncer 1 (BRCA1) and
 BReast CAncer 2 (BRCA2) genes.
 Normally, the BRCA1 and BRCA2 genes inhibit
a cancer cells.
 But the mutation of BRCA1 and BRCA2 genes
cause the occurrence of breast cancer.
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Cont…
 Everyone has two copies of the BRCA1 and
BRCA2 genes, one copy inherited from mother
and the other from father.
 Even if a person inherits a BRCA 1 or BRCA2
mutation from one parent, still have a normal
copy of the BRCA1 or BRCA2 gene from the
other parent.
 Cancer occurs when a second mutation happens
that affects the normal copy of the gene, so that
the person no longer has a BRCA 1 or BRCA 2
gene that works properly.
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Cont….
 Women with BRCA mutations have a high
risk of developing breast cancer during their
lifetime.
 Women born with gene mutations develop
breast cancer younger than other women not
born with one of these gene mutations.
 Mutations in other genes are less common
causes of inherited breast cancer.
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Cont….
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Cont….
Family history of breast cancer
 Women who have a close blood relative with
this disease have a higher risk for breast
cancer.
Personal history of breast cancer
 A woman with cancer in one breast has an
increased risk of developing a new cancer in
the other breast or in another part of the same
breast.
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Cont….
Certain non-cancer breast problems
Previous chest radiation
Women who had radiation to the chest for
another cancer as a child or young adult are at
a much higher risk than those who did not.
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Cont….
Post-menopausal hormone therapy (PHT)
 Increased risk in women who use or recently
used combined PHT for many years.
 Hormone replacement therapy to relive
symptoms of menopause.
DES treatment
DES (Diethylstilbestrol) treatment for pregnant
to lower the risk of miscarriage.
 However, recent studies show that women
have a 35% increased risk of getting breast
cancer.
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Cont….
Recent use of hormonal contraceptives
 Slightly higher risk than in women who never
used them, but this goes down after use stops
Race
 African American women are more likely to
die of this cancer.
Dense breast tissue
 Women with denser breast tissue (as seen on a
mammogram) have a higher risk of breast
cancer.
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Cont….
Not having children or having them later in life
(after age 30) puts a woman at slightly higher
risk
More menstrual cycles
 Slightly higher risk if a woman started
menstruation early or went through menopause
late
Not breastfeeding
 Some studies suggest that breastfeeding may
slightly lower breast cancer risk.
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Cont….
Physical activity
 More active  lowers risk
Overweight
 Obesity  raises risk of having breast cancer,
especially for women after menopause
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Cont….
Alcohol use
 Clearly linked to increased risk
 Risk goes up with the amount of alcohol you
drink
Bras
Induced Abortion
Breast implants
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Signs and symptoms
 A lump in a breast.
 A pain in the armpits or breast (not related to
menstrual period).
 Pitting or redness of the skin of the breast; like
the skin of an orange.
 A rash around (or on) one of the nipples.
 A swelling (lump) in one of the armpits.
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Cont….
 An area of thickened tissue in a breast.
 One of the nipples has a discharge; sometimes
it may contain blood
 The nipple changes in appearance; it may
become sunken or inverted.
 The size or the shape of the breast changes.
 The nipple-skin or breast-skin may have
started to peel, scale or flake.
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Signs of breast cancer
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Cont….
Diagnostic tests and procedures for breast
cancer include:
1. Breast exam
A. Breast Self Exam (BSE)
B. Clinical Breast Exam (CBE)
2. Mammograms
3. Breast ultrasound
Imaging test
4. Breast MRI scan
5. Biopsy
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1. Breast Self Exam (BSE)
 BSE is an option for women starting in their
20s.
 Any changes detected should be reported to a
medical expert.
 BSE: Conducted standing or reclining
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Inspect for:
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Raise Arms Up
Breasts should
rises evenly
Watch for dimpling
and retraction
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Use the Middle of Your Fingers
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Move your hand in small circles
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Then move to another location
• Work your way around the breast in a
clockwise fashion, using small circles
of the hand as you go.
• Make sure the entire breast is
felt.
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 The “Tail” of the Breast is
not perfectly round.
A “Tail” of breast tissue
normally extends into the
armpit.
Make sure to feel for lumps
in that portion of the breast.
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Feel the Armpit
• Use the same circular
motions.
• Feel for breast lumps and
lymph nodes.
• Normal lymph nodes
cannot be felt.
• Enlarged lymph nodes are
about the size of a pencil
eraser, but longer and
thinner
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Try to Express Nipple Discharge
• Strip the ducts towards
the nipple.
• Normally, one or two
drops of clear, milky or
green-tinged secretions.
• Should not be bloody or
in large quantity.
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Cont….
2. Clinical Breast Exam(CBE)
 Women in their 20s and 30s should have a
clinical breast exam every 3 years.
 After age 40, women should have a breast
exam every year
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Cont….
3. Mammogram
 Age 40-50: Every other
year
 Over Age 50: Annually
A
technologist
will
position your breast for
the test.
 The breast is pressed
between 2 plates to flatten
and spread the tissue.
 The pressure lasts only a
few seconds while the
picture is taken.
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Cont….
Mammogram – Difficult Case
Mammogram – Easier Case
Heterogeneously
dense
• With age, breast tissue
breast
becomes fattier and has fewer
• The fibro glandular
glands
tissue (white areas) may
• Cancer is relatively easy to
hide the tumor
detect in this type of breast
• The breasts of younger
tissue
women contain more
glands and ligaments
resulting in dense breast
tissue
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Cont….
Mammograms is used for both screening
& diagnostic purpose
60
4. Breast Ultrasound
 Uses sound waves to outline a part of the body.
 The sound wave echoes are picked up by a
computer to create a picture on a computer
screen.
 Used to investigate areas of concerns found by a
mammogram.
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5. Magnetic Resonance Imaging (MRI)
 Use magnets and radio waves.
 Cross-sectional images of the body.
 MRI scans can take a long time.
 Used if view areas of concern found on a
mammogram.
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 Patients must lie inside a narrow tube, face
down on a special platform.
 The platform has openings for each breast that
allow the image to be taken without pressing
on the breast.
 Contrast material may be injected into a vein
to help the MRI show more details.
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Cont….
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6. Biopsy
 A biopsy is done when other tests show that
you might have breast cancer.
 It confirms if a mass is cancerous or not.
 Mass is removed and studied.
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Type of Breast Biopsy
 Fine needle aspiration (FNA) biopsy
 Core needle biopsy
 Vacuum-assisted biopsies
 Surgical (open) biopsy
 Lymph node biopsy
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Cont …..
Fine Needle Aspiration
(FNA) Biopsy
Very fine needle is used.
Extracts fluid from the
lump.
Guided by ultrasound.
simple but is not 100%
accurate.
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Cont …..
Core Needle Biopsy
 Needle is larger than in
fine needle biopsy.
 Removes more tissues.
 Clearer results
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Cont …..
Vacuum Assisted Biopsy
 Automated Tissue
Excision and Collection
 Guided by MRI
 First the skin is numbed
and a small cut (incision)
is made.
 A hollow probe is put
through the cut into the
breast tissue.
 A piece of tissue is sucked
out.
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Cont …..
Surgical (Open) Biopsy
 Anesthesia is
administered.
 Incision is made.
 Part or whole lump is
extracted and studies
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Cont …..
Lympy Node Biopsy
 Remove flood from LN Needle biopsy
 Remove LN  Surgical biopsy
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Cont …..
Tissues obtained during biopsy are examined
to determine:
 Malignant or Benign
 Type
 Invasive or Non - invasive
 Size
 Has it metastasized
 Is the lymph nodes affected
 Treatment
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Factors considered during an
examination
I. Breast cancer grade
II. Hormone receptor status
III. HER2/neu status
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Cont …..
I. Breast cancer grade
 If a biopsy sample is cancer, it is given a
grade from 1 to 3.
 A lower grade number means a slowergrowing cancer, while a higher number means
a faster growing cancer.
 The grade helps predict the outcome.
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Cont …..
II. Hormone receptor status:
 Hormone receptors are proteins in cells that
can attach to hormones.
 Estrogen and progesterone are hormones that
increase breast cancer growth.
 Hormone status of breast cancer includes:1. Estrogen receptor (ER) Positive
2. Progesterone receptor (PR) positive
3. Hormone receptor (HR) negative
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Cont …..
1. Estrogen receptor (ER) Positive
 The cells of breast cancer have receptors that
allow to use the estrogen hormone to grow.
 Treatment with anti estrogen hormone
(endocrine) therapy can block the growth of
the cancer cells
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Cont …..
2. Progesterone receptor (PR) positive
The type of breast cancer sensitive to
progesterone, and the cells have receptors that
allow to use the hormone to grow.
Treatment with endocrine therapy blocks the
growth of the cancer cell
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Cont …..
3. Hormone receptor (HR) negative
 The type of cancer doesn’t have hormone
receptors, so it won’t be affected by endocrine
treatments aimed at blocking hormones in the
body.
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Cont …..
III.
Human Epidermal growth factor
Receptor/ HER2
 HER2 gene makes HER2 proteins.
 Normally, HER2 receptors help to control a
health breast cell grows, divides, and repairs.
 However, in10-20% of breast, the HER2 genes
doesn’t work correctly and too many copies of
itself known as HER2 gene amplification.
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Cont …..
 All this extra HER2 gene tell breast cells to
make too many HER2 receptors and divided in
an uncontrolled way. This makes breast cell
grow
Breast cancer with HER2 gene amplification is
called HER2 postive
 HER2-positive breast cancer grow faster and
more likely to spred than HER2 negative breast
cancer
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Tests to find metastasis breast cancer
 Chest x-ray: the lungs.
 Bone scan: the bones.
 CT scan (computed tomography): the chest
and/or abdomen.
 MRI : brain and spinal cord.
 Ultrasound: other parts
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Staging of Breast Cancer
 Sage 0 : Non – Invasive breast cancer. Has not
spread to breast tissues.
 Stage I : ≤ 2cm and has not spread to lymph
nodes.
 Stage II
 Stage IIA: ≤ 2 cm and has spread to lymph
nodes or 2-5 cm and has not spread to lymph
nodes.
 Stage IIB: 2-5 cm and has spread to lymph
nodes or > 5 cm and has not spread to lymph
nodes.
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Stage III
 Stage IIIA: ≤ 5cm and spread to lymph
nodes forming clumps or >5 cm and spread
to lymph nodes without forming clumps.
 Stage IIIB: Any size and spread to the skin
or chest wall. Swelling.
 Stage IIIC: Any size , spread to lymph
nodes, skin and chest wall.
Stage IV: Metastasized
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Cont….
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Treatment
1.
2.
3.
4.
5.
Surgery
Radiation therapy
Chemotherapy
Hormone therapy
Biological therapy (targeted drug therapy)
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1. Surgery
I. Surgery for breast cancer:
A. Lumpectomy
B. Mastectomy
II. Lymph node surgery:
A. Sentinel node biopsy
B. Axillary lymph node dissection
III.Breast reconstruction surgery
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Cont …..
I. Surgery for breast cancer
A. Lumpectomy
 Breast-conserving
surgery
(BCS)
or
partial/segmented mastectomy.
 Surgically removing the tumor and a small
margin of healthy tissue around it.
 Followed by radiation therapy
88
Cont …..
B. Mastectomy
 Surgically removing the breast and other infected
components.
A simple mastectomy:- removing the lobules,
ducts, fatty tissue, nipple, areola, and some
skin.
 Modified radical mastectomy :- simple
mastectomy combined with the removal of the
axillary lymph nodes.
 Radical mastectomy:- a simple mastectomy
combined with removing the lymph nodes and
muscles of the chest wall.
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Cont…
Side effects surgery of breast
(Lumpectomy/mastectomy )
 Pain after the surgery and
 Change in the shape of the breast.
 Wound infection, build-up of blood or clear
fluid.
 If axillary lymph nodes are removed
swelling of the arm and chest may occur
(Lymphedema).
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Cont …..
II. Lympy node surgery
A. Axillary lymph node dissection:
 About 10 to 40 lymph nodes are removed.
 Usually done at the same time as the
mastectomy or breast-conserving surgery.
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Cont …..
B. Sentinel lymph node biopsy:
 is used to determine if cancer has spread to
the lymph nodes under the arm without
removing many of them.
 A blue dye/radioactive substance is injected
in order to identify the sentinel lymph nodes
which drains lymph from the tumor.
 They are then removed.
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Cont…
Side effects of lympy node surgery
 Pain
 Swelling
 Bleeding, and infection
 Swelling in the arm or chest
(Lymphedema).
 Lymphedema is mostly due to axillary
lymph node biopsy.
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Cont …..
III.Reconstructive / breast implant surgery
Surgical procedures aimed at recreating a
breast so that it looks as much as possible like
the other breast.
 The surgeon may use a breast implant, or
tissue from another part of the patient's body.
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Cont …..
Adjuvant and Neoadjuvant
Adjuvant therapy:
 After surgery
 Combat metastasis.
 Chemotherapy and hormone therapy.
Neo-adjuvant therapy:
 Before surgery
 Reduce tumors
 Radiation therapy
95
2. Radiation therapy
 Radiation therapy is treatment with high
energy rays (such as x-rays) or particles to kill
cancer cells.
 The patient may require three to five sessions
per week for three to six weeks.
 The type of breast cancer will determine the
type of radiation therapy used.
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Cont …..
Type of radiation therapy for breast Ca
 Breast radiation therapy – applied after a
lumpectomy,.
 Chest wall radiation therapy – applied after a
mastectomy
 Breast boost - a high-dose of radiation therapy
is applied to where the tumor was surgically
removed.
Lymph nodes radiation therapy - aimed at the
axilla and surrounding area to destroy cancer
cells that have reached the lymph nodes
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Cont …..
Type of radiation
 Brachytherapy
 Radiation to the breast by place radioactive
seeds (pellets) into the breast tissue.
 The most common type brachytherapy used to
treat breast cancer is called intracavitary
brachytherapy.
 A device is put into the space left from breast
conserving surgery, a source of radiation is then
placed in the device for a short time and then
removed.
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Cont …..
Side effect of radiation therapy
 Swelling and heaviness in the breast.
 Sunburn-like changes in the skin and feeling
very tired.
 Weakness .
 Damage some of the nerves to the arm. This
can lead to numbness, pain, and weakness in
the shoulder, arm and hand.
 Radiation
to
lymph
nodes
causes
(Lymphedema).
99
3. Chemotherapy
 Chemotherapy (chemo) is the use of cancerkilling drugs.
 Intravenously, given as a shot, or taken as a
pill or liquid.
 They enter the bloodstream and reach most
parts of the body.
 Combats metastasis.
 Damage some normal cells.
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Cont …..
Short – term side effects
 Hair loss
 Loss of appetite or increased appetite
 Nausea and vomiting
 A higher risk of infection (low WBC count)
 Stopping of menstrual periods
 Easy bruising or bleeding (low platelets)
 Being very tired
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Cont …..
Long - term side effects
 Menstrual changes: infertility
 Nerve damage:
 Pain
 burning or tingling and
 sensitivity to cold or hot.
 Heart damage
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4. Hormone therapy
 Used for breast cancers that are sensitive to
hormones.
 These types of cancer are often referred to as
ER positive and PR positive cancers.
 Estrogen and progesterone promotes cancer
growth.
 Drugs used to block estrogen
 Tamoxifen
 Toremifene (Fareston®)
 Fulvestran
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Cont …..
Tamoxifen has substantial clinical efficacy, less
cost, and several decades of use throughout
world
Still the standard for premenopausal
Reasonable for many postmenopausal
Longer duration (> 5 years) may benefit
many patients
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Cont …..
Drugs used to change hormone levels:
 Aromatase inhibitors (AIs): stop fat tissue
from making estrogen after menopause
 Luteinizing
hormone-releasing
hormone
(LHRH) analogs: shuts down the ovaries
105
5. Biological/ Targeted Therapy
 Drugs that target HER2
 Endocrine therapy is the preferred choice for
ER+ metastatic breast cancer
 Less side effects than chemotherapy
 HER2: protein that increase cancer growth.
 Trastuzumab (Herceptin): IV
 Pertuzumab (Perjeta®): IV
 Ado-trastuzumab emtansine (Kadcyla™)
 Lapatinib (Tykerb): pill
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Cont …..
Side effects
 Mouth sores
 Diarrhea
 Nausea
 Fatigue
 Feeling weak or tired
 Low blood counts
 Shortness of breath
 Cough
107
Breast cancer treatment groups
Group 1 (luminal A): This group includes tumors that are ER
positive and PR positive, but negative for
HER2.
 A breast cancer are likely to benefit from
hormone therapy and may benefit from
chemotherapy.
108
Cont…
Group 2 (luminal B): This type includes tumors that are ER
positive, PR negative, and HER2 positive.
 A breast cancer are likely to benefit from
chemotherapy, and may benefit from
hormone therapy and targeted to HER2 .
109
Cont….
Group 3 (HER2 Positive): This type includes tumors that are ER
negative and PR negative, but HER2
positive.
 HER2 breast cancer are likely to benefit
from chemotherapy and treatment targeted
to HER2
110
Cont….
Group 4 (Basal like): This type which also called triple negative
breast cancer, includes tumors that are ER
negative, PR negative, and HER2 negative.
 Basal-like breast cancer are likely to
benefit from chemotherapy.
111
Nursing Interventions
 Care
Patient education
Research
Collaboration(team work)
Advocating
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