Breast Disorders
Breast pain is usu. benign but women have a 1 in 8 chance of developing breast cancer
Assessment
 Yearly mammograms starting at age 40
 Breast self exam (BSE) should start at age 20 (even if it doesn’t prevent breast
cancer it is still helpful to know how your breasts normally look and feel)
o Lie down with arm up and behind your head (lying down spreads out the
breast tissue)
o Use finger pads of the three middle fingers with overlapping circular motions
and different levels of pressure
o Use a pattern (up and down vertical pattern is recommended)
o Stand in front of mirror with hands on your hips (to tighten the pectoral
muscles), look for redness, scaliness, dimpling of breast skin or nipple
o Don’t forget to examine the underarms for lumps, knots, thickening of tissue
o Do monthly right after menstruation when breasts are less lumpy and tender
(if no periods, pick a monthly date)
Diagnostic Studies
Mammograms – xrays to visualize the internal structure of the breast, can find things that
can’t be felt, digital mammograms give clearer images, less sensitive in younger women b/c
of greater density of breast tissue
MRI – sensitive screening tool
Biopsy – provides a definitive diagnosis
Fine needle aspiration (FNA) – insert a needle into the lesion and aspirate fluid,
repeated several times, results available within 24-48 hrs, will do an additional
biopsy if negative
Stereotactic or ultrasound core biopsy – positioned laying face down on a table with
an opening for the breast, use mammogram to locate the lesion, local anesthesia is
done, small skin incision is made to use a biopsy gun device, the gun is fired and a
core sample is removed, repeated several times; ultrasound is done with the patient
on her back
Open surgical biopsy – given general anesthesia, biopsy done by incision
Benign Breast Disorders
Mastalgia – breast pain, most common breast complaint in women, usu. coincides with the
menstrual cycle, decreases with menopause; noncyclic mastalgia may be due to trauma,
arthritic pain, fat necrosis
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Tx – do mammography to exclude cancer and identify cause, decrease caffeine and
dietary fat, take vitamins, continual wearing of a support bra, compresses, ice,
analgesics, antiinflammatories, BCPs
Mastitis – inflammation that occurs most frequently in lactating women; s/s – redness,
pain, tenderness, fever
Tx – antibiotics, continue breastfeeding; if it doesn’t improve need to evaluate more
closely for inflammatory breast cancer; can also develop an abscess that requires
drainage
Fibrocystic changes – lumps that are round, well-delineated, freely movable, pain, can have
nipple discharge (milky, yellow, green), lumps get bigger before menstruation; not
associated with increased breast cancer risk; pain/nodularity increase over time but
subside after menopause if estrogen replacement is not used; symptoms worsen in
premenstrual phase and subside after menstruation
Care – may need aspiration or biopsy if a mass is noted, can wait 7-10 days to see if
the mass is related to the menstrual cycle, teach BSE to self-monitor changes,
reasurre her that cysts can not turn into cancer
Fibroadenoma – common cause of benign breast lumps in younger women, usu. small,
painless, round, well-delineated, very mobile, size is not affected by menstruation
Care – need a biopsy, can have a cryoablation to remove if desired
Nipple discharge – milky discharge (inappropriate lactation) can be due to drug therapy,
endocrine problems, neuro disorders or idiopathic; can also have serous, bloody, brown, or
green discharge that can be due to diseases such as malignancy, cystic disease, papilloma
and ductual ectasia; tx depends on the cause
Intraductal papilloma – benign, soft, wart-like growth in the mammary ducts, usu.
unilateral, bloody nipple discharge, usu. beneath the areola and difficult to palpate; tx –
need to remove surgically, can be associated with an increased risk of cancer
Ductal ectasia – duct dilation, usu. involves several ducts; multicolored sticky nipple
discharge, initially painless but may progress to burning and itching around the nipple,
nipple can retract and discharge may become bloody, not associated with malignancy; tx –
warm compresses, abx, close follow-up, surgical excision of ducts
Gynecomastia – enlargement of one or both breasts in men, usu. temporary and benign; can
occur as a side effect of drugs (ie. Zantac, digitalis, estrogens, androgens, isoniazid,
aldactone) or diseases (ie. Testicular tumors, cancer of the adrenal cortex, pituitary
adenoma, hyperthyroidism, liver disease), use of heroin or marijuana; important to
distinguish between breast cancer
Age-related changes – pendulous breasts in postmenopausal women (need to have a good
support bra), decreased breast tissue in older women makes a breast mass easier to
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palpate (but don’t confuse with the rib margin); need to continue with annual
mammograms and monthly BSE since breast cancer risk increases with age
Breast Cancer
Localized breast cancer without node involvement have a survival rate of 98%
Risk factors – genetics, weight gain in adulthood, sedentary lifestyle, dietary fat intake,
obesity, alcohol intake, increasing age (> 60), first-degree relative with breast cancer, use of
combined HRT (not estrogen therapy alone), long menstrual history (ie. Early menarche
and late menopause), no pregnancies or first pregnancy after age 30
Routine screening for genetic markers without evidence of a strong family history of breast
cancer is not warranted
If many risk factors, may choose to have prophylatic bilateral mastectomy
Types of breast cancer
Noninvasive breast cancer – 20% of cancers, ductal carcinoma in situ (DCIS), tends
to be unilateral, likely to progress to invasive breast cancer if left untreated
Infiltrating ductal cancer – majority of breast cancers, includes Paget’s and
inflammatory breast cancer
Paget’s disease – rare, not the same as Paget’s disease of bone, symptoms all
involve the nipple and can be misdiagnosed as infection or dermatitis
Inflammatory breast cancer – rare, most malignant form, breast skin is red,
warm, and has thickened orange peel appearance (pea d’orange), often
mistaken for infection; tx – chemo first, then radiation, may need surgery and
other therapies
S/S – painless , hard, irregularly shaped, nonmobile lump; usu. found in upper, outer
quadrant of the breast; small percentage have nipple discharge usu. unilateral, can have
induration or dimpling of the skin
Complications – recurrence or metastases
Diagnostic studies that predict the risk of local/systemic recurrence
Axillary lymph node involvement – most impt prognostic factor, the more nodes
involved the greater the risk of recurrence (>4 is bad)
Lymphatic mapping and sentinel lymph node dissection – sentinel node is the node
that drains first from the tumor site; blue dye is injected into the tumor site and the
sentinel node is located and dissected, if the node is positive then a complete
axillary dissection is done
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Tumor size – larger the tumor the poorer the prognosis; the more welldifferentiated the tumor the less aggressive it is
Estrogen and progesterone receptor status – receptor-positive tumors have lower
chance of recurrence and are responsive to hormone therapy
Cell-proliferative indices – the more cells in synthesis (S) phase the higher the risk
HER-2 – if high have a more aggressive form
If triple-negative (estrogen, progesterone, HER-2) have a more aggressive tumor
with poorer prognosis
Treatment
Staging is important – tumor size, nodal involvement, presence of metastasis, number of
lymph nodes involved
After surgery, must be followed up regularly for rest of her life (every 6 months for 2 years,
then annually), still need to do monthly BSE
Most common site of recurrence is at the surgical site
Axillary lymph node dissection (ALND) – done on same side as the cancer, start with
sentinel lymph node dissection (SLND) b/c it’s less invasive; ALND involves removing 1220 nodes
Cx – lymphedema – heaviness, pain, impaired motor function, numbness, can get
cellulitis; not always preventable
Cx – postmastectomy pain syndrome – chest/upper arm pain, numbness,
shooting/pricking pain, unbearable itching; tx – NSAIDs, antidepressants, EMLA,
Neurontin, biofeedback
Breast-conserving surgery (lumpectomy) – remove entire tumor and a margin of normal
surrounding tissue, follow with radiation therapy, may also get chemo
Modified radical mastectomy – removal of the breast and axillary lymph nodes while
preserving the pectoralis major muscle with an option of breast reconstruction can be
immediate or delayed
Cx – postmastectomy pain syndrome – chest/upper arm pain, numbness,
shooting/pricking pain, unbearable itching; tx – NSAIDs, antidepressants, EMLA,
Neurontin, biofeedback
Radiation therapy – if primary tx is done after removal of breast mass, done externally 5
days/week over 5-6 weeks
Side effects – fatigue, skin changes, breast edema (usu. temporary)
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High-dose brachytherapy – internal irradiation, using balloon catheter can take only 5 days,
done outpatient twice a day for 5 days, no radiation remains in the body between tx or
after tx
Chemotherapy – can be given preop to reduce the size of the tumor, almost always use a
combination of drugs to work at different parts of the cell cycle
Side effects – n/v, anorexia, weight loss or weight gain, hair loss, bone marrow
suppression, fatigue
Hormonal therapy – estrogen deprivation by blocking ovarian function through surgery,
radiation, or drugs; Tamoxifen (antiestrogen drug) is also used for prevention in high-risk
ladies, generally treated for 5 years
Side effects – hot flashes, mood swings, vaginal dryness, increases risk of blood clots,
cataracts, vision problems, stroke, endometrial cancer in postmenopausal women
Biologic/targeted therapy – Herceptin is used for tumors that overexpress HER-2
Side effects – heart failure, ventricular dysfunction
Nursing care
Acute
Coping - help with coping, explore advantages/disadvantages of treatment options,
support for pt and family
Pain – most affected by extent of lymph node dissection done, give analgesics 30
min before exercising, shower with warm water can help with joint stiffness
Drains – discharged to home with them in place
Restoring arm function on affected side – semi-Fowler’s position with arm elevated,
flex and extend fingers ASAP, slowly implement arm/shoulder exercises (pg 1323) –
want to return to full function by 4-6 weeks
Prevent lymphedema (risk for life) – do not let arm be dependent even when
sleeping, no BP/venipuncture/injections on affected arm, no elastic bandages in
immediate postop period, protect the affected arm from even minor trauma (ie.
Pinprick, sunburn), if trauma occurs wash carefully and apply abx ointment, sterile
dressing and call surgeon
If lymphedema is acute – massage-like decongestant therapy followed by
compression bandaging and intermittent pneumatic compression sleeve,
elevation of the arm to level of the heart, diuretics, isometric exercises, fitted
elastic pressure gradient sleeve
Psych care – refer to peer support groups
Home Care
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Call for fever, inflammation at surgical site, redness, back pain, weakness,
shortness of breath
4-8 weeks postop can be fitted for prosthesis and bra
Address concerns about sexuality
Mammoplasty
Surgical change in the size or shape of the breast, can be elective for cosmetic reasons or to
reconstruct the breast after mastectomy
Breast reconstruction – can be done simultaneously with mastectomy or done later, will
not be able to restore erotic functions of the breast
Breast implants and tissue expansion – most common technique, implants are
placed under the pectoralis muscle, can use a tissue expander to stretch the skin and
muscle before putting in the implant, expander is gradually filled each week, once
skin is stretched enough the expander is removed and the implant is placed
although sometimes the expander is left in as the implant
Cx – body forms a fibrous capsule around the implant (gentle massage can
prevent this)
Musculocutaneous flap procedure – can use muscle tissue to create a breast mound,
usu. taken from the back (latissimus dorsi) or abdomen (transverse rectus
abdominus – TRAM), TRAM is most frequently used, tunnels the muscle up to
become the breast, also get an abdominoplasty with this surgery; recovery is 6-8
weeks
Nipple-areolar reconstruction – makes the breast look more natural, usu. done a few
months after breast reconstruction, can be grafted or tattooed
Breast augmentation – implant is placed ideally under the pectoral muscle, usu. a silicone
envelope filled with saline or silicone
Breast reduction – resect wedges of tissue from the upper and lower breast quadrants,
remove excess skin and relocate the areola and nipple
Augmentation and reduction are outpatient procedures with general anesthesia,
may have drains for 2-3 days, breast appearance changes as healing progresses,
need to wear a support bra continuously, can usu. get back to activities within 2-3
weeks
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