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BOOK

DISCUSSION
A. Definition
Cancer is characterized by abnormal, unrelated cell proliferation. Cancerous tumors
invade healthy tissues and compete with normal cells for oxygen, nutrients and space. A
diagnosis for cancer is frightening to most people, although reactions depend on the particular
diagnosis, location, stage, treatment effects on bodily functions and prognosis.
Breast cancer is also a type of cancer that has no single known etiologic agent. Breast
cancer can be attributed to multiple factors. Being an older woman is the primary risk factor,
although some women are at higher risk than others. As age increases, so does risk. More than
85% of cases are diagnosed in clients older than 45 years of age. At 25 years of age, the overall
risk for breast cancer is about 1 in 20,000. By 75 years of age, the risk increases to 1 in 11.
Women with a family history of breast cancer, particularly a history of a first-degree
relative (mother, sister, or daughter) with premenopausal breast cancer, have a threefold risk
increase. This risk is further increased if the relative either had breast cancer in both breast or
was diagnosed before 40 years of age (American Cancer Society, 2005). Family history includes
multiple relatives with breast cancer, early age at diagnosis, and some families, ovarian cancer.

B. Anatomy and Physiology of organs/system involved

C. Signs and Symptoms


The primary sign of breast cancer is a painless mass in the breast, most often in the
upper outer quadrant. The tumor may have been developing in situ, without invading the
surrounding tissue, for as long as 2 years before becoming palpable. Other signs of breast
cancer include a bloody discharge from the nipple, a dimpling of the skin over the lesion,
retraction of the nipple, peau d’orange (orange peel) appearance of the skin, and a difference
size between the breasts. The lesion may be fixed or movable, and axillary lymph nodes may be
enlarged. Many of these signs depend on several factors, such as type, location, and duration of
the tumor.
P A T O P H Y S I O L O G Y

D. Management
I. Medical
For clients with late-stage breast cancer, nonsurgical treatment may be the only
alternative. If the disease is in the late stage, such as stage IV, with the presence of confirmed
metastasis, or if the client cannot withstand a major surgical procedure, the tumor may be
removed with a local anesthetic. Follow-up treatment may include hormonal therapy,
chemotherapy, and sometimes radiation. If the tumor is attached to the skin or the underlying
muscle, resection may be impossible. Follow-up therapy involves radiation, usually in
conjunction with chemotherapy.
II. Surgical
Although controversy exists concerning the best treatment for breast cancer,
experts agree that mass itself should be removed to reduce the risk for local recurrence.
Removal of the axillary lymph nodes for staging purposes may also be recommended. Axillary
lymph node dissection (ALND) is usually performed for clients with palpable axillary lymph
nodes. It is unclear whether clients with nonpalpable nodes should also have ANLD because
these nodes could have micrometastasis, which, if not removed or treated, could result in
recurrence. However, the long-term effects of ALND are significant. Thus, women who have
stage I breast cancer have not always had an ALND.
The technique of sentinel lymph node biopsy (SLNB) is a promising method of
identifying clients with axillary involvement who do not have palpable nodes but who may have
microscopic disease in one or more nodes (Zack, 2001). In this method, the one or two sentinel
lymph nodes, which receive all of the lymphatic drainage from an anatomic region are
identified through a lymph node mapping procedure. Mapping involves injecting the area
immediately around a tumor with a blue dye and/or radioactive colloid 1 to 8 hours before the
lymph node biopsy. The main lymph channels for the tumor area carry the marker dye or
radioactive to the first nodes. The nodes that take up the dye (or give off a certain level of
radiation picked up by a handheld counter) are removed and examined for the presence of
cancer cells.
III. Nursing
Patients receiving radiation therapy and their families often have questions and
concerns about its safety. To answer questions and allay fears about the effects of radiation on
the tumor and on the patient’s normal tissues and organs, the nurses can explain the procedure
for delivering radiation and describe the equipment, the duration of the procedure (often
minutes only), the possible need for immobilizing the patient during the procedure, and the
absence of new sensations, including pain, during the procedure. If a radioactive implant is
used, the nurse informs the patient and family about the restrictions placed on visitors and
health care personnel and other radiation precautions. The patient also should understand
his/her role before, during and after the procedure.
Patient who undergo SLNB in conjunction with breast conservation are generally
discharged the same day. A negative sentinel lymph node on frozen section analysis may show
a metastatic disease on subsequent analysis, indicating that ALND is still necessary. Patient
should be reassured that radioisotope and blue dye are generally safe. The patient may notice a
blue-green discoloration in the urine or stool for the first 24 hours as the blue dye is excreted. A
recent study demonstrated that women who have SLNB alone have neuropathic sensations
similar to those who undergo ANLD, although the prevalence and severity of these sensations
and the resulting distress are lower with SLNB.
The nurse must not overlook the psychosocial needs of the patients who has
undergone SLNB. Although SLNB is a less invasive procedure than ALND and results are shorter
recovery period, a patient who has undergone SLNB also has many difficult issues surrounding
her breast cancer diagnosis and treatment. The nurse must listen, provide emotional support,
and refer the patient to appropriate specialists when indicated.

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