Analysis of Breast Cancer - Research Paper Example

Analysis of Breast Cancer Breast cancer is a malignant proliferation of the epithelial cells, which line the lobules or ducts of the breast. Breast cancer is one of the most common cancers occurring in women. The goal of nursing in patients with breast cancer is to help them maintain their strength and to help them cope with the physiological and psychological problems of cancer. The various psychological problems include anxiety, depression, emotional liability, fear of death, etc. This essay aims to explore the pathophysiology and clinical signs and symptoms of breast cancer, identifying the common risks involved with treatment for breast cancer, and the nursing assessment and interventions for breast cancer. This essay will begin by the pathological classification of breast cancer. Breast cancer may arise from the epithelium of the duct system of the nipple (90%) or within the lobular epithelium (10%). Both lobular and ductal breast cancers are further divided into non-infiltrating (not penetrated the limiting basement membranes) and infiltrating (those that have penetrated the basement membrane) (Robbins & Kumar 1987.) One scheme of classification is as follows (Robbins & Kumar 1987) I. Arising in ducts 1. Non-infiltrating a. Intraductal carcinoma (comedocarcinoma) b. Intraductal papillary carcinoma 2. Infiltrating a. Scirrhous carcinoma b. Medullary carcinoma c. Colloid (mucinous) carcinoma d. Paget’s disease of the breast e. Tubular carcinoma II. Arising in lobules 1. Non-infiltrating-insitu lobular carcinoma 2. Infiltrating-lobular carcinoma III. Inflammatory carcinoma Intraductal carcinoma represents about 5% of breast carcinomas. The neoplastic cells either assume a glandular pattern or piles up within the ducts as irregular excrescences. Continued proliferation eventually fills the ducts with compressed tumor cells. Clinically, they present as a palpable mass or as ropy cords within the breast. Eventually, the ducts are filled with cheesy necrotic tumor tissue. This cheesy necrotic tissue can be extruded with slight pressure when the ducts are transected (therefore called comedocarcinoma) About 70 % of these tumors become invasive. Intraductal papillary carcinoma occurs within ducts and is characterized by progressive epithelial atypicality, anaplasia and invasion of the stroma of the stalk or periductal tissue. Usually these lesions are large enough to be palpable and may be manifested by a serous, turbid or bloody discharge from the nipple (Robbins & Kumar 1987) Since these tumors can become invasive, appropriate therapy is warranted. Most centers practice both wide excision with or without radiation therapy, but there are very few randomized studies, which have compared various therapies, and therefore, optimal treatment is not clear. At present, it may be recommended that in those patients who desire to preserve their breast, and in whom the condition appears to be localized, the management can include adequate surgery with pathologic evaluation and breast irradiation. Since there is a 10-15 % likelihood of axillary node involvement (even when there is only microscopic invasion) at least a level 1 and 2 axillary node dissection can be done (Lippman 1998.) Scirrhous carcinoma is composed histologically of dense fibrous stroma with scattered nests or cords of tumor cells. The neoplastic cells frequently invade the perivascular and perineural spaces as well as the blood vessels (Robbins & Kumar 1987). This is the commonest type and usually affects middle-aged or elderly women, and presents as a stony hard mass of 3-4 cm in diameter (Baum 1991). As the tumor advances, it may cause indrawing of the nipple or the overlying skin, giving a peau d’orange appearance, as well as lead to ulceration of skin and fixation to the chest wall (Baum 1991). In the presence of peau d’orange, along with matted or fixed axillary lymph nodes or supraclavicular node involvement even the most radical surgery may not be enough. In such cases, a systemic therapy with either tamoxifen or cytotoxic therapy should be started first (Baum 1991). Medullary carcinoma has scanty stroma and the tumor cells grow in large, irregular sheets of cells. A moderate to marked lymphocytic infiltration is usually present between the tumor cells, representing the host response to the tumor (Robbins & Kumar 1987). Clinically, medullary carcinoma affects a younger age group and is soft and circumscribed, and may attain a large size.  The prognosis is also more favorable (Baum 1991.) Colloid (mucinous) carcinoma is mainly characterized by both intracellular and extracellular production of mucin. Central cystic softening or hemorrhage may be present. Histologically, three patterns are recognized: small islands of tumor cells, well-defined glandular arrangement of tumor cells or as a disorganized mass of undifferentiated tumor cells (mostly signet-ring type) (Robbins & Kumar 1987). Colloid carcinoma appears as well-defined masses in an elderly patient (Baum 1991.) Paget’s disease of the breast is characterized by the invasion of the epidermis by neoplastic cells called Paget cells. The condition begins as a typical intraductal carcinoma but soon involves the main excretory ducts. From here, it extends to infiltrate the skin of the nipple and areola. Because of this, eczematoid changes in the nipple and areola precedes the formation of any palpable breast mass. The involved areolar and periareolar skin may be fissured, ulcerated and oozing. There may be surrounding inflammatory hyperemia and bacterial infection (Robbins & Kumar 1987). The nipple may be eroded slowly and eventually disappears (Baum 1991). The treatment is always surgical, and the prognosis in the absence of any underlying invasive tumor is good ( Baum 1991.) Lobular carcinoma insitu is characterized by terminal ductules within an entire lobule, distended with neoplastic cells. This type of tumor has the potential of making a transition into infiltrating carcinoma. Clinically, the tumor is non-palpable (Robbins & Kumar 1987). The management of lobular carcinoma insitu is controversial. Most patients must be followed with yearly mammography and semiannual physical examinations. It is not clearly established whether they should receive tamoxifen (Lippman 1998.) Infiltrating lobular carcinoma is characterized by strands of tumor cells, loosely dispersed in a fibrous stroma. Clinically, it is poorly circumscribed with a rubbery consistency. These tumors have a high incidence of being bilateral in occurrence (Robbins & Kumar 1987). Inflammatory carcinoma is a rare, highly aggressive cancer, seen usually during pregnancy and lactation. The affected breast is painful, with red, warm overlying skin (Baum 1991). The treatment is usually with systemic chemotherapy, but the prognosis is very poor ( Baum 1991) In all types of breast cancer, subsequent progression of the disease leads to adherence to the pectoral muscles or deep fascia of the chest wall, with consequent fixation of the lesion. In addition, there is also adherence to the overlying skin, leading to retraction or dimpling of the skin or nipple. Localized lymphedema may be caused by involvement of the lymphatic pathways. In such cases, the thickened skin around exaggerated hair follicles gives the appearance of an “orange peel.” Microcalcifications occur commonly in scirrhous carcinoma (Robbins & Kumar 1987.) Breast cancer spreads through hematogenous and lymphatic routes. Lesions present centrally or in the outer quadrants spread to the axillary nodes. Those present in the inner quadrants involve the nodes along the internal mammary arteries. Although the supraclavicular nodes may be the primary site of spread, most often they become involved after the axillary and internal mammary nodes are affected. Eventually, metastases occurs to almost any organ or tissue, but commonly metastasis occurs to the lungs, skeleton, liver, and adrenals, and less often the brain, spleen and pituitary (Robbins & Kumar 1987.) In general, 90% of women with breast cancer present with a painless, solitary and unilateral lump, which may be solid or hard and non-mobile. About 10% present with a stabbing or aching pain, with nipple discharge and redness (Bhatt 2004.) For primary breast cancer, a series of randomized clinical trials have shown that removal of the primary tumor (lumpectomy with or without irradiation to the breast) gives a survival rate that is as good as after mastectomy or modified radical mastectomy. However, this is not suitable for tumors larger than 7cm, for tumors involving the nipple-areolar complex, and for tumors with extensive ductal disease involving multiple quadrants of the breast (Lippman 1998). Premenopausal women for whom any kind of adjuvant systemic therapy is indicated should receive chemotherapy. A breast tumor that has both estrogen and progesterone has a response rate of 70% to endocrine therapy (Lippman 1998.) Some of the risks or side-effects of treatment of breast cancer include: postoperative infection, lymphedema, hair loss, fatigue, and nausea and vomiting. One study found that postoperative wound infection after mastectomy is linked to factors like local drainage, blood transfusion, the time between biopsy and surgery, and the size of the primary tumor (Leinung, Schonfelder et al., 2005). Another study showed that previous anti-cancer chemotherapy was a major risk factor, followed by breast reconstruction. (Lefebvre, Penel et al., 2000) and this was also confirmed by another study (Mortenson, Schneider et al., 2004.) About 28% of those who survive breast cancer develop lymphedema. It may develop immediately in the postoperative period. Lymphedema occurs when the arterial capillary filtration exceeds the lymphatic transport capacity (Ridner 2002.) Many studies have linked the development of lymphedema to the extent of surgical dissection (Kissen 1986 & Ivens1992) and radiation to the axilla (Aitken 1989) Several studies have identified obesity or weight gain following treatment for breast cancer as risk factors for developing lymphedema (Greenfield 1994& Pezner 1986). Alopecia is a common and distressing side-effect of chemotherapy. It can range from sporadic thinning of the hair to complete baldness. Some of the factors that contribute to the severity of hair loss include: the drug used, drug dosage and schedule and hair care practices (Batchelor D. 2001). Alopecia occurs due to the lethal effect of the chemotherapy drug on the fast growing cells of the hair follicles. The affected hair when examined microscopically shows trichorrhexis, fragmentation, decrease in diameter and depigmentation of the hair shaft (Pai, Vimala & Dinesh 2000.) Fatigue is a very common side effect of chemotherapy. Fatigue occurs both during and after adjuvant chemotherapy. The prevalence of fatigue is found to the most severe in the first two days after the initiation of a chemotherapy regimen. Several studies have shown the influence of factors like pain, impaired quality of sleep, and depression on fatigue. In addition, factors such as weight changes menopausal symptoms, inadequate coping, lack of social support, and biochemical changes may potentially contribute to fatigue (De Jong, Courtens et al., 2002) Nausea and vomiting can have numerous causes, including side-effects of certain chemotherapy drugs and radiation effects. The incidence and severity are influenced by various factors, including: the type of chemotherapeutic agent used, the dosage, the schedule and route of administration, and the variability of an individual patient (Takiuchi, Kawabe et al., 2006.) In the period prior to admission to the hospital, the nursing assessment will include trying to identify the following: the patient’s and her family’s reaction to the diagnosis of breast cancer, the major fears and concerns of the patient and her family, the patient’s feelings about her body image changes following any surgery, the patient’s knowledge of breast cancer and how much information has been given by the medical staff, whether any other family member has breast cancer or any other cancer, the kind and degree of support available from family and friends, concurrent stressors like recent bereavements, divorce etc, and any previous history of anxiety/depression (Alexander, Fawcett & Runciman 2000) The nursing intervention at this time will need to focus on assessing the patient’s situation, helping her to cope with anxiety, providing education and psychological support and helping her to make informed choices about treatment options. The rationale for these interventions is based on the fact that the period prior to hospital admission is characterized by anxiety and uncertainty. These interventions will help to allay patient anxiety and create an understanding about her condition and treatment (Alexander, Fawcett & Runciman 2000.) In the phase following admission, the nursing assessment should be more comprehensive and include: medical history, family history, and complete physical and psychological assessment. In particular, an assessment of the preoperative shoulder function should be made, if axillary surgery is to be performed (Alexander, Fawcett & Runciman 2000.) The patient should be given the opportunity to discuss her fears privately. It would be a good idea to play relaxation tapes and perform gentle massage, especially on areas of the neck, shoulders and back. The nurse must make sure that the patient gets adequate information. This involves telling the patient about the type of treatment she is about to receive, and if any surgery is planned, the type and purpose of the operation (Alexander, Fawcett & Runciman 2000.) The preoperative routine including the approximate time of surgery, and type of premedication should be explained to the patient. The patient should be told that following surgery, drainage tubes would be present (one to the breast wound and one in the axilla, to prevent the collection of blood and serous fluid beneath the incision) and that a dressing would cover the wound. If an axillary dissection is also being done, then the patient should be told that some discomfort would be present on moving her arm for a few weeks after surgery (Alexander, Fawcett & Runciman 2000.) The importance of postoperative exercises should be explained, and the nurse should make arrangements for referral to a physiotherapist, who would make an assessment of the shoulder function preoperatively and teach specific shoulder exercises postoperatively. The possibility of a blood transfusion should also be explained. The nurse should explain the possible appearance, size, and position of the scar. Drawings and photographs are valuable for this purpose. It is also important to convey to the patient that some bruising and swelling of the surgical site is to be expected, since the breast is very vascular (Alexander, Fawcett & Runciman 2000). The rationale for these interventions is that it helps the patient to understand about the treatment specifics, what to anticipate after surgery, and to realize the importance of postoperative exercises. She would be better prepared to deal with the scar. The postoperative care involves observing the drains and wound dressing. Any unexpected blood loss should be reported immediately to the surgeon. Normally, the drains would remain in position for 2-5 days till drainage is minimal. During this time, the nurse should ensure that the drains remain patent and that suction is maintained (Alexander, Fawcett & Runciman 2000). The drainage volume should be noted. The rationale for these interventions are that excessive bleeding may require surgical intervention. It is very essential to observe the wound for redness, swelling, pain and discharge. Temperature and pulse is monitored 4-6 hourly, and any raise in temperature is reported. Unnecessary change of dressings is to be avoided. Ideally, a transparent wound dressing covered with gauze may be left in place till the sutures are removed (after 10-14 days) (Alexander, Fawcett & Runciman 2000). The rationale for these interventions are that raised temperature and pulse, redness, swelling, pain and discharge are all signs of an active wound infection. Infection delays wound healing and compromises the general health of the patient. An active infection may require intensive medical treatment. Frequent changes of dressing reduces wound healing and increases the chance of wound infection The other nursing care includes ensuring an adequate nutritional intake (including vitamin C and protein), reduction of stress, ensuring adequate sleep and monitoring other concurrent illness like diabetes (Alexander, Fawcett & Runciman 2000). The rationale for these interventions is that vitamin C and protein are essential for wound healing. Adequate amount of sleep and rest are important for faster healing of the wound. In the presence of diabetes, the wound healing may be impaired and chances for infection are greater. Patients’ always experience some amount of pain. Most often, the pain is present on moving the shoulders. Analgesics should be given for a period of 48 hours and thereafter, depending on the degree of pain. Many women experience the phenomenon of phantom breast and nipple sensation following surgery. A simple reassurance to the patient that this is a normal occurrence and that it will not continue for long, would suffice in most cases (Alexander, Fawcett & Runciman 2000) Problems with shoulder movement are common in those patients who have undergone axillary dissection or those who have undergone radiotherapy postoperatively. Adequate physiotherapy ensures that the full range of shoulder movement is restored within 4 weeks postoperatively. Written information about the exercise should be provided to the patient whenever possible, so that she can continue doing these exercises at home (Alexander, Fawcett & Runciman 2000) Alopecia is a very common side-effect of chemotherapy. Nurses play a vital role in helping the patient to cope with alopecia by educating the patient and by teaching self-care strategies to minimize alopecia. These interventions help the patient pass through this phase easily to a state of well-being (Batchelor D.) Most patients receiving chemotherapy or radiation therapy complain of fatigue. One study has found that a nurse-prescribed, self-paced, home-based walking and monitored exercise program helps to manage symptoms like fatigue and improve physical functioning during radiation therapy. It is also a convenient and low-cost activity (Mock, Dow et al., 1997 ). Another study has found that seated exercise may control fatigue and improve physical well-being (Headley, Ownby & John 2004) For nausea and vomiting, the following are recommended: 5-HT3 receptor antagonist prior to each day's first dose of chemotherapy, oral or intravenous dexamethasone once daily either every day for moderate or highly emetogenic chemotherapy or for 2-3 days after chemotherapy for regimens that cause delayed emesis (Takiuchi, Kawabe et al., 2006.) A critical review of literature on nursing care for breast care revealed that although traditional methods of nursing care were the mainstay for breast cancer, many nursing practioners are increasingly considering complementary therapies. One study assessed the use of complementary and alternative medicine (CAM) for breast cancer patients in Europe. About 44.7% used CAM after the diagnosis of breast cancer. The most common therapies used included herbal medicine and medicinal teas, relaxation techniques, spiritual therapies, homeopathy and vitamins/mineral supplementation. High levels of satisfaction were reported after CAM. (Molassiotis, Scott et al., 2005). Supportive-expressive group therapy is also considered to prolong survival in women with metastatic breast cancer. However, recent studies have not shown any improvement in survival after various psychosocial interventions. It probably improves mood and the perception of pain (Goodwin, Leszcz et al., 2001) In conclusion, breast cancer, which is a malignant proliferation of the epithelial cells lining the lobules or ducts of the breast, is one of the most common cancers occurring in women. Breast cancer may be invasive or non-invasive. Scirrhous carcinoma is the commonest type of breast cancer. The majority of women with breast cancer present with a painless, solitary and unilateral lump, which may be solid or hard and non-mobile. The type of treatment and prognosis of the disease varies with the staging of breast cancer. In general, the various modalities of treatment include: mastectomy, radiotherapy, chemotherapy and endocrine therapy. There are numerous risks or side effects of breast cancer treatment, some of which include: postoperative infection, lymphedema, hair loss, fatigue, and nausea and vomiting. 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