Noninvasive Breast Cancers

Ductal carcinoma in situ (DCIS) is an early noninvasive form of breast cancer. In DCIS, cancer cells are located within the duct and have not invaded the surrounding fatty breast tissue. Because of mammography screening and earlier detection, the number of women diagnosed with DCIS has increased. If left untreated, it may spread into the breast tissue surrounding the ducts over a period of years (invasive breast cancer). Currently there is no way to determine which DCIS lesions will progress to invasive cancer and which ones will remain unchanged, but research is continuing in this area (Muggerud et al., 2010). It is important to remember that although DCIS should be treated to prevent it from developing into an invasive breast cancer, it does not metastasize at this stage.

Another type of noninvasive cancer is lobular carcinoma in situ (LCIS). This cancer type is rare and usually identified incidentally during biopsy for another problem. Having LCIS increases one’s risk for developing a separate breast cancer later. Traditionally, LCIS has been treated with close observation only. However, emerging evidence suggests that many LCIS lesions will progress to invasive cancer and should be treated with surgical excision (Cangiarella et al., 2008).

Invasive Breast Cancers

The most common type of invasive breast cancer is infiltrating ductal carcinoma. As the name implies, the disease originates in the mammary ducts and grows in the epithelial cells lining these ducts. Once invasive, the cancer grows into the tissue around it in an irregular pattern. If a lump is present, it is felt as an irregular, poorly defined mass. As the tumor continues to grow, fibrosis (replacement of normal cells with connective tissue and collagen) develops around the cancer. This fibrosis may cause shortening of Cooper’s ligaments and the resulting typical skin dimpling that is seen with more advanced disease (Fig. 73-2). Another sign, sometimes indicating late-stage breast cancer, is an edematous thickening and pitting of breast skin called peau d’orange (orange peel skin) (Fig. 73-3).

FIG. 73-2 Skin dimpling on a breast as a result of fibrosis or breast cancer.

FIG. 73-3 Breast edema giving the skin an “orange peel” (peau d’orange) appearance.

A rare but highly aggressive form of invasive breast cancer is inflammatory breast cancer (IBC). Symptoms include swelling, skin redness, and pain in the breasts. IBC seldom presents as a palpable lump and may not show up on a mammogram. Because it is usually diagnosed at a later stage than other types of breast cancer, it is often harder to treat successfully (ACS, 2010b).

Breast Cancer in Men

Male breast cancer is rare, occurring in fewer than 1% of all cases. The average age of onset is 60 years. Most cases occur in those with a genetic mutation in either the BRCA1 or the BRCA2 gene. (See discussion of genetic risk below.)

Men usually present with a hard, painless, subareolar mass; gynecomastia may be present. Occasionally the man may have nipple discharge, retraction, erosion, or ulceration. Because men usually do not suspect breast cancer when they feel a lump, diagnosis frequently is delayed (Mattarella, 2010). The disease is often advanced when diagnosed; thus men have poorer survival than women (ACS, 2010a). Treatment of breast cancer in men is the same as in women at a similar stage of disease.

Breast Cancer in Young Women

Approximately 5% of breast cancer cases occur in women younger than 40 years (ACS, 2010a). Genetic predisposition is a stronger risk factor for younger women than older women (Pollán, 2010). Younger women frequently present with more aggressive forms of the disease. Screening tools are often less effective for this group because the breasts are denser. Women of childbearing age with breast cancer may be concerned about infertility after treatment. Distress about interrupted childbearing can have a major impact on their quality of life (Camp-Sorrell, 2009). Nurses should discuss issues of fertility with patients before chemotherapy. Younger women who experience abrupt menopause as a result of chemotherapy or ovarian suppression also report a greater effect on their sexuality than do older counterparts (McLachlan, 2009).

Etiology and Genetic Risk

There is no single known cause for breast cancer. Being an older woman or man is the primary risk factor, although some people are at higher risk than others. Several breast cancer risk factors have been identified; some are modifiable, whereas others are not (ACS, 2010a). Table 73-2 lists major risk factors for breast cancer development.

TABLE 73-2 RISK FACTORS FOR BREAST CANCER

Although most breast cancers occur in women with no family history of the disease, having a first-degree relative (mother, sister, or daughter) with breast cancer increases the risk for the disease. Having more than one first-degree relative or a relative diagnosed at a younger age further increases one’s risk (ACS, 2010a). Certain genetic factors can increase a woman’s risk for both ovarian and breast cancer. Encourage women with a family history of breast or ovarian cancer to discuss this history with their physician.

Breast cancer is usually a sporadic (not having a definite genetic pattern) rather than an inherited or a familial disorder. Many personal and environmental interactions are related to its development. Known factors that increase risk include exposure to high-dose ionizing radiation to the thorax (especially before 20 years of age), early menarche (before 12 years of age), and late menopause (after 50 years of age). A history of previous breast cancer, nulliparity (no pregnancies), and first birth after 30 years of age also appear to increase risk.

Other causative risk factors not as well explained are nutrition and hormone replacement therapy (HRT). Alcohol is clearly linked to an increased risk for invasive breast cancer. Having an average of one or more alcoholic drinks a day increases the risk up to one and a half times (ACS, 2010a). Obesity also increases breast cancer risk, especially for women after menopause. Fat tissue becomes the major source of estrogen after the ovaries stop functioning. Having a greater amount of fat tissue increases hormonal influence on breast cancer development (ACS, 2010b). An increase in the risk for breast cancer has been shown in postmenopausal women receiving HRT after 5 or more years of use, with the combination of estrogen and progestin carrying the highest increased risk. However, the use HRT is not considered a major risk factor for breast cancer compared with other breast cancer risks (Bluming & Tavris, 2009). Encourage women seeking help for menopausal symptoms to discuss the benefits and risks of hormonal therapy with their health care provider.

Incidence/Prevalence

In 2010, the projected breast cancer incidence was more than 207,000 women in the United States. Of these, almost 40,000 women are likely to die of the disease (Jemal et al., 2010).

Mammography

The use of mammography (x-ray of the breasts) screening for healthy, average-risk women has been a subject of recent controversy among various scientific and advocacy groups. In 2009, the U.S. Preventive Services Task Force (USPSTF) recommended against routine screening mammography in average-risk women ages 40 to 49 years and older than 75 years, concluding there is only a small net benefit for women in these age-groups (USPSTF, 2009). Scientific evidence shows there are benefits as well as risks associated with mammography, and disagreement exists about the emphasis that should be placed on each one. However, the ACS and The American College of Obstetricians and Gynecologists (ACOG) continue to recommend that all women age 40 and older have a screening mammogram annually (ACOG, 2011). Nurses working with women must be able to educate women on the risks and benefits of breast screening techniques so that they can make informed decisions about the screening methods best suited to their individual situations (Association of Women’s Health, Obstetric, and Neonatal Nursing [AWHONN], 2010).

Women with known genetic mutations or other high risk factors for breast cancer should have screening with magnetic resonance imaging (MRI) in addition to annual mammography (ACS, 2010b). Encourage women with moderate risk factors to discuss with their health care provider the benefits and limitations of adding MRI screening to their annual mammograms. MRI screening is not recommended for women with low breast cancer risk factors.

Breast Self-Awareness/Self-Examination

Nurses working with women should teach them the importance of becoming familiar with the appearance and feel of their breasts. Any changes detected by the woman should be reported to her health care provider. Teach a woman that lumps are not necessarily abnormal. For premenopausal women, lumps can come and go with the menstrual cycle. Most lumps that are detected and tested are not cancerous.

Some women may want to practice regular breast self-examination (BSE) as a method for breast self-awareness. Evidence shows that monthly BSE is no more beneficial than women simply being aware of what is normal for their own breasts and women are just as likely to find a lump by chance (ACS, 2010b). However, BSE should be presented as an option to women beginning in their early 20s. In addition to breast self-awareness, emphasis should be placed on mammography and clinical breast examination for early detection of breast cancer. The combined approach is better than any single test (ACS, 2010a). A woman who chooses to perform BSE should be taught the correct technique and have it reviewed by a health care professional during her clinical breast examination.

Teach patients how to perform BSE if they choose. The examination technique is similar for women and men. Use teaching models of normal and abnormal breasts when teaching BSE. Discuss the proper timing for BSE. Instruct premenopausal women to examine their breasts 1 week after the menstrual period. At this time, hormonal influence on breast tissue is decreased, so fluid retention and tenderness are reduced. Teach women whose breast tissue is no longer influenced by hormonal fluctuations, such as after a total hysterectomy or menopause, to pick a day each month to do BSE, such as the first day of the month.

Ensure that the setting in which you demonstrate BSE is private and comfortable. Ask the woman to undress from the waist up, and provide a gown and sheet. Teach the woman to stand in front of a mirror to inspect the breast for abnormalities. She should raise her arms above her head and press her hands on her hips to emphasize any changes in the shape of the breasts. Palpation should be performed in a lying position and while bathing or showering. Before teaching breast palpation, ask the woman to demonstrate her own method. If she is unsure or has not performed BSE before, slowly lead her through the examination while explaining the rationale for the technique and answering questions. Demonstrate the correct technique of examining the breasts with the arm overhead instead of having the arm by her side. Showing the difference in the two positions, especially in large-breasted women, reveals the advantage of using the correct method, which spreads the tissue over the chest wall for more effective palpation (Fig. 73-4).

FIG. 73-4 A woman performing breast self-examination (BSE).

It is also helpful to point out different findings at this time, especially those that the woman might perceive as abnormal. Placing the woman’s hand directly on the involved area and showing her precisely what is normal for her can build self-confidence. Teach her that nodular breast tissue may normally feel lumpy, which may be interpreted as widespread cancer. Indicate the inframammary ridge, the area of the breast where the skin folds under the breast. This thickened area may be perceived as a lump instead of a normal finding. In thin or small-breasted women, the ribs may be mistaken for masses. Demonstrate how to follow the rib to the sternum to be sure that what she is feeling is bone and not breast tissue.

Any one of three palpation methods can be used to examine the breast tissue (Fig. 73-5). Teach the importance of covering all tissue during palpation. Demonstrate the proper amount of pressure needed to palpate the breast tissue and the correct position of the hands. The finger pads, which are more sensitive than the fingertips, are used when palpating the breasts. Teach the woman to press firmly enough to detect the underlying tissue.

FIG. 73-5 Breast palpation techniques.