Nursing Management

Breast Disorders

What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others.

1. Summarize screening guidelines for the early detection of breast cancer.

2. Describe accurate clinical breast examination techniques, including inspection and palpation.

3. Explain the types, causes, clinical manifestations, and nursing and collaborative management of common benign breast disorders.

4. Assess the risk factors for breast cancer.

5. Describe the pathophysiology and clinical manifestations of breast cancer.

6. Describe the collaborative care and nursing management of breast cancer.

7. Specify the physical and psychologic preoperative and postoperative aspects of nursing management for the patient undergoing a mastectomy.

8. Explain the indications for reconstructive breast surgery, types and complications of reconstructive breast surgery, and nursing management after reconstructive breast surgery.

Reviewed by Carole Martz, RN, MS, AOCN, CBCN, Clinical Coordinator, Living in the Future Cancer Survivorship Program, Northshore University Health System, Highland Park Hospital, Highland Park, Illinois; Shannon T. Harrington, RN, PhD, Nursing Lecturer, School of Nursing, Old Dominion University, Norfolk, Virginia; Mary Scheid, RN, MSN, OCN, CBCN, Breast Health Nurse, NCMC Breast Center, North Colorado Medical Center, Greeley, Colorado; and Mary Blessing, RN, MSN, Director, Academic RN Residency Program, University of New Mexico Hospitals, Albuquerque, New Mexico.

Breast disorders are a significant health concern for women. Whether the actual diagnosis is a benign condition or a malignancy, the initial discovery of a lump or change in the breast often triggers intense feelings of anxiety, fear, and denial.

The most frequently encountered breast disorders in women are fibrocystic changes, fibroadenoma, intraductal papilloma, ductal ectasia, and breast cancer. In a woman’s lifetime there is a 1 in 8 chance she will be diagnosed with breast cancer.¹ In men, gynecomastia is the most common breast disorder.

eNursing Care Plan 52-1 Patient After Mastectomy or Lumpectomy *

Nursing Diagnosis Impaired physical mobility** related to weakness and muscle loss as evidenced by limitation in movement of upper extremity on surgical side
Patient Goals 1. Identifies activities that can reduce postoperative edema and mobility 2. Demonstrates appropriate hand and arm exercises
Outcomes (NOC)	Interventions (NIC) and Rationales
Coordinated Movement • Steadiness of movement _____ • Strength of muscle contraction (affected side) _____ • Control of movement _____ • Movement in desired direction (affected side) _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Exercise Therapy: Joint Mobility • Determine limitations of joint movement and effect on function to plan appropriate interventions. • Initiate pain control measures before beginning exercise to promote participation in exercise plan. • Instruct patient/caregivers how to systematically perform passive, assisted, or active range-of-motion exercises to prevent contractures and muscle shortening, maintain muscle tone, and improve lymph and blood circulation. Exercise Therapy: Muscle Control • Incorporate ADLs into exercise protocol to reduce dependent behaviors, raise self-esteem, and maintain mobility of affected arm. • Use motor activities that require attention to and use of both sides of the body to prevent guarding of operative side and loss of function.
Nursing Diagnosis Acute pain related to tissue trauma and manipulation as evidenced by verbalization of pain at operative area
Patient Goals 1. Uses pain control measures appropriately 2. Reports progressive reduction in pain
Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control • Uses nonanalgesic relief measures _____ • Uses analgesics as recommended _____ • Reports changes in pain symptoms to health professional _____ • Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Pain Management • Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, and intensity or severity of pain to plan appropriate interventions. • Explore with patient factors that relieve/worsen pain. • Teach the use of nonpharmacologic techniques (e.g., distraction, imagery, and relaxation) to use along with or in place of analgesics. • Provide patient optimal pain relief with prescribed analgesics. • Use pain control measures before pain becomes severe to prevent pain from becoming out of control. Positioning • Support the arm and limit activity to prevent tension on suture line. • Elevate affected limb 20 degrees or greater to improve venous return and prevent pain in arm.
Nursing Diagnosis Anxiety related to a situational crisis and unpredictable outcome secondary to a diagnosis of cancer as evidenced by insomnia, crying, and questioning of prognosis
Patient Goal Demonstrates effective use of coping strategies that provide reduction of anxiety
Outcomes (NOC)	Interventions (NIC) and Rationales
Coping • Uses personal support system _____ • Uses effective coping strategies _____ • Verbalizes sense of control _____ • Seeks reputable information about diagnosis and treatment _____ • Reports increase in psychologic comfort _____ • Reports decrease in physical symptoms of stress _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Coping Enhancement • Encourage verbalization of feelings, perceptions, and fears to promote successful resolution of fear and establish effective coping mechanisms. • Support the use of appropriate defense mechanisms to relieve anxiety. • Encourage the family to verbalize feelings because their fear about the diagnosis and outcome can decrease their effectiveness as a support system. • Provide factual information concerning diagnosis, treatment, and prognosis to help decrease feelings of the unknown. • Assist the patient to grieve and work through the losses of chronic illness and disability to promote emotional and physical healing. • Encourage an attitude of realistic hope as a way of dealing with feelings of helplessness because hope is associated with better physical health.
Nursing Diagnosis Disturbed body image related to perceived effects of mastectomy as evidenced by verbalization of concern about appearance and feelings of loss of femininity, and refusal to view incision
Patient Goals 1. Discusses feelings about and the meaning of changes in physical appearance 2. Identifies community resources and self-help groups available for support
Outcomes (NOC)	Interventions (NIC) and Rationales
Body Image • Attitude toward touching affected part _____ • Satisfaction with body appearance _____ • Adjustment to body changes due to surgery _____ • Attitude toward using strategies to enhance appearance _____ • Congruence between body reality, body ideal, and body presentation _____ Measurement Scale 1 = Never positive 2 = Rarely positive 3 = Sometimes positive 4 = Often positive 5 = Consistently positive	Body Image Enhancement • Identify support groups available to patient so that social support will be available. • Assist patient to separate physical appearance from feelings of personal worth. • Facilitate contact with individuals with similar change in body image (e.g., Reach to Recovery) to serve as a peer support and provide hope for recovery and a normal future. • Assist patient to discuss changes caused by illness and surgery to promote grief work and maintain support from family/friends. • Assist patient to identify actions that will enhance appearance (e.g., prosthesis, breast reconstruction).
Nursing Diagnosis Ineffective self-health management related to decisional conflicts and lack of knowledge regarding disease process and postoperative care as evidenced by frequent questions about disease, treatment, and follow-up care
Patient Goals 1. Demonstrates care of incision site 2. Explains disease process and measures to minimize disease progression
Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Treatment Procedure • Treatment procedure _____ • Steps in procedure _____ • Precautions related to procedure _____ Knowledge: Cancer Management • Signs and symptoms of recurrence _____ • Benefits of different treatment options _____ • Tests and procedures involved in treatment regimen _____ • Medication effects _____ • Potential complications of treatment _____ • Self-care responsibilities for ongoing treatment _____ • Importance of positive attitude for coping with cancer _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	Teaching: Procedure/Treatment • Instruct the patient on how to participate during the procedure (e.g., taking care of incision, applying new dressing, emptying drains, performing return demonstration) to become self-sufficient in own care. • Include caregivers as needed to provide support and assistance. Teaching: Disease Process • Review patient’s knowledge about condition to determine what teaching is needed. • Discuss therapy/treatment options to promote decision making. • Describe rationale behind management/therapy/treatment recommendations to increase commitment to treatment choices. • Instruct patient on measures to prevent/minimize side effects of treatment to promote disease management. • Instruct patient on which signs and symptoms to report to health care provider (e.g., skin changes at surgical site, new changes in breast or chest wall). Breast Examination • Instruct patient about the importance of regular self-examination and advise regular mammograms because they are recommended techniques for identification of local recurrence after mastectomy and for assessing other breast.
Collaborative Problem
Potential Complication Lymphedema related to impaired lymphatic drainage and lack of knowledge of preventive measures
Nursing Goals	Nursing Interventions and Rationales
• Monitor for signs of lymphedema • Report deviations from acceptable parameters • Carry out appropriate medical and nursing interventions	• Assess patient for signs of lymphedema such as edema in hand and/or arm on operative side, heaviness, and/or localized pain to enable early diagnosis and intervention to prevent and treat the complication. • Instruct patient about self-care strategies and precautions to reduce risk of lymphedema so patient will be an active, informed participant in self-care. • Do not perform venipunctures or take blood pressure measurements on affected arm to reduce risk of constriction, infection, and lymphedema in affected arm. • Avoid dependent arm position to allow proper wound healing and decrease stress to incision site. • Use compression bandage if ordered to apply mechanical pressure to reduce fluid collection in affected arm and promote venous return.

ADLs, Activities of daily living.

^*For the patient who has a lumpectomy, many of the specific interventions in this care plan relate to the patient who has also had an axillary node dissection.

^**Nursing diagnoses listed in order of priority.

Assessment of Breast Disorders

Breast Cancer Screening Guidelines

Screening guidelines for the early detection of breast cancer include the following:2–5

• Yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. A controversial recommended change is that women at normal risk for breast cancer should begin annual screening at age 50 and stop screening at age 75.⁶

• Clinical breast examination (CBE) preferably at least every 3 years for women in their 20s and 30s, and every year for women beginning at age 40.⁷

• Women should report any breast changes promptly to their health care provider. Breast self-examination (BSE) is an option for women starting at age 20.

• Women at increased risk (family history, genetic link, past breast cancer) should talk with their health care provider about the benefits and limitations of starting mammography screening earlier, having additional tests (e.g., breast ultrasound or magnetic resonance imaging [MRI]), or having more frequent examinations.

In recent years there has been some controversy regarding the value of BSE and its role in reducing mortality rates from breast cancer in women. While the benefit of BSE in reducing breast cancer deaths continues to be reviewed, BSE remains a useful technique in helping women develop awareness of how their breasts normally look and feel. Teach women beginning at age 20 the benefits and limitations of BSE and the importance of reporting breast changes (e.g., nipple discharge, a lump) to their health care provider.⁸

When teaching the woman about BSE, include information related to potential benefits, limitations, and harm (chance of a false-positive test result). Allow time for questions about the procedure and a return demonstration. At every periodic health examination, ask the woman who is performing BSE to demonstrate her technique. For women who choose to do BSE, the technique has recently been revised (Fig. 52-1).

FIG. 52-1 Breast self-examination and patient instruction. 1, Lie down and place your left arm behind your head. Lying down spreads breast tissue evenly and thinly over the chest wall, making it easier to feel the tissue. 2, Use finger pads of three middle fingers on your right hand to feel for lumps in left breast. Use overlapping dime-sized circular motions to feel the breast tissue. Use three different levels of pressure to feel the breast tissue. Light pressure to feel tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel tissue closest to the chest and ribs. A firm ridge in the lower curve of each breast is normal. 3, The up-and-down (vertical) pattern is recommended for examining the entire breast. Move around the breast in an up-and-down pattern starting at an imaginary line straight down your side from the underarm (including the tail of Spence, which is the triangular breast tissue projecting into the axilla), and moving across the breast to the middle of the sternum. Examine the entire breast going down until you feel only ribs and up to the neck or clavicle. Repeat procedure while examining your right breast. 4, Stand in front of a mirror. Place your hands firmly on your hips, which will tighten the pectoralis muscles. Look at your breasts for size, shape, redness, scaliness, or dimpling of the breast skin or nipple. 5, Examine each underarm while standing or sitting with arm slightly raised. Check for any lump, hard knot, or thickening of tissue.

Diagnostic Studies

Radiologic Studies.

Several techniques can be used to screen for breast disease or to help diagnose a suspicious physical finding. Mammography is a method used to visualize the breast’s internal structure using x-rays (Fig. 52-2). This generally well-tolerated procedure can detect suspicious lumps that cannot be felt. Mammography has significantly improved the early and accurate detection of breast malignancies. Improved imaging technology has also reduced the radiation dose from mammography.

FIG. 52-2 Screening mammogram showing dense breast tissue and benign, scattered microcalcifications of a 57-year-old. A, Using conventional x-rays. B, Using digital x-rays.

Digital mammography is a technique in which x-ray images are digitally coded into a computer (see Fig. 52-2). It is not clear whether mammogram interpretation has improved with the aid of a computer. The associated costs of using computer-aided detection may also outweigh the benefits.⁹

Three-dimensional (3D) mammography, a new type of mammogram that produces a 3D image of the breast, provides a clearer view of overlapping breast tissue structures. 3-D images help to accurately detect and diagnose breast cancer.

Calcifications are the most easily recognized mammogram abnormality (see Fig. 52-2). These deposits of calcium crystals form in the breast for many reasons, such as inflammation, trauma, and aging. Although most calcifications are benign, they may also be associated with preinvasive cancer.

A comparison of current and prior mammograms may show early tissue changes. Because some tumors metastasize late, early detection by mammography allows for earlier treatment and the prevention of metastasis. In younger women, mammography is less sensitive because of the greater density of breast tissue, resulting in more false-negative results.

About 10% to 15% of all breast cancers cannot be seen on mammography and are detected by palpation or additional diagnostic studies, including ultrasound and MRI. If the clinical findings are suspicious and the mammogram is normal, an ultrasound or MRI may be used. Based on these additional findings, a biopsy may be done.

Ultrasound is used in conjunction with mammography. It may be used to differentiate a solid mass from a cystic mass, to evaluate a mass in a pregnant or lactating woman, or to locate and biopsy a suspicious lesion.

The somo-v ABUS is an ultrasound device for breast cancer screening for use in women with dense breasts. The somo-v ABUS scans a woman’s breast, capturing multiple ultrasound images that can be reviewed in 3D. This device is used along with standard mammography in women with a negative mammogram and no breast cancer symptoms.

Biopsies.

A definitive diagnosis of a suspicious area is made by analyzing biopsied tissue. Biopsy techniques include fine-needle aspiration (FNA), core (core needle), vacuum-assisted, and surgical biopsies.

FNA biopsy is performed by inserting a needle into a lesion to sample fluid from a breast cyst, remove cells from intercellular spaces, or sample cells from a solid mass. Before the procedure, the breast area is first locally anesthetized. Then the needle is placed into the breast, and fluid and cells are aspirated into a syringe. Three or four passes are usually made. If the results are negative with a suspicious lesion, an additional biopsy may be necessary. Inform patients that biopsy results are usually available in 1 to 3 days.

A core (core needle) biopsy involves removing small samples of breast tissue using a hollow “core” needle. For palpable lesions, this is accomplished by fixing the lesion with one hand and performing a needle biopsy with the other. In the case of nonpalpable lesions, stereotactic mammography, ultrasound, or MRI image guidance is used. Stereotactic mammography uses computers to pinpoint the exact location of a breast mass based on mammograms. With ultrasound, the radiologist or surgeon watches the needle on the ultrasound monitor to help guide it to the area of concern. Because a core biopsy removes more tissue than an FNA, it is more accurate.

Vacuum-assisted biopsy is a version of core biopsy that uses a vacuum technique to help collect the tissue sample. In core biopsy, several separate needle insertions are used to acquire multiple samples. During vacuum-assisted biopsy, the needle is inserted only once into the breast, and the needle can be rotated, which allows for multiple samples through a single needle insertion.

A surgical biopsy is used to remove a breast mass or lump or to obtain a sample of breast tissue for analysis. A surgical biopsy is usually performed in an operating room. Ten years ago, most breast biopsies were surgical procedures. Today less invasive biopsy procedures, such as core biopsies, are used.

Benign Breast Disorders

Mastalgia

Mastalgia (breast pain) is the most common breast-related complaint in women.¹⁰ The most common form is cyclic mastalgia, which coincides with the menstrual cycle. It is described as diffuse breast tenderness or heaviness. Breast pain may last 2 or 3 days or most of the month. The pain is related to hormonal sensitivity. The symptoms often decrease with menopause.

Noncyclic mastalgia has no relationship to the menstrual cycle and can continue into menopause. It may be constant or intermittent throughout the month and last for several years. Symptoms include a burning, aching, or soreness in the breast. The pain may be from trauma, fat necrosis, ductal ectasia, costochronditis, or arthritic pain in the chest or neck radiating to the breast.

Mammography and targeted ultrasound are frequently done to exclude cancer and provide information on the etiology of mastalgia. Some relief for cyclic pain may occur by reducing intake of caffeine and dietary fat; taking vitamins E, A, and B complex and gamma-linolenic acid (evening primrose oil); and continually wearing a support bra. Compresses, ice, analgesics, and antiinflammatory drugs may also help. Helpful drugs include oral contraceptives and danazol (Danocrine). The androgenic side effects of danazol (acne, edema, hirsutism) may make this therapy unacceptable for many women.

Breast Infections

Mastitis

Mastitis is an inflammatory condition of the breast that occurs most frequently in lactating women (Table 52-1). Lactational mastitis manifests as a localized area that is erythematous, painful, and tender to palpation. Fever is often present. The infection develops when organisms (usually staphylococci) gain access to the breast through a cracked nipple. In its early stages, mastitis can be cured with antibiotics. Breastfeeding should continue unless an abscess is forming or purulent drainage is noted. The mother may wish to use a nipple shield or to hand-express milk from the involved breast until the pain subsides. The woman should see her health care provider promptly to begin a course of antibiotic therapy. Any breast that remains red, tender, and not responsive to antibiotics requires follow-up care and evaluation for inflammatory breast cancer.¹¹

TABLE 52-1

BENIGN BREAST DISORDERS *

Disorder	Risk Factors	Clinical Manifestations
Lactational mastitis	Occurs in up to 10% of postpartum lactating mothers (both primipara and multipara), usually 2-4 wk after birth.	Warm to touch, indurated, painful, often unilateral, most commonly caused by Staphylococcus aureus.
Fibrocystic changes	Most common between ages 35 and 50.	Not usually discrete masses—nodularity instead. Usually accompanied by cyclic pain and tenderness. Mass(es) often cyclic in occurrence (movable, soft).
Cysts	Most common over age 35. Incidence decreases after menopause. Develop in one out of every 14 women.	Palpable fluid-filled mass (movable, soft). Multiple cysts can occur and recur. Rarely associated with breast cancer.
Fibroadenoma	Commonly occurs in 10% of all women ages 15-40.	Palpable mass (firm, movable), usually 2-3 cm in size, rarely associated with breast cancer.
Fat necrosis	Many women report previous history of trauma to breast.	Usually a hard, tender, mobile, indurated mass with irregular borders.
Ductal ectasia	Perimenopausal woman—most common in women in their 50s, previous lactation, inverted nipples.	Fixation of nipple, usually accompanied by nipple discharge of thick gray material. Often associated with breast pain.

^*This list is not inclusive; other benign breast disorders are discussed in the text.

Lactational Breast Abscess

If lactational mastitis persists after several days of antibiotic therapy, a lactational breast abscess may have developed. In this condition, the skin may become red and edematous over the involved breast, often with a corresponding palpable mass, and the patient may have a fever. Antibiotics alone are insufficient treatment for a breast abscess. Ultrasound-guided drainage of the abscess or surgical incision and drainage are necessary. The drainage is cultured, sensitivities are obtained, and therapy with an appropriate antibiotic is begun. Breastfeeding can continue in most cases with ongoing treatment of the abscess.

Fibrocystic Changes

Fibrocystic changes in the breast are a benign condition characterized by changes in breast tissue ¹² (Fig. 52-3). The changes include the development of excess fibrous tissue, hyperplasia of the epithelial lining of the mammary ducts, proliferation of mammary ducts, and cyst formation. Fibrocystic changes are thought to be due to a heightened responsiveness of breast tissue to circulating estrogen and progesterone. These changes produce pain related to nerve irritation from edema in the connective tissue and to fibrosis that pinches the nerve. Fibrocystic changes are the most common breast disorder.

FIG. 52-3 A, Normal breast tissue. B, Fibrocystic breast tissue.

The use of the term fibrocystic disease is incorrect because the cluster of problems is actually an exaggerated response to hormonal influence. The terms fibrocystic condition or fibrocystic complex are more accurate.

Fibrocystic changes alone are not associated with increased breast cancer risk. Masses or nodularities can appear in both breasts. They are often found in the upper, outer quadrants and usually occur bilaterally.

Fibrocystic changes occur most frequently in women between 35 and 50 years of age but often begin as early as 20 years of age. Pain and nodularity often increase over time but tend to subside after menopause unless high doses of estrogen replacement are used. Fibrocystic changes most commonly occur in women with premenstrual abnormalities, nulliparous women, women with a history of spontaneous abortion, nonusers of oral contraceptives, and women with early menarche and late menopause. Symptoms related to fibrocystic changes often worsen in the premenstrual phase and subside after menstruation.

Manifestations of fibrocystic breast changes include one or more palpable lumps that are often round, well delineated, and freely movable within the breast (see Table 52-1). Discomfort ranging from tenderness to pain may also occur. The lump is usually observed to increase in size and perhaps in tenderness before menstruation. Cysts may enlarge or shrink rapidly. Nipple discharge associated with fibrocystic breasts is often milky, watery-milky, yellow, or green.

Mammography may be helpful in distinguishing fibrocystic changes from breast cancer. However, in some women the breast tissue is so dense that it is difficult to obtain a mammogram. In these situations, ultrasound may be more useful in differentiating a cystic mass from a solid mass.

Nursing and Collaborative Management Fibrocystic Changes

With the initial discovery of a discrete mass in the breast by a woman or her health care provider, aspiration or surgical biopsy may be indicated. If the nodularity is recurrent, a wait of 7 to 10 days may be planned in order to note any changes that may be related to the menstrual cycle. With large or frequent cysts, surgical removal may be favored over repeated aspiration. An excisional biopsy may be done if (1) no fluid is found on aspiration, (2) the fluid that is found is hemorrhagic, or (3) a residual mass remains after fluid aspiration. The biopsy is usually performed in an outpatient surgery unit.

Biopsies in women with fibrocystic disease may be indicated if these women have an increased risk for breast cancer. Atypical hyperplasia discovered by breast biopsy increases a woman’s risk of developing breast cancer later in life.

Encourage the woman with cystic changes to maintain regular follow-up care. Also teach her BSE to self-monitor changes. Severe fibrocystic changes may make palpation of the breast more difficult. Teach her to report any changes in symptoms or changes found during the BSE so they can be evaluated.

Treatment for a fibrocystic condition is similar to that described earlier for mastalgia. Teach the woman with fibrocystic breasts that she may expect a recurrence of the cysts in one or both breasts until menopause and that the cysts may enlarge or become painful just before menstruation. Additionally, reassure her that the cysts do not “turn into” cancer. Advise her that any new lump that does not respond in a cyclic manner over 1 to 2 weeks should be examined by her health care provider.

Fibroadenoma

Fibroadenoma is a common cause of discrete benign breast lumps in young women. It generally occurs in women between 15 and 40 years of age. It is the most frequent cause of breast masses in women under 25 years of age.

The possible cause of fibroadenoma may be increased estrogen sensitivity in a localized area of the breast. Fibroadenomas are usually small (but can be large [2 to 3 cm]), painless, round, well delineated, and very mobile. They may be soft but are usually solid, firm, and rubbery in consistency. There is no accompanying retraction or nipple discharge. The lump is often painless. The fibroadenoma may appear as a single unilateral mass, although multiple bilateral fibroadenomas have been reported. Growth is slow and often ceases when the size reaches 2 to 3 cm. Size is not affected by menstruation. However, pregnancy can stimulate dramatic growth.

Fibroadenomas are easily detected by physical examination and may be visible on mammography and ultrasound. However, definitive diagnosis requires FNA, core, or surgical biopsy and tissue examination by a pathologist to exclude other tumors. Treatment of fibroadenomas can include observation with regular monitoring after a malignancy has been ruled out, or surgical excision. In women over 35 years of age, all new lesions should be evaluated by breast ultrasound and possible biopsy.

As an alternative to surgery, tumor removal can be done using cryoablation. In this procedure, a cryoprobe is inserted into the tumor using ultrasound guidance. Extremely cold gas is piped into the tumor. The frozen tumor dies and gradually shrinks.

Nipple Discharge

Nipple discharge may occur spontaneously or as a result of nipple manipulation. A milky secretion is due to inappropriate lactation (termed galactorrhea) and may be a result of problems such as drug therapy, endocrine problems, and neurologic disorders. Nipple discharge may also be idiopathic (no known cause).

Secretions can also be serous, grossly bloody, or brown to green.¹³ These secretions may be caused by either benign or malignant disease. A cytology slide may be made of the secretion to determine the specific disease. Diseases associated with nipple discharge include malignancies, cystic disease, intraductal papilloma, and ductal ectasia. Treatment depends on identification of the cause. In most cases, nipple discharge is not related to malignancy.

Gerontologic Considerations

Age-Related Breast Changes

The loss of subcutaneous fat and structural support and the atrophy of mammary glands often result in pendulous breasts in the postmenopausal woman. Encourage older women to wear a well-fitting bra. Adequate support can improve physical appearance and reduce pain in the back, shoulders, and neck. It can also prevent intertrigo (dermatitis caused by friction between opposing surfaces of skin). Sagging breasts can be surgically lifted (mastopexy). This procedure can be done in conjunction with breast reconstruction after a mastectomy is performed.

The decrease in glandular tissue in older women makes a breast mass easier to palpate. This decreased density is likely a result of age-related decreases in estrogen. Rib margins may be palpable in a thin woman and can be confused with a mass. That is why it is so important that women become familiar with their own breasts and what is normal for them. Because the incidence of breast cancer increases with age, encourage older women to continue BSE, to have annual mammograms and CBEs, and to have any breast mass evaluated by their health care provider.

Breast Cancer

Breast cancer is the most common malignancy in American women except for skin cancer. It is second only to lung cancer as the leading cause of death from cancer in women. In the United States more than 230,480 new cases of invasive breast cancer and more than 57,650 cases of in situ breast cancer are diagnosed annually.¹ About 2140 of those new cases are diagnosed in men. Approximately 39,920 deaths (39,510 women and 410 men) occur each year related to breast cancer.

The incidence of breast cancer is slowly decreasing, with a slight drop in the number of deaths related to breast cancer. This decline may be the result of the decreased use of hormone therapy after menopause.² Approximately 2.6 million women are alive in the United States today who are breast cancer survivors.

Patients diagnosed with localized breast cancer with no axillary node involvement have a 5-year survival rate of 98%. Conversely, only 23% of patients diagnosed with advanced-stage breast cancer with metastases to distant sites will survive 5 years or more.1,2

Etiology and Risk Factors

Although the etiology is not completely understood, a number of risk factors are related to breast cancer (Table 52-2). Risk factors appear to be cumulative and interacting. Therefore the presence of multiple risk factors may greatly increase the overall risk, especially for people with a positive family history.

TABLE 52-2

RISK FACTORS FOR BREAST CANCER

Risk Factor	Comments
Female	Women account for 99% of breast cancer cases.
Age ≥50 yr	Majority of breast cancers are found in postmenopausal women. After age 60, increase in incidence.
Hormone use	Use of estrogen and/or progesterone as hormone therapy, especially in postmenopausal women.
Family history	Breast cancer in a first-degree relative, particularly when premenopausal or bilateral, increases risk.
Genetic factors	Gene mutations (BRCA1 or BRCA2) play a role in 5%-10% of breast cancer cases.
Personal history of breast cancer, colon cancer, endometrial cancer, ovarian cancer	Personal history significantly increases risk of breast cancer, risk of cancer in other breast, and recurrence.
Early menarche (before age 12), late menopause (after age 55)	A long menstrual history increases the risk of breast cancer.
First full-term pregnancy after age 30, nulliparity	Prolonged exposure to unopposed estrogen increases risk for breast cancer.
Benign breast disease with atypical epithelial hyperplasia, lobular carcinoma in situ	Atypical changes in breast biopsy increase the risk of breast cancer.
Dense breast tissue	Mammograms harder to read and interpret. Dense tissue may be associated with more aggressive tumors.
Weight gain and obesity after menopause	Fat cells store estrogen, which increases the likelihood of developing breast cancer.
Exposure to ionizing radiation	Radiation damages DNA (e.g., prior treatment for Hodgkin’s lymphoma).
Alcohol consumption	Women who drink ≥1 alcoholic beverage per day have an increased risk of breast cancer.
Physical inactivity	Breast cancer risk is decreased in physically active women.

Risk Factors for Women.

The risk factors most associated with breast cancer include female gender and advancing age. Women are at far greater risk than men, with 99% of breast cancers occurring in women. Increasing age also increases the risk of developing breast cancer. The incidence of breast cancer in women under 25 years of age is very low and increases gradually until age 60. After age 60, the incidence increases dramatically.

Hormonal regulation of the breast is related to the development of breast cancer, but the mechanisms are poorly understood. The hormones estrogen and progesterone may act as tumor promoters to stimulate breast cancer growth if malignant changes in the cells have already occurred. The Women’s Health Initiative study showed that the use of combined hormone therapy (estrogen plus progesterone) increases the risk of breast cancer and also the risk of having a larger, more advanced breast cancer at diagnosis.¹⁵ The use of estrogen therapy alone for longer than 10 years (for women with a prior hysterectomy) increases a woman’s long-term risk for breast cancer. A link may exist between recent oral contraceptive use and increased risk of breast cancer for younger women.¹⁶

Modifiable risk factors include excess weight gain during adulthood, sedentary lifestyle, smoking, dietary fat intake, obesity, and alcohol intake.¹⁰ Environmental factors such as radiation exposure may also play a role.

Genetic Link

Family history of breast cancer is an important risk factor, especially if the involved family member also had ovarian cancer, was premenopausal, had bilateral breast cancer, or is a first-degree relative (i.e., mother, sister, daughter). Having any first-degree relative with breast cancer increases a woman’s risk of breast cancer 1.5 to 3 times, depending on age. A breast cancer risk assessment tool for health care providers is available through the National Cancer Institute (see Resources at the end of this chapter). About 5% to 10% of all breast cancers are hereditary. This means that specific genetic abnormalities that contribute to the development of breast cancer have been inherited (passed from parent to child). Most inherited cases of breast cancer are associated with mutations in two genes: BRCA1 and BRCA2 (BRCA stands for BReast CAncer). Everyone has BRCA genes. The BRCA1 gene, located on chromosome 17, is a tumor suppressor gene that inhibits tumor development when functioning normally. Women who have BRCA1 mutations have a 40% to 80% lifetime chance of developing breast cancer. The BRCA2 gene, located on chromosome 11, is another tumor suppressor gene. Women with a mutation of this gene have a similar risk of breast cancer.