4. Breast cancer
   • Risk factors:
     1. Women > age 50.
     2. Family history of breast cancer.
     3. Never bore children, or bore first child after age 30.
     4. Had breast cancer in other breast.
     5. Menarche before age 11.
     6. Menopause after age 50.
     7. Exposure to endogenous estrogens.
     8. Exposure to ionizing radiation.
     9. High alcohol and fat intake may increase risk.
   • Annual incidence: 181,600 new cases; 44,190 estimated deaths.
   • Assessment:
     1. Subjective data:
        • Burning, itching of nipple.
        • Reported painless lump.
     2. Objective data:
        • Firm, nontender lump or mass.
        • Asymmetry of breast.
        • Nipple - retraction, discharge.
        • Alteration in breast skin - redness, dimpling, ulceration.
        • Palpation reveals lump.
        • Diagnostic tests: mammography, needle biopsy, core biopsy, excisional biopsy - level of estrogen-receptor protein predicts response to hormonal manipulation of metastatic disease and may represent a prognostic indicator for primary cancer; carcinoembryonic antigen (CEA) useful with metastatic disease of the breast.
   • Analysis/nursing diagnosis:
     1. Risk for injury related to surgical intervention.
     2. Body image disturbance related to effects of surgery, radiation, or chemotherapy.
     3. Altered sexuality patterns related to loss of breast.
   • Nursing care plan/implementation:
     1. Goal: assist through treatment protocol.
        • Radiation - primary treatment modality; adjunctive, external, or implantation to primary lesion site or nodes.
        • Chemotherapy usually given in combinations.
          1. Cytotoxic agents to destroy tumor and control metastasis.
          2. Alkylating agents: cyclophosphamide (Cytoxan).
          3. Antitumor antibiotics: doxorubicin (Adriamycin).
          4. Antimetabolites: fluorouracil (5-FU); methotrexate (Amethopterine, MTX).
          5. Plant alkaloids: vincristine sulfate (Oncovin).
          6. Hormones to control metastasis, provide palliation: androgens, fluoxymesterone (Halotestin), testosterone (Teslac), diethylstilbesterol (estrogen).
          7. Antiestrogens: tamoxifen (Nolvadex) may be used after initial treatment.
          8. Cortisols: cortisone, prednisolone (Delta-Cortef), prednisolone acetate (Meticortelone), prednisone (Deltasone, Deltra).
        • Surgery.
          1. Preoperative:
             • Goal: prepare for surgery-types:
               • Lumpectomy (with or without radiation) - used when lesion is small; section of breast is removed (often accompanied by radiation therapy and then radium interstitial implant).
               • Simple mastectomy - breast removed, no alteration in nodes.
               • Modified radical mastectomy - breast, some axillary nodes, subcutaneous tissue removed; pectoralis minor muscle removed.
               • Radical mastectomy - breast, axillary nodes, and pectoralis major and minor muscles removed.
               • Reconstructive surgery - done at time of initial mastectomy or (most often) later, when other adjuvant therapy has been completed.
             • Goal: promote comfort.
               • Allow patient and family to express fears, feelings.
               • Provide correct information about diagnostic tests, operative procedure, postoperative expectations.
               • Patient may be hospitalized for 24 hours or less. Have telephone number available for questions. Make appropriate community referrals.
          2. Postoperative:
             • Goal: facilitate healing.
               • Observe pressure dressings for bleeding; will appear under axilla and toward the back.
               • Report if dressing becomes saturated; reinforce dressing as need; monitor drainage from Hemovac or suction pump.
               • Position: semi-Fowler’s to facilitate venous and lymphatic drainage; use pillows to elevate affected arm above right atrium, to prevent edema if nodes removed.
             • Goal: prevent complications.
               • Monitor vital signs for shock.
               • Use gloves when emptying drainage.
               • Maintain joint mobility - flexion and extension of fingers, elbow, shoulder.
               • ROM as ordered to prevent ankylosis.
               • If skin graft done, check donor site and limit exercises.
             • Goal: facilitate rehabilitation.
               • Encourage patient, significant others, and family to look at incision.
               • Involve patient in incisional care, as tolerated.
               • Refer to Reach to Recovery program of the American Cancer Society
               • Exercise program, hydrotherapy for postmastectomy patients, to reduce lymphedema.
   • Evaluation/outcome criteria:
     1. Identifies feelings regarding loss.
     2. Demonstrates postmastectomy exercises.
     3. Gives rationale for avoiding fatigue and avoiding constricting garments on affected arm; necessity for avoiding injury (cuts, bruises, burns) while carrying out activities of daily living.
     4. Describes signs and symptoms of infection.
     5. Demonstrates correct BSE technique.