Brenda thought it was just a routine exam. But the results transformed her life within weeks. Shortly after entering a breast clinic, Brenda, a 50-year-old orthopedic nurse, was facing a diagnosis of breast cancer.

With no family history of breast cancer, no palpable mass to be felt, and no risk factors other than being a woman, the diagnosis caught Brenda off guard. As a postmenopausal woman, Brenda had dutifully performed monthly breast self-exams. All of her mammograms, taken yearly since she turned 40, had been normal. Then, the last one showed microcalcifications in her right breast. Within a few days, she had a breast biopsy. After two days of anxious waiting, she received a diagnosis of cancer. Within a week, Brenda had surgery, and her journey was in full stride. Her life would be changed forever, as well as the lives of her husband and two grown daughters. For now, she is a breast-cancer survivor.

Breast cancer is the most common cancer that women may have to face in their lifetime excluding skin cancer. Approximately 1 in 7 women will have a lifetime probability of developing breast cancer.¹ It will touch the lives of most nurses, either personally, like Brenda, or professionally. Breast cancer ranks second behind lung cancer among cancer deaths in women. Based on the most recent statistics by the American Cancer Society, researchers predicted the diagnosis of 211,240 new cases of breast cancer in the U.S. in the year 2005. Of newly diagnosed cases, about 1,690 new cases were in men. Overall, of an estimated 40,870 deaths from breast cancer this year, 40,410 were women, and 460 were men.¹

The good news is that mortality rates declined by 2.3% annually between 1990 and 2002. The largest decreases were in women younger than 50 years old. These reductions are thought to be due to earlier detection and improved treatment.^1,2 Nurses can help lower these statistics further by educating patients, family, and friends about screening, early detection guidelines, and current treatment and support options. Because nursing is predominately a profession of women, nurses must also consider their own risk.

Every woman is at risk

Like many women with breast cancer, Brenda had no known risk factors. However, her sex and age fit the typical profile of a person with breast cancer. Certain factors seem to increase the likelihood of having this disease. Some of these have significance for Brenda and her family.

Risk factors associated with breast cancer are age, family history, previous occurrence of breast or ovarian cancer, benign epithelial hyperplasia, hormonal therapy, diet, environment, occupation, lifestyle, and socioeconomic status.

Age: Besides being a woman, age is the single most important risk factor for developing breast cancer. Seventy-seven percent of new breast-cancer diagnoses occur in women older than 50 years.² The women in nursing with an average age of 45 are advancing toward this critical number.³

Family History: Brenda’s breast cancer may put her two daughters at greater risk of developing the disease, and they may want counseling about risk factors and symptoms. Women with one or more first-degree relatives with breast cancer have a two to four times greater risk of getting the disease. A first-degree relative is a parent, sibling, or child. The risk is even higher if the occurrence is multigenerational, if the relative was diagnosed before menopause, or if the disease involved both breasts. Women with a strong family history may desire genetic counseling and/or testing.

Researchers have associated BRCA1 (breast cancer one) and BRCA2 (breast cancer two) gene mutations with 5% of breast cancer.¹ These genes prevent cancer by making proteins that keep cells from mutating and growing abnormally. However, women who inherit a mutation of either of these from either parent lose this protection and risk getting breast or ovarian cancer. About 50% to 60% of women with one of these mutations will develop breast cancer by age 70.2 Hereditary cancers tend to occur at an earlier age. Mutations in BRCA2 are also associated with rare male breast cancer.¹

Previous History of Breast or Ovarian Cancer: Brenda, along with her daughters, will need to continue to conduct monthly breast self-exams (BSE). Ten percent to 15% of women with a history of breast cancer will develop a recurrence within 20 years.⁴

Benign Epithelial Hyperplasia: Breast tissue is made up of glands that produce milk called lobules and the ducts that connect lobules to the nipple. Benign epithelial hyperplasia, also known as proliferative breast disease, is an overgrowth of the cells that line either the milk ducts or the lobules. When the duct is involved, it is called lobular hyperplasia. Hyperplasia is classified as typical (the usual type) or atypical. Women with typical hyperplasia have 1.9 times the risk of getting breast cancer than women in the general population. However, atypical hyperplasia further increases the risk of developing breast cancer if there is a family history for the disease. Nurses can assist women with a diagnosis of hyperplasia by helping them to understand that a closer clinical follow-up is recommended. Yearly mammograms are recommended for these women regardless of age.²

Hormonal Factors: Women who started menstruating before the age of 12, who have had no children or had their first child after age 30, or who have not reached menopause by age 55 are at a greater risk of developing breast cancer.² The use of oral contraceptives may slightly increase the risk of breast cancer. The good news is that women who have not used oral contraceptives for 10 or more years have the same risk as women who have never used them. The use of estrogen replacement therapy for more than five years slightly increases risk. The longer the use, the higher the risk. This effect also disappears five to 10 years after therapy is stopped.²

Diet: Researchers continue to investigate the relationship between diet and breast cancer risk. Obesity, especially after menopause, may increase a woman’s risk of developing breast cancer. A diet low in fat and high in fiber may reduce the risk of getting breast cancer.²

Environmental and Occupational Factors: Environmental exposures to substances such as DDT may be associated with breast cancer. Research is continuing in this area because no data has been strong enough to establish cause-and-effect relationships.²

Lifestyle Factors: Investigators are examining lifestyle factors, such as alcohol consumption and exercise, for links to breast cancer. Some studies show that a greater use of alcohol may increase the risk of breast cancer. On the other hand, exercise may protect women from some cancers, including breast cancer.²

Socioeconomic Factors: More women who are affluent and have a higher educational level are diagnosed with breast cancer. An increased mortality occurs in women with a lower socioeconomic status and less education.²

Identifying breast cancer

Many women have few or no risk factors for developing breast cancer. In these cases only routine screening and vigilance can lead to early diagnosis and improved survival. In Brenda’s case, there were no symptoms, and a routine mammogram detected her cancer. Other women discover a palpable mass during BSE.

Several guidelines exist for screening, and some controversy remains regarding which ones to use. However, the American Cancer Society (ACS) screening guidelines are most commonly used. If a woman has questions about screening or is at risk for developing breast cancer, she should consult with her health care professional. The ACS recommends monthly BSE and a clinical breast exam every three years for women aged 20 years to 39 years. Women who are 40 years or older also need to have a monthly BSE, as well as a mammogram and an annual clinical breast exam by a health care professional.^1,2

BSE is done monthly because a small percentage of breast cancers could be missed by mammography, particularly in younger women who may have dense breasts. It should be done three to five days after the completion of the menstrual cycle when the breasts are less tender. Postmenopausal women should perform BSE on the same day of each month.

Persistent changes to the breast, such as thickening, swelling, skin irritation or distortion, and nipple symptoms, such as discharge, erosion, inversion, or tenderness, can be symptoms of a developing breast cancer. These changes indicate that the cancer is altering the normal look and feel of the breast.² Women at increased risk should talk with their providers about the benefits and limitations of starting mammography earlier; additional screening tests, such as breast ultrasound and MRI; or more frequent exams.¹ Because the early stages of breast cancer are the easiest to treat, nurses should not only instruct women to follow the recommended guidelines for breast cancer screening and detection, but also follow those guidelines themselves.

Of course, not all lumps and abnormalities in the breast are cancer. Many irregularities, such as those attributed to cysts, papillomas, fibrocystic breast disease, fat necrosis, plugged milk ducts, and fibroadenomas, are benign. Diagnostic mammography and ultrasound can help in differentiating these conditions.

Mammography is the single most effective method of early detection because it can identify cancer several years before physical symptoms occur. Mammography is a low-dose x-ray of the breast, including two x-rays of each breast, one from above and one from the side. During mammography the breast is pressed between two plates for a few seconds while the x-ray is being taken. Mammography should be performed after a woman’s menstrual cycle when the breasts are less tender and discomfort can be minimized. An ultrasound is useful in distinguishing whether a mass is solid or just a fluid-filled cyst. Nurses have a unique opportunity to instruct women about what to expect during these tests and to help allay their fears and concerns as well as provide support during these often anxiety-producing times.⁵

Biopsy

A stereotactic breast biopsy confirmed Brenda’s cancer. Although she was a nurse herself, she received extensive teaching about the biopsy procedure and what to expect afterward, including the typical time required for receiving the results.

A provider can only diagnose a suspicious abnormality after a biopsy has been done and a pathologist has examined the cells. Diagnostic staging occurs after the biopsy confirms the presence of cancer, although final staging can only be done after surgery. Currently available biopsies include —

• Fine needle aspiration/core needle biopsy, where a needle is inserted to aspirate breast tissue for cytological analysis. This procedure is usually done under local anesthetic in a physician’s office.⁵
• Excisional biopsy, the surgical removal of the entire mass, leaves a margin of normal tissue.⁵
• Incisional biopsy, the surgical removal of a part of the tumor through a skin incision.⁵
• Endoscopic biopsy, a new technique that can help identify breast cancer cells missed by mammograms. It is an outpatient procedure that takes less than 30 minutes and requires only mild anesthesia. The endoscope, a thin tube-like probe with a tiny camera on the tip, is inserted into the breast tissue. This technique is not yet a common practice, but could be in the near future.⁶
• Stereotactic breast biopsy, an x-ray-guided method for localizing and sampling nonpalpable breast lesions found by mammography. Radiologists perform this procedure with the patient lying on a specially designed table with an opening through which the breast is suspended. Two plates similar to those used in a mammogram compress the breast, which is marked with coordinates that identify the position of the lesion. The radiologist numbs the area and uses a spring-loaded needle to take the biopsy. Several biopsies are usually taken from the lesion. The procedure takes about one hour from start to finish. Benign lesions can be diagnosed with less scarring and trauma.⁵

Specimens obtained from biopsy procedures are sent to a lab for analysis. Although reporting times vary from institution to institution, the results are usually ready within a week. The waiting period can be an extremely stressful time. Nurses who are caring for women who have had a biopsy and are waiting for results need to be aware that their anxiety will be high. Part of a nurse’s role in caring for these patients is to provide support during all phases of the breast cancer journey. Nurses need to be available by telephone for the patients.

Types of breast cancer

After her biopsy, Brenda received the news — invasive ductal breast cancer. This stage of diagnosis is important because “one size (treatment) does not fit all” women with breast cancer. Treatment options vary with the woman’s age, as well as the size, type, and extent of her disease. Brenda was stunned with the diagnosis and needed time to think about her options for treatment before discussing them with her family. As a nurse, Brenda thought she knew what she was dealing with, but she was wrong. Now she was the patient and it was a different ballgame.

Noninvasive breast cancer — also called cancer “in situ” or “precancer” — is confined to the ducts or lobules. As such, the two main types are ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). These cancer cells divide abnormally, but have not yet spread to other body parts.

DCIS is usually nonpalpable and found by mammography or during biopsy of another lesion. LCIS is also called lobular neoplasia. Having LCIS can increase a woman’s risk for developing invasive breast cancer.

Invasive, or infiltrating, breast cancer is the most common type, accounting for 80% of all breast cancer cases.⁵ This cancer is not confined to a duct or lobule, but has spread into the surrounding tissue. After it leaves the surrounding tissue it can metastasize. The most common sites for metastasis of breast cancer are the lungs, liver, bone, and brain.⁶

The most common types of invasive breast cancers are —

• Invasive ductal breast cancer, the most common type of breast cancer, representing 70% of all diagnosed breast cancer.⁵
• Invasive lobular breast cancer, accounting for 10% of breast cancers. This type of tumor is painful, tender, and can be found in more than one area of the breast. The breast mass appears abnormally firm and enlarged with nipple retraction. These symptoms become more severe as the cancer advances.⁵
• Inflammatory breast cancer is rare, usually characterized by edema, pain, induration, and skin thickening due to invasion of the dermal lymphatics. The breast changes are diffuse, and there may not be a dominant mass.⁵
• Other types of breast cancer are tubular, papillary, mucinous, and medullary. These types of breast cancer are rare and usually have a favorable prognosis.⁵

A team approach for treating breast cancer

Although patients may meet with team members individually, Brenda met with a multidisciplinary health care team about treatment options and their management. She learned that her treatment would be individualized according to the stage and type of her breast cancer. She would come to rely on the diverse expertise and collaborative approach of the team members to help her explore options of surgery, radiation therapy, chemotherapy, and hormonal therapy.

Once a definitive diagnosis of breast cancer is made and depending on its suspected extent, treatment planning may begin by meeting with an interdisciplinary team to evaluate the woman and explore treatment options. The meeting may occur before surgery, if the cancer is assumed to be extensive, or after surgery, to discuss the course of adjuvant therapy. The team may consist of representatives from medical oncology, surgical oncology, radiation oncology, plastic surgery, radiology, pathology, oncology nursing, genetics, social work, pastoral care, physical therapy, and nutrition. A nurse is an integral part of this team. Ideally, the team is part of a multidisciplinary breast clinic that will allow the woman access to providers from various disciplines. The nurse will be able to help the woman navigate the system and assist her in processing all the information she will be receiving along her treatment journey. In addition, the nurse will provide support and education throughout the process.

Treatment options include surgery, radiation therapy, chemotherapy, and hormonal therapy. A woman may receive one or all of these at some point in her disease trajectory, depending on individual circumstances and personal choice. Nurses in a variety of settings can help women understand treatment options and make an informed choice. One resource readily available to nurses, patients, and families is the American Cancer Society (ACS) booklet, For Women Facing Breast Cancer.⁷

Surgery — the first choice

The type of surgery a woman chooses is a personal one. No decision is right or wrong; it is an individual choice. After much discussion with the team Brenda decided to have a lumpectomy, followed by radiation and chemotherapy. One week following the stereotactic biopsy Brenda was scheduled for lumpectomy surgery with axillary lymph node dissection. She received intensive teaching from her nurses, who covered the whole perioperative experience, including pre-, intra-, and postoperative phases and follow-up care at home.

Surgical treatment options depend on the size of the tumor after mammogram and ultrasound and whether the physician thinks that lymph nodes are involved, based on physical assessment. Breast conservation therapy, that is, a lumpectomy and axillary node dissection with radiation to the breast and/or axilla, is an alternative to mastectomy. In most cases, it is just as effective, except when multiple cancerous areas exist in the breast or when the woman would not be able to tolerate or comply with six weeks of accompanying daily radiation. There seems to be some regional popularity of various therapies. For example, more lumpectomies are performed on the east and west coasts than in the central part of the U.S. where mastectomies are more routine.⁵

Lumpectomy removes the suspicious area and a small surrounding margin of tissue. If the area is nonpalpable, needle localization is performed. This procedure involves the insertion of a fine, thin guide wire into the mass under local anesthesia in a radiology department. The surgeon subsequently removes tissue surrounding the guide wire in the operating room. A follow-up mammogram is done about three months after the needle-localization lumpectomy to ensure that the whole area has been removed. If the area is palpable, needle localization is not needed. The surgeon may just remove the lump.

Patients who have lumpectomies need teaching about wound care. Dressings usually remain in place for three days. Patients may shower after the sutures or staples are removed from the incision, at one to two weeks after surgery. They should avoid excessive sun exposure to the incision. Vitamin E oil or aloe vera cream may be helpful to keep the scar soft, once the incision is healed.

Axillary dissection involves the removal of about 10 to 30 lymph nodes from the axilla to determine whether the cancer has spread. This procedure is done during the lumpectomy if a previous breast biopsy or a frozen section examined at the time of the lumpectomy is positive for cancer. The histologic status of these nodes is important in determining prognosis and adjuvant treatment.

Patients who have an axillary dissection are discharged with a Jackson-Pratt drain. Most institutions have preprinted material to teach them how to empty and measure drainage at home. The drain stays in place until the total daily output is less than 25 mL to 30 mL per day, which usually occurs between one and two weeks. Drainage is serous to serosanguineous. Nurses will teach arm exercises to help the patient maintain range of motion on the operative side. The types of exercises and when they are begun vary with each surgeon and the type of surgery performed.

Complications from an axillary dissection include cellulitis, frozen shoulder, diminished range of motion in the shoulder, hematoma, pain or burning, and lymphedema.⁸

Lymphedema is a swelling of the arm caused by the removal or damage of underarm lymph nodes and their connecting vessels. The circulation of lymph fluid is slowed, making it more difficult to fight infection. To reduce the possibility of infection and lymphedema, nurses can instruct patients to —

• Apply sunscreen to avoid sunburn.
• Wear protective gloves when gardening.
• Use an oven mitt to avoid burns when cooking.
• Use a thimble when sewing.
• Have injections, blood draws, and blood pressures done on the nonoperative arm, when possible.
• Use an electric razor to shave underarms.
• Carry heavy items, such as purses, on the nonoperative arm.
• Wear watches or jewelry loosely on the affected arm.
• Avoid tight clothing or elastic cuffs.
• Use insect repellent.

Signs and symptoms that need to be reported to the physician —

• A temperature of 101 F or higher
• Bleeding
• Excessive drainage
• Redness, tenderness, swelling, increased pain, or warmth at the incision site
• Cough, chest pain or shortness of breath
• Any arm swelling.⁸

Sentinel lymph node biopsy is a relatively new procedure that can reduce the necessity for axillary lymph node dissection in early stage breast cancer. The procedure is still being studied. The sentinel node(s) is the first axillary lymph node(s) that would receive cancerous cells from lymph flowing from the area of the tumor, if cells were metastasizing. If the sentinel node(s) is negative, the patient does not need an axillary lymph node dissection, therefore saving patients from potential complications of more extensive surgery. If it is positive, an axillary node dissection is done. The procedure begins in the nuclear medicine department, where the radioisotope, technetium, and a more traditionally used blue dye are injected around the tumor or biopsy cavity. A lymphoscintigram scan and a hand-held gamma probe check for the migration of the radioisotope to the axilla. After the patient is transferred to the operating room, further probing identifies the sentinel node(s), which is biopsied. If the node(s) is positive via frozen section, an axillary dissection is performed.⁹

Mastectomy involves the removal of the breast. When a simple mastectomy is done, all of the breast tissue and the nipple are removed. A modified radical mastectomy includes removal of some of the axillary lymph nodes as well as the breast tissue and nipple. Because the pectoralis major muscle is no longer removed, lymphedema is less likely, arm strength remains, and reconstruction is easier. Postoperative nursing care is similar to the lumpectomy with axillary dissection surgery.

With any of the surgical procedures, nurses can make a referral to the American Cancer Society’s Reach to Recovery program before discharge. A volunteer who has had the same surgery will visit the patient and act as a peer counselor.

Breast prosthesis and reconstruction

After the mastectomy incision has healed, patients can buy a prosthesis. This breast form fits into a bra, bathing suit, or lingerie. The prosthesis should be obtained from a trained fitter, who can be located through a listing provided by the local American Cancer Society. Medicare and most insurance carriers will reimburse the cost of the prosthesis with a note from the surgeon.

At the time of the mastectomy, a plastic surgeon can perform breast reconstruction, either by breast implant or TRAM (transverse rectus abdominis musculocutaneous) flap. The breast implant is a saline-filled shell, which is inserted under the chest muscle at the time of mastectomy or later. The incision can be made through the mastectomy scar. A nipple can be reconstructed after the implant procedure is completed. If there is not enough skin and chest muscle to cover an implant, a tissue expander is used. The surgeon injects fluid through a metal port into an empty implant shell. The fluid gradually stretches the muscle and tissue so that a permanent implant can be placed. Surgery to match the remaining breast with the implant breast is also sometimes needed.

TRAM flap is a fairly extensive abdominal surgery that reconstructs a breast from abdominal muscle, fat, and skin. A flap of skin and muscle from the lower abdomen is attached to one of the rectus muscles in the abdomen. A tunnel is made under the skin from the abdomen to the mastectomy site, and the flap is pulled through the mastectomy incision and formed into the shape of a breast. A nipple and areola is created at a later date. The formed breast may also need further adjustments. Because it is made of the woman’s tissue, this reconstruction feels more like a normal breast. A three-day to five-day hospital stay is necessary, and the woman returns home with several Jackson-Pratt drains in place. Arm exercise may be delayed until the flap has healed.

Extent and prognosis

During surgery, Brenda’s surgeon removed a 2.1 cm mass with clear margins; it was easily excised. The pathology report identified invasive ductal breast cancer, ER/PR-positive with two positive nodes (2/12). HER-2/neu oncogene was negative. She was staged as T2, N1, M0 and will need adjuvant therapy. Even though she was a nurse, this language was unfamiliar to her.

Once breast cancer has been diagnosed, a complete evaluation and metastatic workup needs to be done to determine the stage of the disease and the best treatment options for the patient. The staging or metastatic workup for breast cancer may include a chest x-ray, blood tests, and bone and liver scans, if metastasis is suspected. Following this initial evaluation the patient is staged based on metastatic workup, physical exam, and the characteristics of the primary tumor. The staging system used for breast cancer is the TNM (Tumor, Node, and Metastasis) system (see appendix). Other factors that assist with prognosis and determine whether a patient might benefit from adjuvant treatment include tumor size, axillary node status, estrogen/progesterone receptor levels, multicentricity, nuclear grade, invasive nature of the tumor, HER-2/neu oncogene, histologic type, and DNA content.

Tumor Size: Larger tumors are associated with a greater likelihood of recurrence. Likewise, the probability of recurrence increases, as tumors are more invasive. Tumors measuring 2.1 cm, like Brenda’s, or less are considered to be small and indicative of a more favorable prognosis.

Axillary Node Status: Pathological evaluation of lymph nodes is necessary to properly stage the breast cancer. As the number of positive nodes increases, the prognosis gets worse. Brenda’s two positive nodes indicate a good prognosis, as long as she receives adjuvant treatment.

Estrogen (ER)/Progesterone Receptor (PR) Levels: Hormone receptor status allows clinicians to determine which women will benefit from hormonal therapy. ER- and PR-negative tumors are associated with a less favorable prognosis. Brenda’s ER/PR-positive status indicates that she will probably respond to hormonal therapy.

Multicentricity refers to the presence of one or more areas of breast cancer in the same or opposite breast.

Nuclear Grade refers to the nuclear characteristics of the cancer cells. A high nuclear grade means that the tumor is rapidly growing.

Invasive Nature is the capability of the tumor to invade the surrounding tissues.

HER-2/Neu Oncogene: This protein transforms normal cells into cancer cells and regulates their growth. About a third of all breast cancers have excess amounts of this growth-promoting protein, which correlates with a poor prognosis in women with node-positive disease. The expression of HER-2/neu occurs more often in advanced cancers and those that are poorly differentiated, that is, breast cancer cells that no longer resemble normal breast tissue.

Histological Type: More differentiated tumor cells (those that more closely resemble normal breast tissue) are associated with a better prognosis. Tumors are usually classified as grade one, which is well differentiated; grade two, which is moderately differentiated; and grade three, which has poorly differentiated cells.

DNA Content: Flow cytometry is a laboratory test that evaluates cellular DNA and growth. Tumors with normal DNA content have a better prognosis than those with abnormal DNA.⁵

Chemotherapy

Before Brenda started her radiation therapy, she visited her medical oncologist to begin chemotherapy. Her first course consisted of four cycles of cyclophosphamide (Cytoxan) and doxorubicin (Adriamycin) every three weeks, followed by four cycles of paclitaxel (Taxol) every three weeks. Because doxorubicin can be cardiotoxic if not given in the correct doses or if administered to a patient who has a compromised cardiac status, Brenda had a MUGA (multiple gated acquisition) scan to determine baseline cardiac function before starting chemotherapy. Finally, she was started on oral tamoxifen (Nolvadex), 20 mg a day, which will continue for five years. The nurses spent a lot of time teaching her about the adverse effects of chemotherapy and how to manage them. Brenda found that their encouragement and support helped her to anticipate and manage these adverse effects, and she was able to work throughout the treatment. The adverse effect that most worried Brenda was alopecia. Before the chemotherapy she spoke with her nurses, who instructed her to cut her hair short so the hair loss would be less traumatic. She also bought a wig and wore it faithfully throughout her treatment. Brenda has a positive outlook and a great sense of humor. She told the nurses, “I always wanted to be a blonde — now is my chance!”

Surgery and radiation therapies are considered local therapies because they are intended to treat the primary tumor. Systemic therapy is given to reach cancer cells that may have spread beyond the breast. Chemotherapy and hormonal therapy are both examples of systemic therapies. Adjuvant therapy is chemotherapy or hormonal therapy that is given in addition to surgery and radiation therapy to women with no clinical evidence of breast cancer metastasis.

Usually several chemotherapeutic agents are given at the same time. They are more effective when working together. Most combinations are given every two to four weeks for six to eight cycles, depending on the regimen. The most common agents used to treat breast cancer are doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), paclitaxol (Taxol), methotrexate (Mexate), 5-FU (fluorouracil), epirubicin (Ellence), and docetaxel (Taxotere).

The adverse effects of chemotherapy depend on the type of drug, the dose, and the length of treatment. Common adverse effects of systemic chemotherapy include —

• Myelosuppression (neutropenia, anemia, and thrombocytopenia)
• Nausea and vomiting
• Diarrhea
• Mucositis (inflammation of the mucosal cells)
• Alopecia
• Fatigue
• Peripheral neuropathy¹⁰

Growth factors, such as epoetin alfa (Procrit) and darbepoetin alfa (Aranesp), help maintain hemoglobin levels by stimulating red blood cell production, and filgrastim (Neupogen) and pegfilgrastim (Neulasta) help decrease the duration and severity of neutropenia by promoting white blood cell production and activity. These growth factors help women receive the planned chemotherapy dose on time that in turn has as impact on survival.

A new biological drug is available to some women in addition to standard chemotherapy. Trastuzumab (Herceptin) is a monoclonal antibody that is given to women who produce excessive amounts of the protein HER-2/neu, which is found on the surface of cancer cells. IV trastuzumab is usually given weekly on an outpatient basis. The drug is thought to work by blocking HER-2/neu oncogene’s effect of transforming a normal cell into a cancer cell and signaling immune cells to attack and kill cells that contain the receptor HER-2/neu.²

Patients who are taking chemotherapy should know to call their provider if any of the following occur —

• A temperature of 100.5 F or greater
• Severe shaking or chills
• Shortness of breath
• Unusual bleeding, such as nosebleeds, black tarry stools, easy bruising, or bleeding gums
• Sore throat or pain upon swallowing
• Mouth sores
• Nausea and vomiting for more than 24 hours
• Six or more episodes of diarrhea within 24 hours
• Constipation for more than 48 hours
• Swelling of the feet or arms.

Radiation therapy

Brenda started her radiation therapy after her chemotherapy. When she felt fatigued toward the end of the treatment course, her nurses taught her how to incorporate energy conservation methods into her daily schedule. She learned to plan ahead and to do things when she felt especially strong. She also learned to ask for help from friends and family.

Radiation therapy is most often used for local control of clinically undetectable cancer cells following surgery. It is directed to the breast and/or the axilla. Radiation is used to —

• Reduce the chance of local recurrence for women with large tumors or evidence of tumor cells in the margins following lumpectomy or mastectomy.
• Treat chest wall recurrence following mastectomy.
• Preoperatively shrink large breast tumors, so that they are more easily resected.
• Palliatively manage metastasis to other sites, such as bone or brain, or to relieve pain from bone metastasis.

After the initial planning session, called simulation, radiation treatments are scheduled for a few minutes per day, Monday through Friday, for six weeks. Many women continue to work or maintain their usual lifestyle while undergoing treatment. Fatigue can occur and is especially pronounced toward the end of treatment.

Adverse effects associated with radiation include fatigue, skin redness or dryness, and moist or dry desquamation. Desquamation is the breakdown of the squamous cell layer of the skin due to radiation therapy. The skin can appear dry and flaky with severe pruritus or reddened and moist with drainage. Skin reactions usually resolve one week to two weeks after completion of therapy. Nurses caring for women undergoing radiation therapy to the breast need to teach them to use only skin products that are approved by their radiation oncologist. Deodorant should not be worn on the side that is irradiated because it may heighten effects of the radiation, such as edema, irritation, and changes in skin color. Women who are taking doxorubicin (Adriamycin) chemotherapy after radiation therapy should be aware that they might experience “radiation recall,” skin redness in the treated area.⁵

A new operative procedure delivers targeted radiation therapy to the tumor bed, thereby limiting damage to healthy breast tissue and reducing the length of treatment needed. Clinicians directly deliver radiation internally to the tissue surrounding the original tumor, minimizing radiation exposure to the rest of the breast, skin, ribs, lungs, and heart. During the lumpectomy procedure or shortly thereafter, they place a deflated balloon inside the tumor resection cavity. The applicator shaft, a tube connected to the balloon, remains outside the breast. Once in place, the balloon is inflated with saline to fill the cavity, the catheter site is dressed, and the patient may go home. The balloon remains inflated for the entire time that the patient is receiving radiation therapy. The patient returns to the hospital for treatment on an outpatient basis where a radioactive “seed” is inserted within the inflated balloon, beginning a one-to-five day sequence of treatments. No source of radiation remains in the patient’s body between treatments or after the final procedure. When the therapy is concluded, the balloon is deflated and the catheter is easily removed.¹¹

Hormonal therapy

Due to the positive ER/PR status of her breast tumor, Brenda started taking tamoxifen, an antiestrogen agent that blocks estrogen production. Because a breast cancer tumor can be estrogen responsive, her provider hopes that besides treating the current problem, this drug will help prevent breast cancer in the other breast as well. Women who have breast cancer are at increased risk of occurrence in the other breast.

Estrogen promotes the growth of some breast cancers, especially those that are estrogen receptor/progesterone receptor (ER/PR) positive. An estrogen-blocking agent like tamoxifen, 20 mg orally once a day, is the most commonly used hormonal agent to treat these tumors. The most common adverse effects related to this agent are edema, weight gain, hot flashes, and bone pain. Other less common adverse effects are nausea and vomiting, headaches, and thrombophlebitis. Women usually take tamoxifen for five years. Recent studies have shown that five years of postoperative tamoxifen therapy, but not longer, prolongs a disease-free period and overall survival. Taking another hormonal agent, letrozole (Femara), after tamoxifen therapy is discontinued may improve the outcome.¹² Letrozole is one agent in a class of drugs called aromatase inhibitors. Other agents in this class are anastrozole (Arimidex) and exemestane (Aromasin). These agents were first approved for treating advanced breast cancer. Aromatase inhibitors work by blocking an enzyme responsible for producing small amounts of estrogen in postmenopausal women. They do not block the ovaries from producing estrogen, so they are not effective for premenopausal women. In 2005 the American Society of Clinical Oncologists updated its recommendations for hormonal therapy for postmenopausal women to include aromatase inhibitors as initial therapy or following treatment with tamoxifen. At this time further research is necessary to determine the optimal timing and duration of hormonal therapy.²

Nurses should advise patients to use non-hormonal contraception, such as diaphragms and condoms, during therapy and to have a yearly GYN exam to check for endometrial cancer, because tamoxifen increases the risk for endometrial cancer.¹³

Hormonal therapy also has a role in breast cancer prevention. The first study from the National Surgical Adjuvant Breast and Bowel Project (NSABP), documented a 49% reduction in the incidence of invasive breast cancer in women at increased risk who took tamoxifen compared to those who did not receive the drug. The second major NSABP breast cancer prevention trial — the Study of Tamoxifen and Raloxifene (STAR) trial — began in the spring of 1999 and ended in 2005. This study is examined whether raloxifene (Evista), a drug similar to Tamoxifen, is also effective in preventing breast cancer in women who have not had the disease and if raloxifene offers any benefits over those obtained with tamoxifen, such as fewer adverse effects. This study includes 22,000 postmenopausal women aged 35 and older who are at increased risk of developing breast cancer.¹³ Results from this study are expected to be released sometime in 2006.²

How nurses can really make a difference

Nurses can be excellent sources of information and support to women and their significant others during every phase of the disease continuum. For example, women may experience a high level of anxiety during the prediagnostic period. Nurses can help them by keeping them informed about what to expect. Discuss how long they will have to wait for the results of tests and procedures, such as mammograms and biopsies. If possible, the woman should be able to determine how and where the results will be disclosed to her. The diagnosis of cancer itself can produce feelings of shock, disbelief, despair, helplessness, guilt, and vulnerability. There are many decisions to make. Nurses can provide information about available treatments. If metastasis is present at the time of the diagnosis, the woman may be confronting the possibility of death. The nurse can recommend a breast cancer support group. Women who are part of a support group can survive longer. A list of area support groups can be obtained from the closest ACS office or the local hospital.

The treatment phase brings its own issues. Again, nurses need to prepare women for what to expect. For example, women undergoing surgery may experience body image changes. In this society, the breast represents sexuality, love, and nurturing. As a result of changes in body and self-image, women may become anxious, angry, or depressed. Talking to someone else who has been through the same kind of surgery is helpful. The ACS has a program called “Look Good-Feel Better” that can help women cope with the issues regarding changes in body image and looks. It teaches make-up and hair techniques to women who have had chemotherapy or radiation therapy. The ACS’s “Reach to Recovery” program provides peer support. Patients get to meet with trained volunteers of the same age who have had similar surgery. Treatment issues can also affect women’s partners and other family members. The ACS’s “I Can Cope” program is an additional program designed to help women and their families deal with a breast cancer diagnosis.

Issues related to survivorship

Nurses working with survivors of breast cancer need to be aware of the issues women face related to surviving. Living with a potentially life-threatening illness can change the way they perceive life itself. Survivors often look for some meaning in the cancer experience. They may try to integrate the disease and its treatment into their current lives. They may be dealing with a change in their relationship with others.

Nurses, particularly those in ambulatory areas, can identify women who are having more difficulty adjusting to their disease and refer them to resources for counseling or to a breast cancer support group. One terrific resource they can recommend in conjunction with the Oncology Nursing Society and the Association of Oncology Social Workers is The Cancer Survivor’s Toolbox®. This set of audiotapes covers topics related to cancer and surviving with the challenge of a chronic illness; and can be accessed or ordered online at www.cancersurvivaltoolbox.org. The National Coalition for Cancer Survivorship can also provide additional resources. They can be reached at www.canceradvocacy.org or by phone at (877) NCCS-YES.

Brenda completed her treatment. She has follow-up visits with her medical oncologist every three months. Brenda has been disease-free for two years. She donates her time as a Reach to Recovery volunteer, telling anyone who will listen that living with breast cancer has changed her outlook. She enjoys life more and doesn’t sweat the small stuff. The experience strengthened her relationships with her family and friends; she knows who her true friends are. They supported her through diagnosis and treatment and remain a positive influence in her life. She also feels that the experience has made her a better nurse because she truly understands the patient’s role. She knows the importance of keeping patients informed and advocating for them.

Thinking back, the most remarkable interventions came from other nurses. Although they knew that Brenda was a nurse herself, they left nothing to chance. She is continuing to work and volunteer and is eagerly looking forward to her daughter’s wedding next year.