B REAST D ISORDERS

B REAST C ANCER M ASS (M ALIGNANT T UMOR ) Usually occurs as a single mass (lump) in one breast Usually nontender Irregular shape Firm, hard, embedded in surrounding tissue Referral and biopsy indicated for definitive diagnosis

B REAST C YST (B ENIGN M ASS ) Occur as single or multiple lumps in one or both breasts Usually tender (omitting caffeine reduces tenderness); tenderness increases during premenstrual period Round shape Soft or firm, mobile Referral and biopsy indicated for definitive diagnosis, especially for first mass; later masses may be evaluated over time by a specialist

F IBROADENOMA (B ENIGN B REAST L UMP ) Usually occurs as a single mass in women aged 15–35 years Usually nontender May be round or lobular Firm, mobile, and not fixed to breast tissue or chest wall No premenstrual changes Referral and biopsy indicated for definitive diagnosis

A CUTE M ASTITIS (I NFLAMMATION OF THE B REASTS ) Associated with lactation but may occur at any age Nipple cracks or abrasions noted Breast skin reddened and warm to touch Tenderness Systemic signs include fever and increased pulse

D IAGNOSTIC E VALUATION Breast Self-Examination Mammography Ultrasonography Magnetic Resonance Imaging Procedures for Tissue Analysis: Percutaneous Biopsy Fine-Needle Aspiration (FNA)

Mammography is a breast-imaging technique that has been shown to reduce breast cancer mortality rates. It can detect nonpalpable lesions and assist in diagnosing palpable masses. The procedure takes about 15 minutes and can be performed in a hospital radiology department or independent imaging center. Two views are taken of each breast. The breast is mechanically compressed from top to bottom (craniocaudal view) and side to side

Mammography may detect a breast tumor before it is clinically palpable (ie, smaller than 1 cm); however, it has limitations. The false-negative rate ranges between 5% and 10%. Younger women, or those taking HT, may have dense breast tissue, making it more difficult to detect lesions with mammography

S URGICAL B IOPSY Surgical biopsy is usually performed using local anesthesia and IV sedation. After an incision is made, the lesion is excised and sent to a laboratory for pathologic examination

T YPES OF S URGICAL B REAST B IOPSY Excisional Biopsy Excisional biopsy is the standard procedure for complete pathological assessment of a palpable breast mass. The entire mass, plus a margin of surrounding tissue, is removed.

Incisional biopsy surgically removes a portion of a mass. This is performed to confirm a diagnosis and to conduct special studies that will aid in determining treatment Complete excision of the area may not be possible or immediately beneficial to the patient, depending on the clinical situation

B REAST C ANCER

R ISK F ACTORS FOR B REAST C ANCER Female gender Increasing age Personal history of breast cancer Family history of breast cancer Genetic mutations (BRCA-1 and BRCA-2 mutations are responsible for majority of inherited breast cancer cases)

Hormonal factors Early menarche Late menopause Nulliparity First child after 30 years of age Hormone therapy (HT) Exposure to ionizing radiation during adolescence and early adulthood History of benign proliferative breast disease Obesity High-fat diet (controversial) Alcohol intake

M ANAGMENT Chemoprevention Chemoprevention is a primary prevention modality that aims at preventing the disease before it starts

P ROPHYLACTIC M ASTECTOMY Prophylactic mastectomy is another primary prevention modality. This procedure can reduce the risk of cancer by 90% and is sometimes referred to as a “risk-reducing” mastectomy. The procedure consists of a total mastectomy (removal of breast tissue only) and is usually accompanied by immediate breast reconstruction. Possible candidates include women with a strong family history of breast cancer, atypical hyperplasia, a BRCA gene mutation, an extreme fear of cancer (“cancer phobia”), or previous cancer in one breast. A patient who is considering prophylactic mastectomy is often faced with a very controversial and emotional decision

Prognosis Several different factors must be taken into consideration when determining the prognosis of a patient with breast cancer. The two most important factors are tumor size and whether the tumor has spread to the lymph nodes under the arm (axilla).

S URGICAL M ANAGEMENT The main goal of surgery is to obtain local control of the disease. With breast cancer being diagnosed today at earlier stages, options for less invasive surgical procedures are available. Surgical treatment options for noninvasive and invasive breast cancer

M ODIFIED R ADICAL M ASTECTOMY Modified radical mastectomy is performed to treat invasive breast cancer. The procedure involves removal of the entire breast tissue, including the nipple-areola complex. In addition, a portion of the axillary lymph nodes are also removed in axillary lymph node dissection (ALND). If immediate breast reconstruction is desired, the patient is referred to a plastic surgeon prior to the mastectomy so that she has the opportunity to explore all available options. Radical mastectomy is rarely performed today

T OTAL M ASTECTOMY Like modified radical mastectomy, total mastectomy (i.e., simple mastectomy) also involves removal of the breast and nipple-areola complex but does not include ALND. Total mastectomy may be performed for patients with noninvasive breast cancer, which does not have a tendency to spread to the lymph nodes. It may also be performed prophylactically for patients who are at high risk for breast cancer (eg, LCIS, BRCA mutation). A total mastectomy may also be performed in conjunction with sentinel lymph node biopsy (SLNB) for patients with invasive breast cancer

P REOPERATIVE N URSING D IAGNOSES Deficient knowledge about the planned surgical treatments Anxiety related to the diagnosis of cancer Fear related to specific treatments and body image changes Risk for ineffective coping (individual or family) related to the diagnosis of breast cancer and related treatment options Decisional conflict related to treatment options

P OSTOPERATIVE N URSING D IAGNOSES Pain and discomfort related to surgical procedure Disturbed sensory perception related to nerve irritation in affected arm, breast, or chest wall Disturbed body image related to loss or alteration of the breast Risk for impaired adjustment related to the diagnosis of cancer and surgical treatment Self-care deficit related to partial immobility of upper extremity on operative side

Risk for sexual dysfunction related to loss of body part, change in self-image, and fear of partner's responses Deficient knowledge: drain management after breast surgery Deficient knowledge: arm exercises to regain mobility of affected extremity Deficient knowledge: hand and arm care after an axillary lymph node dissection (ALND