Problems of the breasts
- Include both benign and malignant breast disease
- Two goals of initial evaluation
o Distinguish benign from malignant tumors
o Assess the risk of developing breast cancer associated with leison
Overview
- These problems affect women throughout most of their lives, can start at an early age
- These changes can occur through menopause
- Can be benign or malignant
- Nurses play an important role in care, support, education and advocacy for these
condition
Fibrocystic breasts
- The most common BENIGN breast problem
- Can occur in healthy women
- Usually occurs between ages 20-50
- Due to changes in ovarian hormone
- Ch
- Benign breast conditions- nipple discharge
o Most nipple discharge is physiologic
o Can be very concerning to a woman
o Galactorrhea- bilateral, milky, sticky discharge
▪ Normal in pregnancy
▪ Seen when prolactin levels are elevated
o Can have nipple discharge related to endocrine disorder or malignancy
▪ So need to assess carefully
o Possible causes
▪ hypothyroidism, pituitary adenomas (growth on pituitary gland- that
secrete prolactin)
▪ Elevated prolactin levels could= nipple d/c
▪ normal vs worrisome: differences in actual d/c
• Normal/ benign: nipple d/c bilateral, serous (clear), coming out of
multiple ducts (holes), expressed with nipple stimulation
• Worrisome: can be associated with malignancy: nipple d/c is
spontaneous w/o expression or stimulation, bloody d/c, comes
from only 1 or 2 ducts in nipple, one sided
• Unilateral * very concerning for malignancy
,- Malignant conditions of the breast
o Incidence
▪ 2nd leading cause of cancer death in women ages 45-55
▪ 1 in 8 women at risk for breast cancer
▪ 79% found in women over age 50
• aging= huge risk factor
• White women have a higher incidence of breast cancer= more
cases, but African American women have more mortality/ death
rates
• Upper outer quadrant: 50% of breast cancers happen- pay special
attn when assessing!
o Male breast cancer
▪ <1% of all breast cancers
• Men: breast cancer seen less, but higher mortality rate (usually
caught later)
• Usually detected as hard lump underneath nipple and areola
o Risk factors (nonmodifiable )
▪ Gender
▪ Age
▪ Early menarche or late menopause
• Prolonged exposure to estrogen
▪ Age at first live birth
• Older like 35/40= inc risk
▪ Nulliparity
▪ Fam history
▪ Personal history of breast cancer
▪ Dense breast tissue
• Mammograms more difficult to interpret
• May do ultrasound instead
▪ Genetics
• BRCA 1 and BRCA 2
o Risk factors (modifiable)
▪ Obesity
▪ Lack of exercise
▪ Diet high in saturated fat
▪ Moderate to high alc consumption
▪ Use of exogenous hormones for more than 10 years
▪ Not breastfeeding
, • chronic anovulation with obesity: don’t have progesterone in
second part of cycle to oppose estrogen, so inc estrogen= more risk
for breast cancer
• Hormones for 10 yrs could be birth control, etc
o Pathophysiology
▪ Begins in the epithelial cells lining the mammary ducts and lobules
• Invasive (infiltrating)- grow into the wall of mamary ducts and into
surrounding tissue
• Nonivasive (in situ): hasnt invaded wall or surrounding tissue
▪ Generally either ductal or lobular
▪ Metastasis
• once penetrates wall: becomes invasive carcinomas
• In situ: has not invaded wall yet/ or any surrounding tissue
• breast has a lot of lymphatic drainage: enables cancer cells to
spread really easily
• most common places to spread: brain, bone, liver and long
• Bcs of direction of lymphatic drainage
- Clinical manifestations
o RED FLAGS:
▪ Usually painless
▪ Immobile, palpable lump
▪ Nipple retraction
▪ Nipple discharge
▪ Dimpling of breast tissue
▪ Skin changes
• Peau d’orange
▪ Change in breast size or shape
• one-sided: always more concerning than bilateral for malignancy
• Nipple retraction: as cancer grows will pill nipple inward
• Paeu d’ orange: those dots that look like orange peel
o Prognosis
▪ Nodal involvement
▪ Tumor size
▪ Various molecular and biologic markers
▪ Estrogen/ progesterone receptor status
• HER2: positive cancers have more positive prognosis
• Goes to pathology and they test for certain markers that will help
us know her prognosis, and how to treat
- Maligant conditions of the breast: screening and diagnsois
o Mammography
, ▪ Gold standard for screening and early detection
o Ultrasound
▪ Used in women with significant breast density
▪ Distinguishes between fluid filled (cysts) and solid masses (benign and
malignant)
o MRI
▪ High sensitivity for breast cancer, expensive
o PET scan
▪ add on test if woman HAS breast cancer
▪ Will look for metastatic disease in body
o Biopsy
▪ can take lump/ mass and look at benign vs malignant
▪ Confirmatory for breast cancer!!
o Extra info:
▪ women starting at 20-39 don’t need mammogram, but need clinical breast
exam by provider
▪ Every 3 years at a MINIMUM
▪ Early fam hx- may start mammograms earlier, etc
▪ 40 and older: breast exam every year
▪ Mammograms annually at age 40
▪ Ultrasound: adjust to screening esp with dense breast tissue
▪ Can also help with like biopsies for placement
- Care managment for women with breast cancer
o Treatment options
▪ Breast conserving surgeries
• Lumpectomy: small tumor remove and little bit of healthy tissue to
ensure clean margins
o Still large scar on breast
• Partial masectomy: mass plus little larger rim of healthy tissue
o Small quadrant of breast taken
▪ Mastectomy
• Total simple masectomy: removal of breast, nipple, aerola
• Radical masectomy: removal of breast, lymph nodes, pectoralis/
chest wall
o Much more extensive
▪ Chemotherapy
▪ Hormone therapy
▪ Radiation
▪ Info:
• Breast reconstruction usually done with mastectomy: put
expanders in during SAME surgeries and then wait to put fluid in
- Include both benign and malignant breast disease
- Two goals of initial evaluation
o Distinguish benign from malignant tumors
o Assess the risk of developing breast cancer associated with leison
Overview
- These problems affect women throughout most of their lives, can start at an early age
- These changes can occur through menopause
- Can be benign or malignant
- Nurses play an important role in care, support, education and advocacy for these
condition
Fibrocystic breasts
- The most common BENIGN breast problem
- Can occur in healthy women
- Usually occurs between ages 20-50
- Due to changes in ovarian hormone
- Ch
- Benign breast conditions- nipple discharge
o Most nipple discharge is physiologic
o Can be very concerning to a woman
o Galactorrhea- bilateral, milky, sticky discharge
▪ Normal in pregnancy
▪ Seen when prolactin levels are elevated
o Can have nipple discharge related to endocrine disorder or malignancy
▪ So need to assess carefully
o Possible causes
▪ hypothyroidism, pituitary adenomas (growth on pituitary gland- that
secrete prolactin)
▪ Elevated prolactin levels could= nipple d/c
▪ normal vs worrisome: differences in actual d/c
• Normal/ benign: nipple d/c bilateral, serous (clear), coming out of
multiple ducts (holes), expressed with nipple stimulation
• Worrisome: can be associated with malignancy: nipple d/c is
spontaneous w/o expression or stimulation, bloody d/c, comes
from only 1 or 2 ducts in nipple, one sided
• Unilateral * very concerning for malignancy
,- Malignant conditions of the breast
o Incidence
▪ 2nd leading cause of cancer death in women ages 45-55
▪ 1 in 8 women at risk for breast cancer
▪ 79% found in women over age 50
• aging= huge risk factor
• White women have a higher incidence of breast cancer= more
cases, but African American women have more mortality/ death
rates
• Upper outer quadrant: 50% of breast cancers happen- pay special
attn when assessing!
o Male breast cancer
▪ <1% of all breast cancers
• Men: breast cancer seen less, but higher mortality rate (usually
caught later)
• Usually detected as hard lump underneath nipple and areola
o Risk factors (nonmodifiable )
▪ Gender
▪ Age
▪ Early menarche or late menopause
• Prolonged exposure to estrogen
▪ Age at first live birth
• Older like 35/40= inc risk
▪ Nulliparity
▪ Fam history
▪ Personal history of breast cancer
▪ Dense breast tissue
• Mammograms more difficult to interpret
• May do ultrasound instead
▪ Genetics
• BRCA 1 and BRCA 2
o Risk factors (modifiable)
▪ Obesity
▪ Lack of exercise
▪ Diet high in saturated fat
▪ Moderate to high alc consumption
▪ Use of exogenous hormones for more than 10 years
▪ Not breastfeeding
, • chronic anovulation with obesity: don’t have progesterone in
second part of cycle to oppose estrogen, so inc estrogen= more risk
for breast cancer
• Hormones for 10 yrs could be birth control, etc
o Pathophysiology
▪ Begins in the epithelial cells lining the mammary ducts and lobules
• Invasive (infiltrating)- grow into the wall of mamary ducts and into
surrounding tissue
• Nonivasive (in situ): hasnt invaded wall or surrounding tissue
▪ Generally either ductal or lobular
▪ Metastasis
• once penetrates wall: becomes invasive carcinomas
• In situ: has not invaded wall yet/ or any surrounding tissue
• breast has a lot of lymphatic drainage: enables cancer cells to
spread really easily
• most common places to spread: brain, bone, liver and long
• Bcs of direction of lymphatic drainage
- Clinical manifestations
o RED FLAGS:
▪ Usually painless
▪ Immobile, palpable lump
▪ Nipple retraction
▪ Nipple discharge
▪ Dimpling of breast tissue
▪ Skin changes
• Peau d’orange
▪ Change in breast size or shape
• one-sided: always more concerning than bilateral for malignancy
• Nipple retraction: as cancer grows will pill nipple inward
• Paeu d’ orange: those dots that look like orange peel
o Prognosis
▪ Nodal involvement
▪ Tumor size
▪ Various molecular and biologic markers
▪ Estrogen/ progesterone receptor status
• HER2: positive cancers have more positive prognosis
• Goes to pathology and they test for certain markers that will help
us know her prognosis, and how to treat
- Maligant conditions of the breast: screening and diagnsois
o Mammography
, ▪ Gold standard for screening and early detection
o Ultrasound
▪ Used in women with significant breast density
▪ Distinguishes between fluid filled (cysts) and solid masses (benign and
malignant)
o MRI
▪ High sensitivity for breast cancer, expensive
o PET scan
▪ add on test if woman HAS breast cancer
▪ Will look for metastatic disease in body
o Biopsy
▪ can take lump/ mass and look at benign vs malignant
▪ Confirmatory for breast cancer!!
o Extra info:
▪ women starting at 20-39 don’t need mammogram, but need clinical breast
exam by provider
▪ Every 3 years at a MINIMUM
▪ Early fam hx- may start mammograms earlier, etc
▪ 40 and older: breast exam every year
▪ Mammograms annually at age 40
▪ Ultrasound: adjust to screening esp with dense breast tissue
▪ Can also help with like biopsies for placement
- Care managment for women with breast cancer
o Treatment options
▪ Breast conserving surgeries
• Lumpectomy: small tumor remove and little bit of healthy tissue to
ensure clean margins
o Still large scar on breast
• Partial masectomy: mass plus little larger rim of healthy tissue
o Small quadrant of breast taken
▪ Mastectomy
• Total simple masectomy: removal of breast, nipple, aerola
• Radical masectomy: removal of breast, lymph nodes, pectoralis/
chest wall
o Much more extensive
▪ Chemotherapy
▪ Hormone therapy
▪ Radiation
▪ Info:
• Breast reconstruction usually done with mastectomy: put
expanders in during SAME surgeries and then wait to put fluid in
