56
Breast Problems
Deena D. Dell
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Coping Pain
Cellular Regulation Sexuality
Infection
LEARNING OUTCOMES
1. State screening guidelines for the early detection of breast 5. Describe the interprofessional and nursing management of
cancer. breast cancer.
2. Explain the types, causes, clinical manifestations, and 6. Specify the physical and psychologic aspects of nursing
interprofessional and nursing management of common management for the patient undergoing breast cancer
benign breast problems. surgery.
3. State the risk factors for breast cancer. 7. Explain the indications for, types and complications of, and
4. Describe the pathophysiology and clinical manifestations of nursing management after reconstructive breast surgery.
breast cancer.
KEY TERMS
ductal ectasia lumpectomy
fibroadenoma lymphedema
fibrocystic changes mammoplasty
galactorrhea mastalgia
gynecomastia mastitis
intraductal papilloma Paget disease
Breast problems are a significant health concern for women. ASSESSMENT OF BREAST PROBLEMS
Whether the actual diagnosis is a benign condition or cancer,
the initial discovery of a lump or change in the breast often trig- Breast Cancer Screening Guidelines
gers intense feelings of anxiety and fear. The potential loss of a Screening guidelines for the early detection of breast cancer vary
breast, or part of a breast, may be devastating for many women depending on a woman’s age and risk (Table 56.1).2 Average risk
because of the significant psychologic, social, sexual, and body women include those with no personal history of breast cancer,
image implications associated with it. a strong family of breast cancer, a genetic mutation known to
The most common breast problems are fibrocystic increase breast cancer, and has not had chest radiation therapy
changes, fibroadenoma, intraductal papilloma, ductal ecta- before the age of 30.
sia, and breast cancer. In a woman’s lifetime, there is a 1 in 8 Women at increased risk for breast cancer (family history,
(12%) chance that she will be diagnosed with breast cancer.1 genetic link, prior breast cancer, history of thoracic radiation
Although rare, breast cancer does occur in men. Being aware therapy, or certain atypical findings on a prior breast biopsy)
of personal risk, including genetic factors, and taking part should talk with their HCP about the benefits and limitations
in recommended screening are important health promotion of starting screening earlier with 3D mammography and breast
activities. magnetic resonance imaging (MRI) and having more frequent
1371
,1372 SECTION 11 Problems Related to Regulatory and Reproductive Mechanisms
clinical breast encounters. A clinical encounter includes an Diagnostic Studies
assessment of risk factors, instruction in ways to reduce the risk Radiologic Studies
factors, and a clinical breast examination (CBE).3 We use several techniques to screen for breast problems or help
Consistent breast self-examination (BSE) may be a useful diagnose a suspicious physical finding. Mammography is used
way to increase self-awareness of how one’s breasts normally to view the breast’s internal structure using x-rays (Fig. 56.1). It
look and feel. However, research has shown that BSE has no can detect suspicious lumps that cannot be felt. Mammography
effect on reducing deaths from breast cancer. However, you still has significantly improved the early and accurate detection of
need to teach women the importance of knowing how their breast cancer. Improved imaging technology has reduced the
breasts look and feel and to report breast changes (e.g., nipple radiation dose from mammography.
discharge, a lump) to their HCP.3 A comparison of current and prior mammograms may show
If a woman wants to learn about BSE, include information early tissue changes. Because some tumors metastasize late, early
about the potential benefits and limitations. Allow time for detection by mammography allows for earlier treatment and the
questions and a return demonstration. For women who choose prevention of metastasis. In younger women, mammography
to perform BSE, teach the method described at www.breastcan- is less sensitive because of the greater density of breast tissue,
cer.org/symptoms/testing/types/self_exam/. resulting in more false-negative results. Having dense breasts
makes mammographic detection of cancer more difficult.
With digital mammography x-ray images are digitally coded
TABLE 56.1 Breast Cancer Screening and stored in a computer (Fig. 56.1). It is more accurate than
Guidelines traditional film mammography in younger women with dense
The American Cancer Society (ACS) recommends the following guidelines for breasts. The availability and associated costs of digital mam-
screening women at average risk for breast cancer: mography are issues with this technology.
• Women should undergo regular screening mammography starting at age
3D mammography, or tomosynthesis mammography, pro-
45 years duces a 3D image of the breast. It gives a clearer view of over-
• Women should be offered the chance to begin annual screening between lapping breast tissue structures. It can increase the number of
the ages of 40 and 44 cancers detected and decrease the number of false-positive
• Women aged 45–54 years should be screened annually results (a result stating a cancer is present when it is not).
• Women 55 years and older can switch to every other year screening or Calcifications are the most easily recognized mammogram
can continue screening annually abnormality (Fig. 56.1). They are deposits of calcium crystals
• Women should continue screening if their overall health is good, and they that form in the breast. Causes include inflammation, trauma,
have a life expectancy of 10 years or longer and aging. Although most calcifications are benign, they may
• The ACS does not recommend CBE as screening for breast cancer occur with breast cancer.
A B
Fig. 56.1 Screening mammogram showing dense breast tissue and benign, scattered microcalcifications.
(A) Using conventional x-rays. (B) Using digital x-rays. (From Patel B, Lobbes M, Lewin J: Contrast enhanced
spectral mammography: a review, Semin Ultrasound CT MR 39:70, 2018e.)
, CHAPTER 56 Breast Problems 1373
About 10% to 15% of all breast cancers cannot be seen on related to hormonal sensitivity. Symptoms often decrease with
mammography. They may be detected by palpation or other menopause.
breast imaging studies, such as ultrasound and MRI. If the clin- Noncyclic mastalgia has no relationship to the menstrual
ical findings are suspicious and the mammogram is normal, cycle. It can continue into menopause. Pain may be constant or
an ultrasound or MRI may be done. Based on these findings, a intermittent throughout the month and last for several years.
biopsy may be done. Symptoms include a burning, aching, or soreness in the breast.
Ultrasound is used in conjunction with mammography It usually affects only 1 breast. The pain may be from trauma, fat
to discern a solid mass from a cystic mass, to evaluate a mass necrosis, ductal ectasia, costochondritis, or arthritic pain in the
in a pregnant or lactating woman, and to locate and biopsy a chest or neck radiating to the breast.
suspicious lesion. MRI is recommended as a screening tool in For patients with breast pain, mammography and targeted
addition to mammography for women who are at high risk for ultrasound are often done to exclude cancer and provide infor-
breast cancer (e.g., first-degree relative with a BRCA mutation). mation on the cause of the pain. Reassure women that mastalgia
is not a usual sign of breast cancer.4
Biopsies There is no specific treatment for breast pain. Some relief
A definitive diagnosis of a suspicious area is made by analyzing for cyclic pain may occur by reducing intake of caffeine and fat;
biopsied tissue. Biopsy techniques include fine-needle aspira- taking vitamin E or gamma-linolenic acid (evening primrose
tion (FNA), core (core needle), vacuum-assisted, and excisional oil); and continually wearing a supportive bra. Compresses, ice,
biopsies. analgesics, and antiinflammatory drugs may help. Tamoxifen
FNA biopsy is done by inserting a needle into a lesion to may provide relief in up to 70% of women with few side effects.
sample fluid from a breast cyst, remove cells from intercellular Bromocriptine, a prolactin inhibitor, may provide some with
spaces, or sample cells from a solid mass. Before the procedure, relief. It causes GI upset and lightheadedness. Danazol is an
the breast area is first locally anesthetized. Then, the needle is FDA-approved treatment. The androgenic side effects (acne,
placed into the breast, and fluid and cells are aspirated into a edema, hirsutism) make this therapy unacceptable for many
syringe. Usually, 3 or 4 passes are made. If the results are nega- women.
tive with a suspicious lesion, another biopsy may be necessary.
A core (core needle) biopsy involves removing small sam- BREAST INFECTIONS
ples of breast tissue using a hollow “core” needle. For palpable
lesions, this is done by fixing the lesion with one hand and per- Mastitis
forming a needle biopsy with the other. In the case of nonpal- Mastitis is an inflammatory breast condition. It occurs most
pable lesions, stereotactic mammography, ultrasound, or MRI often in lactating women (Table 56.2). Lactational mastitis
image guidance is used. Stereotactic mammography uses com- presents as a localized area that is red, painful, and tender to
puters to pinpoint the exact location of a breast mass based on palpation. Fever is often present. The infection develops when
mammograms. With ultrasound, the HCP watches the needle pathogens (usually staphylococci) gain access to the breast
on the ultrasound monitor to help guide it to the area of con- through a cracked nipple. In its early stages, mastitis can be
cern. A core biopsy is more accurate because it removes more cured with antibiotics. Breastfeeding should continue unless an
tissue than an FNA. abscess is forming, or there is purulent drainage. The mother
Vacuum-assisted biopsy is a version of core biopsy that uses may wish to use a nipple shield or to hand-express milk from
a vacuum technique to help collect the tissue sample. In core the involved breast until the pain subsides. The woman should
biopsy, several separate needle insertions are used to obtain see her HCP promptly to begin antibiotic therapy. Any breast
multiple samples. During vacuum-assisted biopsy, the needle is that stays red, tender, and not responsive to antibiotics requires
inserted only once into the breast, and the needle can be rotated, follow-up care and evaluation for inflammatory breast cancer.4,5
allowing for multiple samples through a single needle insertion. Mastitis sometimes develops in women who are not lactat-
Minimally invasive breast biopsies have become the standard ing. This is called periductal mastitis. It occurs most often in reg-
of care for diagnosing abnormalities found either on imaging ular smokers aged late 20s to early 30s. Treatment is the same as
studies or through CBE. However, in some cases, an excisional for lactating mastitis.
biopsy is recommended. An excisional biopsy is done in an
operating room. Lactational Breast Abscess
If lactational mastitis persists after several days of antibiotic
therapy, a lactational breast abscess may be present. In this
BENIGN BREAST PROBLEMS condition, the skin may become red and edematous over the
involved breast, often with a corresponding palpable mass. The
MASTALGIA patient may have a fever. Antibiotics alone are insufficient treat-
Mastalgia, or breast pain, is the most common breast-related ment for a breast abscess. Ultrasound-guided drainage of the
symptom reported in women. The most common form is cyclic abscess or surgical incision and drainage are done. The drainage
mastalgia, which coincides with the menstrual cycle.4 Women is cultured, and sensitivities are obtained. Antibiotic therapy is
describe it as diffuse bilateral breast tenderness or heaviness. started. Breastfeeding can continue in most cases with ongoing
Breast pain may last 2 or 3 days or most of the month. It is treatment.
Breast Problems
Deena D. Dell
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Coping Pain
Cellular Regulation Sexuality
Infection
LEARNING OUTCOMES
1. State screening guidelines for the early detection of breast 5. Describe the interprofessional and nursing management of
cancer. breast cancer.
2. Explain the types, causes, clinical manifestations, and 6. Specify the physical and psychologic aspects of nursing
interprofessional and nursing management of common management for the patient undergoing breast cancer
benign breast problems. surgery.
3. State the risk factors for breast cancer. 7. Explain the indications for, types and complications of, and
4. Describe the pathophysiology and clinical manifestations of nursing management after reconstructive breast surgery.
breast cancer.
KEY TERMS
ductal ectasia lumpectomy
fibroadenoma lymphedema
fibrocystic changes mammoplasty
galactorrhea mastalgia
gynecomastia mastitis
intraductal papilloma Paget disease
Breast problems are a significant health concern for women. ASSESSMENT OF BREAST PROBLEMS
Whether the actual diagnosis is a benign condition or cancer,
the initial discovery of a lump or change in the breast often trig- Breast Cancer Screening Guidelines
gers intense feelings of anxiety and fear. The potential loss of a Screening guidelines for the early detection of breast cancer vary
breast, or part of a breast, may be devastating for many women depending on a woman’s age and risk (Table 56.1).2 Average risk
because of the significant psychologic, social, sexual, and body women include those with no personal history of breast cancer,
image implications associated with it. a strong family of breast cancer, a genetic mutation known to
The most common breast problems are fibrocystic increase breast cancer, and has not had chest radiation therapy
changes, fibroadenoma, intraductal papilloma, ductal ecta- before the age of 30.
sia, and breast cancer. In a woman’s lifetime, there is a 1 in 8 Women at increased risk for breast cancer (family history,
(12%) chance that she will be diagnosed with breast cancer.1 genetic link, prior breast cancer, history of thoracic radiation
Although rare, breast cancer does occur in men. Being aware therapy, or certain atypical findings on a prior breast biopsy)
of personal risk, including genetic factors, and taking part should talk with their HCP about the benefits and limitations
in recommended screening are important health promotion of starting screening earlier with 3D mammography and breast
activities. magnetic resonance imaging (MRI) and having more frequent
1371
,1372 SECTION 11 Problems Related to Regulatory and Reproductive Mechanisms
clinical breast encounters. A clinical encounter includes an Diagnostic Studies
assessment of risk factors, instruction in ways to reduce the risk Radiologic Studies
factors, and a clinical breast examination (CBE).3 We use several techniques to screen for breast problems or help
Consistent breast self-examination (BSE) may be a useful diagnose a suspicious physical finding. Mammography is used
way to increase self-awareness of how one’s breasts normally to view the breast’s internal structure using x-rays (Fig. 56.1). It
look and feel. However, research has shown that BSE has no can detect suspicious lumps that cannot be felt. Mammography
effect on reducing deaths from breast cancer. However, you still has significantly improved the early and accurate detection of
need to teach women the importance of knowing how their breast cancer. Improved imaging technology has reduced the
breasts look and feel and to report breast changes (e.g., nipple radiation dose from mammography.
discharge, a lump) to their HCP.3 A comparison of current and prior mammograms may show
If a woman wants to learn about BSE, include information early tissue changes. Because some tumors metastasize late, early
about the potential benefits and limitations. Allow time for detection by mammography allows for earlier treatment and the
questions and a return demonstration. For women who choose prevention of metastasis. In younger women, mammography
to perform BSE, teach the method described at www.breastcan- is less sensitive because of the greater density of breast tissue,
cer.org/symptoms/testing/types/self_exam/. resulting in more false-negative results. Having dense breasts
makes mammographic detection of cancer more difficult.
With digital mammography x-ray images are digitally coded
TABLE 56.1 Breast Cancer Screening and stored in a computer (Fig. 56.1). It is more accurate than
Guidelines traditional film mammography in younger women with dense
The American Cancer Society (ACS) recommends the following guidelines for breasts. The availability and associated costs of digital mam-
screening women at average risk for breast cancer: mography are issues with this technology.
• Women should undergo regular screening mammography starting at age
3D mammography, or tomosynthesis mammography, pro-
45 years duces a 3D image of the breast. It gives a clearer view of over-
• Women should be offered the chance to begin annual screening between lapping breast tissue structures. It can increase the number of
the ages of 40 and 44 cancers detected and decrease the number of false-positive
• Women aged 45–54 years should be screened annually results (a result stating a cancer is present when it is not).
• Women 55 years and older can switch to every other year screening or Calcifications are the most easily recognized mammogram
can continue screening annually abnormality (Fig. 56.1). They are deposits of calcium crystals
• Women should continue screening if their overall health is good, and they that form in the breast. Causes include inflammation, trauma,
have a life expectancy of 10 years or longer and aging. Although most calcifications are benign, they may
• The ACS does not recommend CBE as screening for breast cancer occur with breast cancer.
A B
Fig. 56.1 Screening mammogram showing dense breast tissue and benign, scattered microcalcifications.
(A) Using conventional x-rays. (B) Using digital x-rays. (From Patel B, Lobbes M, Lewin J: Contrast enhanced
spectral mammography: a review, Semin Ultrasound CT MR 39:70, 2018e.)
, CHAPTER 56 Breast Problems 1373
About 10% to 15% of all breast cancers cannot be seen on related to hormonal sensitivity. Symptoms often decrease with
mammography. They may be detected by palpation or other menopause.
breast imaging studies, such as ultrasound and MRI. If the clin- Noncyclic mastalgia has no relationship to the menstrual
ical findings are suspicious and the mammogram is normal, cycle. It can continue into menopause. Pain may be constant or
an ultrasound or MRI may be done. Based on these findings, a intermittent throughout the month and last for several years.
biopsy may be done. Symptoms include a burning, aching, or soreness in the breast.
Ultrasound is used in conjunction with mammography It usually affects only 1 breast. The pain may be from trauma, fat
to discern a solid mass from a cystic mass, to evaluate a mass necrosis, ductal ectasia, costochondritis, or arthritic pain in the
in a pregnant or lactating woman, and to locate and biopsy a chest or neck radiating to the breast.
suspicious lesion. MRI is recommended as a screening tool in For patients with breast pain, mammography and targeted
addition to mammography for women who are at high risk for ultrasound are often done to exclude cancer and provide infor-
breast cancer (e.g., first-degree relative with a BRCA mutation). mation on the cause of the pain. Reassure women that mastalgia
is not a usual sign of breast cancer.4
Biopsies There is no specific treatment for breast pain. Some relief
A definitive diagnosis of a suspicious area is made by analyzing for cyclic pain may occur by reducing intake of caffeine and fat;
biopsied tissue. Biopsy techniques include fine-needle aspira- taking vitamin E or gamma-linolenic acid (evening primrose
tion (FNA), core (core needle), vacuum-assisted, and excisional oil); and continually wearing a supportive bra. Compresses, ice,
biopsies. analgesics, and antiinflammatory drugs may help. Tamoxifen
FNA biopsy is done by inserting a needle into a lesion to may provide relief in up to 70% of women with few side effects.
sample fluid from a breast cyst, remove cells from intercellular Bromocriptine, a prolactin inhibitor, may provide some with
spaces, or sample cells from a solid mass. Before the procedure, relief. It causes GI upset and lightheadedness. Danazol is an
the breast area is first locally anesthetized. Then, the needle is FDA-approved treatment. The androgenic side effects (acne,
placed into the breast, and fluid and cells are aspirated into a edema, hirsutism) make this therapy unacceptable for many
syringe. Usually, 3 or 4 passes are made. If the results are nega- women.
tive with a suspicious lesion, another biopsy may be necessary.
A core (core needle) biopsy involves removing small sam- BREAST INFECTIONS
ples of breast tissue using a hollow “core” needle. For palpable
lesions, this is done by fixing the lesion with one hand and per- Mastitis
forming a needle biopsy with the other. In the case of nonpal- Mastitis is an inflammatory breast condition. It occurs most
pable lesions, stereotactic mammography, ultrasound, or MRI often in lactating women (Table 56.2). Lactational mastitis
image guidance is used. Stereotactic mammography uses com- presents as a localized area that is red, painful, and tender to
puters to pinpoint the exact location of a breast mass based on palpation. Fever is often present. The infection develops when
mammograms. With ultrasound, the HCP watches the needle pathogens (usually staphylococci) gain access to the breast
on the ultrasound monitor to help guide it to the area of con- through a cracked nipple. In its early stages, mastitis can be
cern. A core biopsy is more accurate because it removes more cured with antibiotics. Breastfeeding should continue unless an
tissue than an FNA. abscess is forming, or there is purulent drainage. The mother
Vacuum-assisted biopsy is a version of core biopsy that uses may wish to use a nipple shield or to hand-express milk from
a vacuum technique to help collect the tissue sample. In core the involved breast until the pain subsides. The woman should
biopsy, several separate needle insertions are used to obtain see her HCP promptly to begin antibiotic therapy. Any breast
multiple samples. During vacuum-assisted biopsy, the needle is that stays red, tender, and not responsive to antibiotics requires
inserted only once into the breast, and the needle can be rotated, follow-up care and evaluation for inflammatory breast cancer.4,5
allowing for multiple samples through a single needle insertion. Mastitis sometimes develops in women who are not lactat-
Minimally invasive breast biopsies have become the standard ing. This is called periductal mastitis. It occurs most often in reg-
of care for diagnosing abnormalities found either on imaging ular smokers aged late 20s to early 30s. Treatment is the same as
studies or through CBE. However, in some cases, an excisional for lactating mastitis.
biopsy is recommended. An excisional biopsy is done in an
operating room. Lactational Breast Abscess
If lactational mastitis persists after several days of antibiotic
therapy, a lactational breast abscess may be present. In this
BENIGN BREAST PROBLEMS condition, the skin may become red and edematous over the
involved breast, often with a corresponding palpable mass. The
MASTALGIA patient may have a fever. Antibiotics alone are insufficient treat-
Mastalgia, or breast pain, is the most common breast-related ment for a breast abscess. Ultrasound-guided drainage of the
symptom reported in women. The most common form is cyclic abscess or surgical incision and drainage are done. The drainage
mastalgia, which coincides with the menstrual cycle.4 Women is cultured, and sensitivities are obtained. Antibiotic therapy is
describe it as diffuse bilateral breast tenderness or heaviness. started. Breastfeeding can continue in most cases with ongoing
Breast pain may last 2 or 3 days or most of the month. It is treatment.
