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Breast Cancer Fundamentals

Melanie Calderwood, RN, BSN, OCN

Breast Oncology Nurse Navigator,EvergreenHealth

MACalderwood@evergreenhealth.com

QUIZ

• True or False:• Less than 15% of women with breast cancer have a family member diagnosed

with it

• 1 in 10 women in the US get breast cancer

Overview

• Risk factors

• Workup

• Pathology

• Treatment

• Surveillance

Risk Factors

• Gender

• Age

• Genetics

• Physical Characteristics and Lifestyle

• Previous cancer treatments

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Gender

• Female greater than male

• 100 times more common in women

• Lifetime risk for women = 1 in 8

• Lifetime risk for men = 1 in 1,000

• True for the last 30 years

Age

20 1 in 1,674

30 1 in 225

40 1 in 69

50 1 in 44

60 1 in 29

70 1 in 26

Lifetime 1 in 8

*ACS

Genetics

• Family History• Primary relatives

• Inherited factors (5-10%)• BRCA 1 and BRCA 2

• Other

Physical & Lifestyle Characteristics

•BMI•Alcohol use, smoking, high fat diet, sedentary lifestyle•Age at first childbirth, number of children, not having

children

•Menstrual history-age at menarche (before 12 yo) & menopause (after 55 yo)•Hormone use-contraceptives and HRT•Radiation exposure (Hodgkin’s Mantle cell radiation

when a teenager)•Person history of breast cancer•High breast density

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Density Workup- Imaging

• Mammograms

• Ultrasound

• MRI

Mammograms

• Best imaging to detect early non-invasive breast cancer

• 3D tomosynthesis digital- new standard of care

• Begin at age 40 and annually thereafter

• Is done < age 40 in certain situations

Ultrasound

•Used to image certain findings found on mammogram or MRI

•Used first line in younger women with palpable lump

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MRI

• Screening tool for high risk women

• Staging tool for newly diagnosed breast cancers- use varies across US

• Check implant integrity

Biopsy Types

•Needle biopsies• Stereotactic (using mammo)

• US Core

•Surgical biopsies(aka excisional biopsy)

•Skin punch biopsy (inflammatory)

Nursing Interventions for Newly Diagnoses Patients with Breast Cancer

• Appointment coordination• Surgeon, MedOnc, RadOnc, Genetics Counselor, Social Work, Dietitian, and

needed additional imaging and biopsies

• Education

• Psychosocial support• Using Caring Skills- listening, empathy, knowing your resources,

anxiety management, anticipating needs, etc.

• Consider patient’s individual barriers to care. Video from Living Beyond Breast Cancer site- https://lbbc.org/

• https://www.lbbc.org/beyond-shock-young-women-reflect-impact-breast-cancer-0

Pathology

Benign

• Hyperplasia- increases breast cancer risk

• Usual hyperplasia- normal looking cells

• Atypical ductal (ADH) or lobular hyperplasia (ALD)- not cancer, but needs to be surgically excised. Refer to breast surgeon.

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Breast Cancer Classifications

• In Situ (Pre-Invasive) vs. Invasive

• Type of cells: Ductal vs. Lobular

• Nottingham grade: low, intermediate, high

• Receptor status: Estrogen and progesterone can be positive or negative

• HER2 Protein overexpression- yes or no

• Lymph node involvement- yes or no

Grade (not stage)

• 1 = low

• 2 = intermediate

• 3 = high

Hormone Receptors

• Estrogen (ER) & Progesterone (PR) –

can be negative or positive with varying percent's up to 100%

• Human epidermal growth factor (HER2) –

protein on surface of some breast cancer cells. HER2+ means overexpression of this protein.

• Triple negative –

Mean ER, PR, HER2 negative (more aggressive type of breast cancer)

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Herceptin Lymph Nodes

• Cancer cells enter blood vessels or lymph channels

• This may suggest a more aggressive tumor.

Genetic Screening

• Screening, Counseling & Testing • Know your institution's genetic referral pathway and resources

• NCCN guidelines for genetic testing for breast cancer• Individual insurances may/may not follow these guidelines

• Most genetic companies do prior auth

NCCN Criteria for Further Breast/Ovarian GeneticRisk Evaluations as of 1.2018

1. Individual with ovarian cancer

2. Breast cancer dx with any of the following:• Known cancer mutation within family

• Diagnosed ≤ age 50

• Triple negative ≤ age 60

• 2 breast cancer primaries

• ≥ 1 close relative with breast cancer < age 50

• Relative with invasive ovarian cancer at any age

• ≥ 2 close blood relatives with breast ca, prostate ca, or pancreatic ca

• Person history of pancreatic ca

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NCCN Genetic Guidelines (Continued)

3. Male breast cancer

4. Individual with metastatic prostate cancer

5. Ashkenazi Jewish descent with breast, ovarian, or pancreatic ca

6. Individual with personal and/or family hx of 3 or more of the following: breast ca, pancreatic ca, prostate ca, melanoma, sarcoma, adrenocortical carcinoma, brain tumors, leukemia, gastric ca, colon ca, endometrial ca, thyroid ca, kidney ca, hamartomatous polyps of the GI tract

7. Additional criteria for non-cancer patients that can be used for high risk screening

In Situ

• LCIS- Lobular carcinoma In Situ

• DCIS- Ductal carcinoma In Situ (pre-invasive cancer)

Lobular Carcinoma In Situ (LCIS) Ductal Carcinoma In Situ (DCIS)

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NCCN Guidelines for DCIS

DCIS = Stage 0

• Treatment1. Surgical

• Lumpectomy without lymph node sampling

• Mastectomy with/without lymph node sampling and +/- Reconstruction

2. Radiation Therapy if lumpectomy (in most cases)

3. Endocrine Therapy for 5 years

Invasive Breast Cancer

• Can be lobular (ILC) or ductal origin (IDC)

• Treatments modalities can include surgery, chemotherapy, radiation therapy, and hormonal therapy

Treatments

Surgery

• Lumpectomy

• Mastectomy

• Sentinel node mapping (lymphoscintigraphy) in invasive cancers to determined chemotherapy and radiation plan

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Sentinel Node Mapping Lumpectomy

Supporting Patients with Lumpectomy

• Nursing interventions• Typically day surgery- know you institution's day or surgery routine

• Educate patients on pre-procedures such as wore loc & sentinel node

• Recommend supportive bra to be worn 24hours/day after surgery

• Consider giving small pillow

• Typically require about 1 week off from work

Margins

• Measurement of cancer free zone around the cancer

• Measured in mm

• DCIS margin should be ≥22 mm

• Invasive margin – “no ink on tumor”

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Mastectomy

1. Simple 2. Modified radical

Supporting Patients with Mastectomy

• Nursing interventions• Typically overnight stay with 3 to 4 weeks of time off work

• Discuss surgical camisole and where to obtain

• Listen and provide emotional support to patient• body image & sexuality concerns

• Educate patient on sentinel node

• Prepare patient for drains

• Discuss ways to prepare ahead of time• meal plans, move objecting from high to low, have tops that button or zip up from the front,

etc.

• Consider providing small pillow

• Offer support groups

• Discuss oncology rehab role in lymphedema education/prevention, ROM, strength

Plastic Surgery

• Should be discussed prior to surgery

• Coordination between surgeon & plastic surgeon is important

• Implants- saline & silicone

• Flap- longer surgery and recovery

• Can be done bilaterally for symmetry

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Chemotherapy

• Possible indications:• Positive lymph node

• Metastatic disease

• Triple negative cancer

• Inflammatory breast cancer

• HER2+

• Tumor size greater than 2 cm

• Intermediate (18-30) to high (>31) OncotypeDX score

• Can be given before (neoadjuvant) surgery or after surgery (adjuvant)

Neoadjuvant Chemotherapy

• Candidates for neoadjuvant chemo:1. Inflammatory breast cancer

2. Bulk axillary nodal disease

3. Large tumor relative to breast size in patient who desires breast conservation

• Benefits of neoadjuvant chemo are:1. Shrinking of an inoperable tumor to make it operable

2. A way to monitor effectiveness of chemotherapy, especially in triple negative and HER2+ disease.

3. Allows time for genetic testing & to plan breast reconstruction if desired

Chemotherapy Regimens

• Common Regimens (HER2-):1. Dose dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel

every 1 or 2 weeks

2. TC (docetaxel and cyclophosphamide)

3. CMF (cyclophosphamide/methotrexate/fluorouracil)

• HER 2+ Regimens1. AC followed by trastuzumab (Herceptin) +/- pertuzumab (Perjeta)

2. TCH (docetaxel/carboplatin/trastuzumab) +/- pertuzumab (Perjeta)

Radiation Therapy

• RT almost always offered after lumpectomy for invasive cancer, and is typically offered for DCIS

• If chemo is needed, chemo is given prior to radiation

• RT offered after mastectomy if high-risk features

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Radiation Contraindications

• Pregnancy

• Lupus

• Scleroderma

• Prior radiation therapy to chest wall or breast that would exceed tissue tolerance

Nursing Interventions for Patients Receiving Radiation Therapy

• Skin, skin, skin• Skin can become rashy, reddened, peel, tan and even have moist

desquamation

• Know your institution's recommendations for skin care including rules around deodorants, lotions, powders, sun exposure, etc.

• Radiation nurses are a great resource for skin care tips if you patient is having a skin reaction

• Fatigue management

Radiation Videohttps://youtu.be/tIRAWVV6tzg

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Endocrine Therapy

• Endocrine Therapy 5-10 years• Tamoxifen for premenopausal patients

• Tamoxifen or Aromatase inhibitors for postmenopausal patient

Special Considerations

• Inflammatory breast cancer

• Women of child bearing age

• Pregnancy and breast cancer

• Metastatic breast cancer• Full staging required

• Treatment can include chemotherapy or palliative radiation

• If only bony involvement. Then sometimes just endocrine Zometa or pamidronate is used

Metastatic Breast Cancer Nursing Interventions

• Educate on language- Metastatic vs Stage IV

• Psychosocial support- know local resources including social workers, counselors, online resources and support groups• https://www.lbbc.org/ https://www.breastcancer.org/

• Coaching patients on communicating with family & team

• Treatment related side effect management for chemo, palliative radiation treatment, hormone therapy

Surveillance

• DCIS• H&P every 6-12 months for 5 years then annually

• Mammogram every 12months (first mammo 6-12 months after breast conservation therapy)

• Invasive• H&P exam- 4x/yr for 5 years

• Mammogram every 12 months (not necessary if non-nipple sparing mastectomy)

• No indication for routine labs or screening for mets if no clinical s/s of recurrent disease.

• Monitor bone health with DEXA for women on Aromatase inhibitor

• Women on tamoxifen- annual GYN assessment if uterus present.

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References

• American Cancer Society

• National Cancer Institute

• ASTRO

• Living Beyond Breast Cancer

• National Comprehensive Cancer Network (NCCN)