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UPH – Dr. Jose G. Tamayo Medical UniversitySto. Niño, Biñan, Laguna

COLLEGE OF NURSING

MASTECTOMY(Breast Cancer)

SANTE, Kevin B

BSN – IV Sect. 6 / Gr.24

Dexter Mirabueno, RN

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Breast Cancer

  The most common cancer in FEMALES

I.  Risk Factors

Female gender  – 99% of cases occur in women.

Increasing age – Increasing age is associated with an increased risk.

Personal history of breast cancer – Once treated for breast cancer, the risk of developing breast

cancer in same or opposite breast is significantly increased.

Family history of breast cancer – Having first-degree relative with breast cancer (mother, sister,

and daughter) increases the risk twofold; having two first degree relatives increases the risk 

fivefold. The risk is higher if the relative was premenopausal at the time of diagnosis. The risk is

increased if a father or brother had breast cancer (exact risk is unknown).

Genetic mutation –   BRCA1and  BRCA2 mutations account for the majority of inherited cases of 

breast cancer.

Hormonal Factors 

  Early menarche  – Before 12 years of age

  Late menopause – After 55 years of age

  Nulliparity – No full-term preganancies

  Late age at first full-term pregnancy –  After 30 years of age

  Hormone therapy  – estrogen and progesterone

Exposure to ionizing radiation

Obesity

High-fat diet

Alcohol intake (beer, wine, liquor)

II.  Epidemiology

It is estimated that there will be a total of 12, 262 new breast cancer cases in 2010 with 4,371deaths. Latest data reveals that three out of every 100 Filipinas are likely to develop breast cancer

in their lifetime and that one out of every 100 are likely to die from the disease before age 75

(Philippine Cancer Facts and Estimates 2010).

III.  Anatomy and Physiology Male and female breasts mature comparably until puberty, when in females estrogen and

other hormones initiate breast development. This development usually occurs from 10 to 16 years

of age, although the range can vary from 9 to 18 years. Stages of breast development are

described as Tanner stages 1 through 5.

  Stage 1 describes a prepubertal breast

  Stage 2 is breast budding, the first sign of puberty in female.  Stage 3 involves further enlargement of breast tissue and the areola (a darker

tissue ring around the nipple).

  Stage 4 occurs when the nipple and areola from a secondary mound on top of the

breast tissue.

  Stage 5 is the continued development of a larger breast with a single contour.

The breast are located between the second and sixth ribs over the pectoralis muscle from

the sternum to the midaxillary line. An area of breast tissue, called the tail of Spence, extends into

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the axilla. Fascial bands, called Cooper’s ligaments, support the breast on the chest wall. Theinframammary fold (or crease) is a ridge of fat at the bottom of the breast.

Each breast contains 12 to 20 cone-shaped lobes, which are made up of glandular

elements (lobules and ducts) and separated by fat and fibrous tissue that binds the lobes together.

Milk is produced in the lobules and then carried through the ducts to the nipple.

IV.  Clinical Manifestations   Firm, nontender, nonmobile mass 

  Solitary, irregularly shaped mass 

  Adherence to muscle or skin, causing dimpling effect 

  Involvement of upper outer quadrant or central nipple portion of the breast. 

 Asymmetry of the breasts 

  “Orange peel” skin (Peau d’ Orange) 

  Retraction of the nipple 

  Abnormal discharge from the nipple 

V.  Assessment and Diagnostic Findings

  Laboratory Findings  Biopsy

  Mammography

  Staging

  Stage I –  Tumors that are 2 cm or less with no involvement of axillary lymphnodes  Stage II – Tumors that are 2cm to 5 cm with involvement of axillary lymphnodes

  Stage III – Tumors greater than 5cm with involvement of axiallary lymphnodes

  Stage IV – Tumor of any size, with distant metastases

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VI.  Management

  Medical Management  Chemotherapy   Tamoxifen therapy   Radiation therapy 

  Surgical Management

  MASTECTOMY  Removal of the breast, with or without surrounding structures.

  Surgical treatment for breast cancer. 

Mastectomies can be performed in four distinct methods, depending on the

diagnosis and the extent of the pathologic findings.

  Lumpectomy (Tylectomy) - is a common surgical procedure designed to remove a

discrete lump, usually a benign tumor or breast cancer, from an affected man or

woman's breast. 

  Subcutaneous Mastectomy - Removal of all breast tissue. Overlying the skin and

nipple are left intact.

  Simple Mastectomy –  Removal of entire breast, pectoralis muscles, and the nipples

remain intact.   Modified Radical Mastectomy –  Removal of breast, pectoralis major and axillary

lymphnodes. 

  Radical Mastectomy  – MRM with removal of pectoralis muscles, axillary and neck 

lymphnodes, followed by skin grafting. 

  Stage I and II

Options

1.  Breast conservative surgery

(lumpectomy/quadrandectomy/segemental mastectomy with separate axillary

node dissection and irradiation)

2.  Modified radical mastectomy

(Total mastectomy with axillary dissection)

  Stage IIIA

Options 

1.  Modified radical mastectomy

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2.  Induction chemotherapy + MRM + Radiation

  Stage IIIB

1.  Induction chemotherapy first then with

- Good Response – MRM – Radiation

- Poor response – Radiation – MRM

  Stage IV 1.  Radiation and/or palliative (hygienic mastectomy) + chemotherapy and/or

hormonal therapy 

Complications of surgery1.  Lymphedema2.  Hematoma

3.  Infection

  Nursing Management

  PRE-Operative Care  Psychological support – involve the husband as necessary. 

  Teach arm exercises to prevent lymphedema.   Inform about wound section drainage.(Hemovac, Jackson-Pratt) 

  Deep breathing exercise to prevent post-operative respiratory complications 

  POST-Operative Care  Place on semi-fowlers position with affected arm elevated on pillows

abducted, to promote venous return and prevent edema. 

  Monitor hemovac output (serosanguinous for the first 24 hours) 

  Check behind for bleeding   Post signs warning against taking BP, starting IV line or drawing blood on

affected side.   Reinforce special mastectomy exercise as prescribed.   Provide adequate analgesia to promote ambulation and exercise. 

  Encourage regular coughing and deep breathing exercises.  Prepare for size and appearance of the incision and provide support when

incision is viewed for the first time.   Provide with detailed information concerning breast prosthesis. Fitting is not

possible for 4 to 6 weeks. 

  A temporary prosthesis or lightly padded bras worn until healing iscompleted. Avoid constructive clothing and report persistent edema, redness

or infection of incision.   Teach the importance of continuing monthly BSE on the remaining breast.