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Breast Cancer ( FL INITIAL Autonomous Practice- Differential Diagnosis)

4 Contact Hours
Only FL APRNs will receive credit for this course.
This course is only applicable for Florida nurse practitioners who need to meet the autonomous practice initial licensure requirement.
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN)
This course will be updated or discontinued on or before Monday, February 20, 2023

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

The purpose of this course is to enable the participants to be up to date on information and techniques used for the screening, diagnosis and treatment of patients with breast cancer.

Objectives

After completing this course, the learner will be able to meet the following objectives:

  1. Describe the patient population with the lowest risk of breast cancer.
  2. Discuss which genetic mutation is most frequently associated with the development of breast cancer.
  3. List the 2 hormones which are most frequently implicated with the risk of breast cancer.
  4. Identify the most common type of breast cancer diagnosed in the US.
  5. Recognize the most frequent post mastectomy complication.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
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    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Berthina Coleman (MD, BSN,RN)

Epidemiology

Breast cancer is the most common cause of cancer in women in the US. It is the second-highest cause of death from cancer after lung cancer in women. Since the implementation of breast cancer screening, most of the increase in cases of breast cancer diagnoses are increases in ductal carcinoma in situ and early-stage cancer diagnoses.

Globally, breast cancer is the most commonly diagnosed cancer in women. And it is the leading cause of cancer deaths among women. Breast cancer rates are highest in North America and Europe, and they are lowest in sub-Saharan Africa and Asia.

In 2014, approximately 180,000 breast cancer cases occurred in the United States (US), plus an additional 2000 breast cancer cases diagnosed in men. Additionally, there were 40,000 reported deaths secondary to breast cancer. Most breast cancers in the US refer to epithelial malignancies of the breast, namely, ductal and lobular malignancies. Additional malignancies occur in the breast, such as lymphoma and sarcomas. Mortalities rates from breast cancer have dropped significantly in the US with early detection and treatment.

Breast cancer may remain clinically dormant for years before presentation. However, with increased compliance with breast cancer screening, patients are getting diagnosed a lot earlier in the disease process, which has significant implications for estimating disease survival and progression.

Risk Factors

Risk factors for the development of breast cancer include; age over 50, increased exposure to estrogen over their lifetime, including early menarche, late menopause, family history of breast cancer, especially in a first-degree relative diagnosed before menopause. About 8% of all breast cancers are hereditary, and up to 50% of these are seen in patients with a BRCA1 and BRCA2 mutation. Hereditary breast cancers are more likely to present as bilateral cancers, present in women with multiple generations of breast cancer occurrences in their genealogy and premenopausal patients at the time of diagnosis. Note that when obtaining a patient's past family history, women from the paternal side of the family are also included when assessing the past medical history.

Breast cancer is hormone-dependent cancer. Consequently, women with the endogenous supply of estrogen via their ovaries or women who never receive estrogen therapy are at significantly lower risk of developing breast cancer. Breast cancer predominantly affects women relative to men, with a male to female ratio of 1:150. In all women, 3 notable events have a massive impact on the risk of developing breast cancer; age at onset of menses, age at full first term pregnancy, and age at menopause. Note that women who start their menses at age 16 only have approximately 50% of the risk of women who start their menstrual cycle at age 12. Likewise, early menopause at least 10 years before the median reported age of 52 years would significantly reduce the risk for breast cancer. It is important to recognize that whether menopause is naturally or surgically induced, the risk of developing breast cancer remains equally reduced. All women who give birth to their first child by age 18 will also have a 20-40% reduction in their risk of developing breast cancer.

The Li-Fraumeni syndrome is related to a tumor suppressor gene p53. Other genetic mutations related to breast cancer in women include; PTEN mutation, BRCA1, and BRCA2 genes. The BRCA1 gene has been linked to the increased occurrence of breast and prostate cancer in men and women. All patients diagnosed with a BRCA1 or BRCA2 mutation need to be counseled extensively about their risk of breast cancer and other malignancies, especially women of Ashkenazi Jewish descent.

In addition to the genetic risks associated with breast cancer, there has been a substantial difference in the reported breast cancer rates, which cannot be explained by genetic risk alone. Migrant women from various parts of the world who immigrate to the United States tend to have similar estrogen levels to women in the United States after a few years. However, their counterparts who remained in their country of origin have significantly lower estrogen levels. This suggests that nutritional influences on hormone levels may affect the risk of developing breast cancers. Note that the role of diet in determining the risk of breast cancer remains very controversial. Thus, further research is needed on this topic.

It is imperative that clinical providers in the US fully understand the relationship between exogenous hormone administration and the risk of developing breast cancer, given that millions of American women use postmenopausal hormone supplementation and oral contraceptives each year. Most research examining the relationship between oral contraceptives and breast cancer suggests a mildly increased risk of developing breast cancer using oral contraceptives. On the other hand, there is a well-documented decreased risk of endometrial and ovarian cancers using oral contraceptives or postmenopausal hormone replacement therapy.

The Women's Health Initiative study showed that the use of both estrogen plus progesterone resulted in a clear increased risk of developing breast cancer while reducing the risk of colorectal cancer and bone fractures.

Prior radiation exposure is a significant risk for the development of breast cancer. Women who received radiation therapy before age 30 to treat certain malignancies or radiation exposure from radiologic procedures have a significantly increased risk of developing breast cancer. Radiation exposure after the age of 30 does not demonstrate an increased risk of developing breast cancer.

Screening for Breast Cancer

The American Medical Association, American College of Radiology, American Cancer Society, and the American College of Obstetrics and Gynecology recommend routine screening for breast cancer starting at age 40. The United States Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50 to 74 years(USPS, nd).

Currently, monthly breast self-exams are recommended in women who are able and willing to perform them consistently each month. Infrequent or inappropriate breast self-exams have been linked to an increased risk of performing unnecessary diagnostic tests and procedures and are therefore not recommended. There is a direct link between the early detection of breast cancer and improved outcomes and longer survival rates. Unfortunately, many patients cannot perform breast self-exams appropriately and must rely on radiologic screening studies for those in the appropriate age range. Unfortunately, most physicians do not regularly perform breast self-exams as part of their physical exam during the yearly checkup or a focused visit. As a default, breast exams in the clinical setting are best performed by gynecologic providers. Currently, monthly breast self-exams are not recommended to be performed in men.

Mammography is very efficient in detecting breast cancer in women. Up to 90% of breast malignancies are detected on mammography. Breast cancer screening has improved survival in patients diagnosed with breast cancer. Several studies have shown a 25-30% reduction in the probability of dying in patients diagnosed with breast cancer through screening after 50.

Physical Exam

A palpable mass is the most common physical symptom in patients with breast cancer. However, it is important to note that up to 90% of all palpable masses are benign upon further workup.

A medical professional's clinical physical examination of the breast can be performed upright, sitting, or reclined. Clinicians should evaluate the breast for asymmetry in the size of the breast or the nipple. Special attention should be paid to the nipple to rule out skin retraction and nipple inversion. In addition, clinicians should evaluate for nipple discharge. If nipple discharge is present, it should be clarified if it is spontaneous or manually expressed or with manipulation of the breast. Also, the discharge's color, smell, and frequency should be noted. Also, any specific timing noted around the discharge time should be documented. For example, discharge occurs at the beginning of the menstrual cycle. Nipple discharge related to infection tends to be purulent. Nipple discharge from a pregnancy of systemic hormone stimulation tends to be bilateral, watery, and whitish. In addition, it is important to ask the patient if nipple discharge originates from one duct or multiple ducts. Note that unilateral, spontaneous discharge from a single duct is suspicious for malignancy. Bilateral discharge is considered less likely to represent a malignancy.

Skin retraction should be ruled out. Occasionally, the breast containing the cancerous mass may have visible inflammation and infection signs. The axilla should also be palpated to evaluate for lymphadenopathy and completely evaluate the breast tissue in the axilla.

If a lump is palpated, the following characteristics should be documented: size, mobile or immobile, adherence to the chest wall or the skin, associated pain, how long the lump has been present—any aggravating or alleviating factors associated with the mass. Bilateral breast pain is rarely associated with breast cancer. This type of pain is usually related to hormone-controlled fibrocystic breast changes.

Management of a Palpable Breast Mass

Any palpable breast lesion must be promptly reported to a physician or other clinical provider for further evaluation. Note that physical examination alone cannot exclude the risk of malignancy. Concerning features in a lesion include; hard, tethered, or painless lesions. Note that a negative mammogram in the presence of a palpable mass does not exclude malignancy. Note that palpable masses require diagnostic evaluation, including mammography, ultrasound, or MRI evaluation.

There is a difference between a screening mammogram and a diagnostic mammogram. A diagnostic mammogram is usually performed after an abnormality has been palpated.

Notice that a screening mammogram cannot confidently diagnose cancer in a patient. Additional views are required to diagnose a mass confidently, thereby making the study a diagnostic mammogram. Most breast cancers are diagnosed either by using diagnostic imaging or by biopsy. Imaging findings in the breast are reported using a specific system known as the BIRADS (Breast Imaging Reporting And Diagnostic System).

Breast Imaging Reporting And Diagnostic System

There are six distinct categories in the BIRADS classification namely, BIRADS categories 0, 1, 2, 3, 4, 5, 6.

Chart 1: BIRADS Classification
BIRADS 0This implies an incomplete diagnostic workup. Additional workup is required.
BIRADS 1This implies no abnormal findings. The risk of cancer in this category is nonexistent.
BIRADS 2This implies there are findings which are within normal limits such as simple cysts in the breast. The risk of cancer in this category is negligible.
BIRADS 3This category relates to findings that are probably benign. The chance of breast cancer being identified in the breast is less than 2%
BIRADS 4This category relates to findings which are suspicious for malignancy. There is a risk of cancer between 2% to 95%
BIRADS 5This category relates to findings which are highly suspicious for breast cancer. There is an associated risk of cancer greater than 95%
BIRADS 6This category refers to findings associated with a known malignancy.

Benign Breast Masses

Most benign breast masses are due to fibrocystic disease changes, including small fluid-filled cysts, fibrous hyperplasia, and heterogeneous glandular tissues. A prime example of a benign breast mass commonly found in younger patients is fibroadenoma. Note that fibroadenomas do not confer an increase. Patients with fibrocystic breast changes may be at higher risk of developing breast cancer, especially if they have had a prior biopsy demonstrating atypical hyperplasia or ductal atypia.

Cystic breast lesions are usually multiple lesions that may feel rubbery on palpation. They are common in women under the age of 40. Simple breast cysts are not concerning for malignancy. However, mixed solid and cystic lesions are slightly more concerning for cancer.

Malignant Breast Lesions

Ductal Carcinoma In Situ (DCIS)

DCIS is a malignant intraductal lesion that can progress into invasive ductal carcinoma. It usually does not present as a breast mass. Rather, it presents as calcifications and enhancement on MRI imaging. Note that at least 33% of patients with DCIS develop invasive carcinoma in 5 years. However, most of these lesions do not progress and remain unchanged in the same time frame. Therefore, there is grave concern that patients with these lesions may be overtreated. There is no definite way of predicting which patients will progress to invasive carcinoma and those who will not. This is an area of continued research (Rao et al., 2016).

Lobular Carcinoma In Situ

Lobular carcinoma in situ (LCIS) is typically identified as an incidental finding in breast biopsy specimens. It is not a precancerous lesion as opposed to ductal carcinoma in situ. It does not require additional surgical excision when identified (Rao et al., 2016). Although LCIS lesions tend not to progress into invasive lobular carcinoma, the presence of an LCIS lesion increases the risk of an invasive breast carcinoma being found in either breast.

Invasive Ductal Carcinoma

This is the most common type of invasive breast cancer diagnosed in the US. There are multiple subtypes with high-grade tumors characterized by high mitotic rate and a distorted breast architecture (Rao et al., 2016). Invasive ductal carcinomas usually present as a circumscribed palpable mass. Note that tumors that do not have progesterone, estrogen, and HER 2 receptors are termed "triple-negative" tumors and are more likely to recur than tumors with these receptors.

Invasive Lobular Carcinoma

This is less common than invasive ductal carcinoma and is the second most common type of breast cancer diagnosed in the US. It tends to present as an ill-defined tumor with poor margins, which can be hard to perceive on a physical exam. It is not uncommon for invasive lobular carcinomas to involve a much larger breast area than clinically suspected.

Inflammatory Breast Cancer

Usually presents as a diffuse induration of the skin overlying the breast. Usually, the skin is reddened, swollen without a distinct, palpable mass within the breast. Occasionally patients will present with a painful and rapidly enlarging breast. In inflammatory breast cancer, a common term used to describe the breast is "peau d'orange," which means orange skin in French. This is used to describe the indurated, thickened appearance of the cancerous breast. Any time patients present with what looks like mastitis (infected breast) that cannot be relieved with antibiotics, inflammatory breast cancer should be suspected.

Inflammatory breast cancers account for less than 2% of invasive breast cancers, but most inflammatory breast cancers present as advanced diseases. By the time women with inflammatory breast cancers present, one-third of them have distant metastases, and almost all have lymph node involvement.

Breast Biopsy

Note that breast biopsies can be performed under ultrasound, mammography, MRI, or stereotactic techniques. After a biopsy, a clip is left in place to mark the site of the lesion, which may not always be apparent in patients with non-mass findings such as suspicious calcifications. Often, patients will ask if this metallic clip in their breast will set off the alarms at the airport. The answer is no. Breast biopsy clips will not detonate airport metal detectors, and an overwhelming majority of the clips are safe for MRI scanning.

Nursing care of patients after a breast biopsy usually revolves around post-procedural bleeding. It is not unusual for patients to have bruising and swelling after a biopsy, and they should be treated accordingly. It is usually unnecessary to check anticoagulation labs related to platelet levels or PT/INR. Occasionally patients may be asked to hold anticoagulation medications before the procedure at the clinical provider's discretion.

Treatment of Breast Cancer

Breast cancer treatment regimens are a combination of chemotherapy, radiation, and surgical excision depending on the stage of the disease at the time of diagnosis. In essence, the local contained disease can be treated with lumpectomy plus or minus chemoradiation. On the other hand, the extensive disease may require neoadjuvant chemotherapy (meaning chemotherapy before surgical excision to help reduce the disease burden before excision). In addition, surgical excision may include lumpectomy or mastectomy.

Approximately one-third of the women treated with breast cancer in the US receive a breast lumpectomy. Breast-conserving therapy is suitable for tumors less than 5 cm, tumors that do not involve the nipple and alveolar, and patients whose disease does not involve multiple quadrants.

Sentinel Lymph Node Biopsy

TThis is considered the standard of care in patients with localized breast cancer with no evidence of disease in the axilla. If the sentinel lymph node biopsy is negative, the patients can avoid extensive axillary lymph node dissection and thus reduce the risk of getting lymphedema after surgery. If there is no or minimal involvement of the sentinel lymph nodes, further surgery is not required. Note that involvement of the axillary lymph nodes is associated with an increased risk of breast cancer recurrence.

Neoadjuvant versus Adjuvant Chemotherapy

Adjuvant therapy refers to systemic medication or interventions for patients who have received local therapy but remain at increased risk of relapse. Essentially, this is the administration of chemotherapy after the patient has received local treatment such as surgical excision and local radiation. On the other hand, Neoadjuvant chemotherapy involves administering systemic medications and other therapies before definitive surgery. This is frequently used to downstage patients with large tumors to make them eligible for breast-conserving surgery.

Radical Mastectomy

This procedure involves removing the entire breast, removing the pectoralis major and pectoralis minor muscles, axillary lymph nodes, supraclavicular lymph nodes, and even mediastinal lymph nodes in some cases. The technique for radical mastectomy was first fully described by Dr. Halsted in the late 1800s. It remained the mainstay of surgical treatment for over 70 years before being challenged (Rao et al., 2016).

Radical mastectomies were traditionally performed in women with advanced disease. However, with the improved options for chemoradiation therapy, radical mastectomies are now of historical significance.

Modified Radical Mastectomy

This is the current standard of care for patients undergoing a mastectomy. The modified radical mastectomy involves removing the breast, underlying pectoralis major fascia without removing the muscle, and evaluating selected axillary lymph nodes.

Lumpectomy

This is a surgical procedure characterized by removing a tumor within the breast while preserving the rest of the breast. Several names describe a lumpectomy, including segmental mastectomy, wide local excision, and a partial mastectomy. These names all refer to one thing, taking out the entire tumor while preserving the cosmetic appearance of the breast. The decision to perform a lumpectomy versus a mastectomy depends on the size of the tumor, size of the breast, location of the tumor within the breast, and patient preference. Lumpectomy is usually accompanied by an axillary lymph node dissection or a sentinel lymph node biopsy. In addition, patients who get a lumpectomy usually get radiation therapy as part of their treatment plan(Hunt, 2017).

Radiation Therapy

Patients undergoing radiation therapy usually have known residual disease or have undergone a lumpectomy. Contraindications to breast radiation therapy are either characterized as absolute or relative. The only absolute contraindication to radiation therapy is pregnancy due to radiation's teratogenic and severely detrimental effects on the developing fetus. Relative contraindications include; prior radiation to the chest wall or breast, inability to lie prone, inability to abduct the arm on the affected side, severe cardiac disease, severe pulmonary disease, systemic scleroderma, active lupus erythematosus, and a p53 mutation. A p53 mutation puts a patient at notable risk of developing radiation-induced cancers. Lastly, patients on immunosuppressants should be treated cautiously because these medications, such as methotrexate, can be radiosensitizers. Putting the patient at even greater risk (Hunt, 2017; Rao et al., 2016).

Special Situations

Breast Cancer in Men

Breast cancer is much more frequently diagnosed in women than in men, with a ratio of 150:1. In men, breast cancer often presents as a palpable nodule in the breast. Often, diagnosis is delayed due to a lack of breast self-exams being performed. In addition, men are more likely to delay a consultation with a gynecologic specialist. As a result, most patients present with locally advanced diseases. Any unilateral palpable mass in a man over 40 should be worked up for potential biopsy. A physician should evaluate men with unilateral breast lesions.

Gynecomastia is defined as palpable enlargement of the male breast, unilateral and asymmetric. It can either be glandular gynecomastia which tends to be tender on palpation, or fatty gynecomastia, which tends to be non-tender. Note that gynecomastia in men can be unilateral and asymmetric.

Most bilateral symmetric masses in men are usually gynecomastia. Often gynecomastia will present as an asymmetric mass. Several medications have been linked to gynecomastia, including; marijuana, steroid use, and psychiatric medications such as Haldol, risperidone, and tricyclic antidepressants. Over-the-counter medications have also been associated with gynecomastia, such as omeprazole and cimetidine. Cardiovascular medications such as amiodarone and digitoxin have also been linked to gynecomastia. Natural supplements are not exempt, such as lavender and tea tree oil (Fitzgerals, 2018).

Breast Masses in Pregnant or Lactating Patients

During pregnancy, the breast grows directly under the influence of progesterone and estrogen. Lactation is suppressed in the pregnant breast by the pregnancy hormone progesterone, which inhibits the effects of prolactin (the lactating hormone). After delivery, progesterone levels in the body drop significantly, leaving prolactin's actions unopposed, therefore allowing the new mother to lactate. A growing mass lesion in a pregnant breast cannot and should never be explained by the hormonal changes in pregnancy. These patients must be sent for further evaluation of the palpable mass (Moulder, Thompson, et al., 2016).

Pregnancy-associated breast cancer is defined as breast cancer diagnosed during pregnancy or 12 months after delivery. Pregnancy-associated breast cancer usually presents as a palpable mass in the breast, often painless. Several factors may contribute to a delay in diagnosing patients with pregnancy-associated breast cancer, including clinical provider familiarity with pregnancy-associated breast cancer. Pregnancy should not exempt patients from getting a biopsy of suspicious masses. Any masses that do not resolve in 2 or fewer weeks should receive additional diagnostic attention.

Mammography can be safely performed during pregnancy using abdominal shielding for the fetus. The radiation delivered to the fetus is well below the threshold established for fetal malformations. Ultrasound is preferred for imaging in pregnancy, given that there is no risk of radiation to the fetus. Magnetic resonance imaging with the administration of gadolinium contrast has not been studied in pregnant women. Currently, it is not routinely used to diagnose breast cancer in pregnant women because Gadolinium is a class C drug as ranked by the US Food and Drug Administration. Gadolinium has been shown to cross the placenta, and its effects on the growing fetus are unknown (Moulder, Thompson, et al., 2016).

The most common type of breast cancer diagnosed during pregnancy is invasive ductal carcinoma. Breast cancer treatment during therapy is similar to that of non-pregnant patients, with a few exceptions. Although anesthesia is not contraindicated during pregnancy, most patients elect to wait until the end of the first trimester before they undergo surgery to minimize the risk to the fetus, including spontaneous abortion. In addition, radiation therapy is contraindicated in pregnant patients because of the risk to the fetus.

Breastfeeding is contraindicated in chemotherapy patients since most chemotherapeutic agents are excreted in breast milk. Men with BRCA mutations have a much higher breast cancer risk than the general population. Patients with a BRCA 2 mutation risk between 4% to 40% of having cancer during their lifetime. Patients with a BRCA 1 mutation have a risk of cancer as high as 4%. Other risk factors associated with an elevated risk of breast cancer include; Klinefelter's syndrome, increasing age, positive family history including female relatives, increasing age, Jewish ancestry, radiation exposure, obesity, gynecomastia, and infertility (Ottini & Capablo, 2017).

Breast Cancer Prevention

Patients with breast cancer in one breast are at increased risk of developing another breast cancer in the contralateral breast. Aromatase inhibitors or Tamoxifen (a selective estrogen receptor modulator) administered in the adjuvant setting have been shown to reduce the risk of contralateral breast cancers developing. Studies on the efficacy of Raloxifene (another SERM) remain indeterminate at this time.

Women who have a family history of a BRCA mutation should receive annual breast cancer screening between ages 25 and 35. In addition, MRI is used to screen women with known BRCA mutations or those with first-degree relatives who have a BRCA mutation. Note that MRI is much more sensitive for detecting breast cancer than mammography. However, it is not specific. Specific criteria determine when breast MRI should be performed in patients. 

With the increased use of breast-conserving therapy, radical mastectomies have become essentially obsolete. This allows women to have a more cosmetically acceptable surgical result. Occasionally breast replacements are performed at the time of mastectomy.

Patient Education

Patients should be educated about the need for continued monitoring of the contralateral breast in the case of a mastectomy and the need for continued bilateral breast monitoring in the case of a lumpectomy. After a mastectomy, the patients must be shown how to care for the mastectomy site. In the postoperative setting, the surgical team usually performs the first surgical dressing change. If the patient is discharged home in the immediate postoperative setting, the dressing is usually removed at home with specific instructions from the physician.

In the postoperative setting, bleeding from the surgical site is usually a bigger issue in post-mastectomy patients. Occasionally nursing staff may need to use sandbags or compression devices to maintain pressure on the surgical site in the case of an active bleed. If a patient develops a hematoma at the surgical site, the site may become hard on palpation, the patient may experience increased pain, and there may be increased discoloration at the surgical site. Nurses need to evaluate the axillary region since hematomas tend to collect in this area. Hematomas tend to collect in the axilla because this is the most dependent area in the breast, especially when the patients lie down in bed.

Once a hematoma is identified, the surgeon should be immediately notified, and vital signs should be trended until the patient becomes hemodynamically stable. Most often, patients with mastectomies will have drains in place. Drain output should be closely monitored. Nurses should document the volume of the drain output and the quality of the output. If the drain output becomes more bloody, this is another concerning sign for an active bleed at the surgical site.

In a case of a nipple-sparing mastectomy, the surgical team is extremely careful when placing the dressing over the surgical site. Usually, no pressure dressings should be applied over the nipple. In addition, nitroglycerin should be applied over the nipple to increase vasodilation to the nipple and peri areolar tissue. This intervention is used to prevent skin flap necrosis.

Case Study

You are the nurse on a postoperative surgical unit, and you are taking care of a patient who had a modified radical mastectomy two days ago. You are the nurse discharging the patient later in your shift, and you are reviewing the discharge instructions and discharge materials. What should you include in your discharge instructions?

Case Study Discussion

Patients with a mastectomy with lymph node dissection are at mild to moderately increased risk for lymphedema. However, this risk is much lower than was previously reported when radical mastectomies were performed as the standard of care. Patients should avoid blood draws and blood pressure checks on the mastectomy side. After the incision has completely healed, the patient can use deodorant on the side of the mastectomy. Contrary to common belief, it is okay for a patient to wear a watch on the mastectomy side. In addition, the previously reported weight limit restrictions imposed on patients post-mastectomy are less stringent given that radical mastectomies are no longer performed as the standard of care. Specific weight limitations should be individualized to the patient's care, specifically relying on patient size, type of lymph node dissection (sentinel lymph node biopsy with a few nodes removed versus an axillary lymph node dissection with up to 20+ nodes removed), and how long it has been since the procedure. This information should be clarified with the clinical team when it is unclear, especially for patients who must return to a job where they are expected to lift heavy objects as part of their duties.

Summary

Breast cancer is the most commonly diagnosed malignancy in the US, and it is the second most deadly malignancy in the US. Screening for breast cancer is recommended by all the major specialties involved in caring for patients with breast cancer. In addition, the USPSTF, an independent organization, recommends screening for breast cancers in certain populations. Nurses are often at the forefront of patient care. They are heavily relied upon to educate or reinforce education for patients at risk for breast cancer, diagnosed with breast cancer, currently receiving treatment for breast cancer, and finally, those who are breast cancer survivors.

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References

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  • Moulder-Thompson S, Mitri Z, Wolff RA. Special Situations in Breast Cancer. In: Kantarjian HM, ed. The MD Anderson Manual of Medical Oncology. 3rd ed. New York, NY: McGraw Hill; 2016.
  • Ottini L, Capalbo C. Male Breast Cancer. Breast Cancer. 2017:753-762. doi:10.1007/978-3-319-48848-6_63.
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  • (USPS) Final Recommendation Statement: Breast Cancer: Screening - US Preventive Services Task Force. Final Update Summary: Breast Cancer: Screening - US Preventive Services Task Force.