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.
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.
After completing this course, the learner will be able to meet the following objectives:
Breast cancer is the most common cause of cancer in women in the US. It is the second highest cause of death in women from cancer after lung cancer. Since the implementation of breast cancer screening, most of the increase in the 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.1
In 2014, approximately 180,000 cases of breast cancer occurred in the United States (US) plus an additional 2000 cases of breast cancer 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. There are additional malignancies which 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.2
Breast cancer may remain clinically dormant for years prior to presentation. With increased compliance with breast cancer screening, however, patients are getting diagnosed a lot earlier in the disease process which has significant implications when it comes to estimating disease survival and progression.
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 who was diagnosed prior to menopause. About 8% of all breast cancers are hereditary, and up to 50% of these are seen in patients with a BRCA 1 and BRCA 2 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 as well as in patients who are premenopausal 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.1
Breast cancer is a hormone-dependent cancer. Consequently, women with an 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, there are 3 notable events that 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 have only approximately 50% of the risk of women who start their menstrual cycle at age 12. Likewise, early menopause at least 10 years prior to the median reported age of 52 years will 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 by at least 35%.2 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 mutation in a tumor suppressor gene p53. Other genetic mutations related to the occurrence of breast cancer in women include; PTEN mutation, BRCA1 and BRCA 2 genes amongst others. Note that the BRCA 1 gene has been linked to the increased occurrence of breast and prostate cancer in men and women. All patients diagnosed with a BRCA1 or BRCA 2 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 rates of breast cancer 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 there may be nutritional influences on hormone levels which in turn 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 post-menopausal hormone supplementation and oral contraceptives each year. Most research examining the relationship between oral contraceptives and breast cancer suggests that there is mildly increased risk of developing breast cancer with the use of oral contraceptives. On the other hand, there is a well-documented decreased risk of endometrial and ovarian cancers with the use of oral contraceptives or post-menopausal 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. The risk of breast cancer was nearly doubled with a 7-year use of hormone replacement therapy. Data from a parallel WHI trial showed that women who only had estrogen replacement therapy alone did not have a significant increase in the risk of breast cancer.1
Prior radiation exposure is a significant risk for the development of breast cancer. Women who received radiation therapy before age 30 for the treatment of 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.
The American Medical Association, American College of Radiology, American Cancer Society and the American College of Obstetrics and Gynecology all recommend routine screening for breast cancer starting at age 40.3 The United States Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50 to 74 years.4
Currently, monthly breast self-exams are recommended for 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 are unable to perform breast self-exams appropriately and must, therefore, rely on radiologic screening studies for those who are in the appropriate age range. Unfortunately, most physicians do not regularly perform breast self-exams as part of their physical exam either during the yearly checkup or during a focused visit. As a default, the 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 by mammography. Breast cancer screening has been shown to improve survival in patients diagnosed with breast cancer. Several studies have shown a reduction of 25-30% reduction in the probability of dying in patients diagnosed with breast cancer through screening after the age of 50.
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 work up.
The clinical physical examination of the breast by a medical professional can be performed in the upright, sitting or reclined position. 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 the discharge is spontaneous or if it occurs when manually expressed or with manipulation of the breast. Also, the color, smell, frequency of the discharged should be noted. Also, any specific timing noted around the time of discharge should be documented. For example, discharge occurring at the beginning of the menstrual cycle, nipple discharge related to infection tends to be purulent. Nipple discharge from pregnancy of systemic hormone stimulation tends to be bilateral, watery and whitish. In addition, it is important to ask the patient if nipple discharge is originating from one duct of from 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 signs of inflammation and or infection. The axilla should also be palpated to evaluate for lymphadenopathy as well as to evaluate the breast tissue in the axilla thoroughly.
If a lump is palpated, the following characteristics of the lump 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.
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 some type of diagnostic evaluation including mammography and/or 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 be used to diagnose cancer in a patient confidently, additional views are required to diagnose a mass 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).
There are six distinct categories in the BIRADS classification namely, BIRADS categories 0, 1, 2, 3, 4, 5, 6.
|BIRADS 0||This implies an incomplete diagnostic workup. Additional workup is required.|
|BIRADS 1||This implies no abnormal findings. The risk of cancer in this category is nonexistent.|
|BIRADS 2||This 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 3||This category relates to findings that are probably benign. The chance of breast cancer being identified in the breast is less than 2%|
|BIRADS 4||This category relates to findings which are suspicious for malignancy. There is a risk of cancer between 2% to 95%|
|BIRADS 5||This category relates to findings which are highly suspicious for breast cancer. There is an associated risk of cancer greater than 95%|
|BIRADS 6||This category refers to findings associated with a known malignancy.5|
Most benign breast masses are due to fibrocystic disease changes in the breast which included small fluid-filled cysts, fibrous hyperplasia and heterogeneous glandular tissues. A prime example of a benign breast mass commonly found in younger patients is a fibroadenoma. Patients with fibrocystic breast changes may be at higher risk for developing for breast cancer especially if they have had a prior biopsy demonstrating atypical hyperplasia or ductal atypia.
Cystic breast lesions are usually multiple lesions which 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.
DCIS is a malignant intraductal lesion which 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, the majority of these lesions do not progress and remain unchanged in the same time frame. There is, therefore, some grave concern that patients with these lesions may be overtreated. There is no definite way of predicting which patients will progress to an invasive carcinoma and those who will not. This is an area of continued research.6
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.6 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.7
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.6 Invasive ductal carcinomas usually present as a circumscribed palpable mass. Note that tumors which do not have progesterone, estrogen and HER 2 receptors are termed “triple negative” tumors and are more likely to recur than tumors which have these receptors.
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 physical exam. It is not uncommon for invasive lobular carcinomas to involve a much larger area of the breast than clinically suspected.
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. A common term used to describe the breast in inflammatory breast cancer is “peau d’orange” which means orange skin in French. This is used to describe the indurated, thickened skin 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 the majority of inflammatory breast cancers present as advanced disease. By the time women with inflammatory breast cancers present, one-third of them have distant metastases, and almost all of them have lymph node involvement.1
Note that breast biopsies can either be performed under ultrasound, mammography, MRI or using stereotactic technique. After 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 postprocedural bleeding. It is not unusual for patients to have bruising and swelling after a biopsy and they should be treated accordingly. It is usually not necessary to check anticoagulation labs related such as platelet levels or PT/INR. Occasionally patients may be asked to hold anticoagulation medications prior to the procedure at the clinical provider’s discretion.
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, local contained disease can be treatment with lumpectomy plus or minus chemoradiation. However, extensive disease, on the other hand, may require neoadjuvant chemotherapy (meaning chemotherapy prior to surgical excision to help reduce the disease burden prior to excision). In addition, surgical excision may include lumpectomy or mastectomy.
Currently, approximately one-third of the women treated with breast cancer in the US, receive a breast lumpectomy. Breast-conserving therapy is suitable for patients with tumors less than 5 cm, tumors that do not involve the nipple and alveolar and for patients whose disease does not involve multiple quadrants.
Adjuvant therapy refers to the use of systemic medication or interventions to 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. Neoadjuvant chemotherapy, on the other hand, involves administering systemic medications and other therapies prior to definitive surgery. This is frequently used to downstage patients with large tumors to make them eligible for breast-conserving surgery.
This is a procedure which involves removal of the entire breast, removal of the pectoralis major and pectoralis minor muscles, axillary lymph nodes, supraclavicular lymph nodes and even mediastinal lymph nodes in some cases. The technique for a radical mastectomy was first fully described by Dr. Halsted in the late 1800’s. It remained the mainstay of surgical treatment for over 70 years before it was challenged.2,6
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.
This is the current standard of care for patients undergoing a mastectomy. The modified radical mastectomy involves removal of the breast, underlying pectoralis major fascia without removing the muscle, and evaluation of selected axillary lymph nodes.
This is a surgical procedure which is characterized by the removal of a tumor within the breast while preserving the rest of the breast. Several names are used to describe a lumpectomy including a segmental mastectomy, segmentectomy, wide local excision and partial mastectomy. This 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 several factors; 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.8
Patients undergoing radiation therapy are often patients with known residual disease or patients who 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 the teratogenic and severely detrimental effects of radiation on the developing fetus. Relative contraindications include; prior radiation to the chest wall or breast, inability to lie supine, inability to abduct the arm on the affected side, severe cardiac disease, severe pulmonary disease, systemic scleroderma, active lupus erythematosus and a p53 mutation. Note that a p53 mutation puts a patient at notable risk of developing radiation-induced cancers. Lastly, patients who are on immunosuppressants should be treated cautiously because these medications such as methotrexate can be a radiosensitizer thus putting the patient at even greater risk.2,6,8
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 time diagnosis is delayed due to lack of breast self-exams being performed. In addition, men are more likely to delay consultation with a gynecologic specialist. As a result, most patients present with locally advanced disease. Any unilateral palpable mass in a man over the age of 40 should be worked up for potential biopsy. Men with unilateral breast lesions should be evaluated by a physician.
Gynecomastia is defined as palpable enlargement of the male breast which can be unilateral and asymmetric. It can either be glandular gynecomastia which tends to be tender on palpation or fatty gynecomastia which tends to be nontender. 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, use of 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.9
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, the levels of progesterone in the body drop significantly leaving the actions of prolactin 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.11
Pregnancy-associated breast cancer is defined as breast cancer diagnosed during pregnancy or during the 12-month period after delivery.10 Pregnancy-associated breast cancer usually presents as a palpable mass in the breast which is often painless. There are several factors which may contribute to a delay in diagnosis of 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. As a matter of fact, any masses that do not resolve in 2 or less weeks should receive additional diagnostic attention.
Mammography can be safely performed during pregnancy with the use of 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 effects on the growing fetus are unknown at this time.11
The most common type of breast cancer diagnosed during pregnancy is invasive ductal carcinoma. Treatment of breast cancer during therapy is similar to the treatment that non-pregnant patients receive with a few exceptions. Although the use of anesthesia is not contraindicated during pregnancy, most patients elect to wait until the end of the first trimester before they undergo surgery in order to minimize the risk to the fetus including spontaneous abortion.12 In addition, radiation therapy is contraindicated in pregnant patients because of the risk to the fetus.
Breastfeeding is absolutely contraindicated in patients receiving chemotherapy since most chemotherapeutic agents are excreted in the breast milk. Men with BRCA mutations have a much higher risk of breast cancer compared to the general population. Patients with a BRCA 2 mutation have a 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 in female relatives, Jewish ancestry, radiation exposure, obesity, gynecomastia and infertility.13,14
Men with BRCA mutations have a much higher risk of breast cancer compared to the general population. Patients with a BRCA 2 mutation have a 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 in female relatives, Jewish ancestry, radiation exposure, obesity, gynecomastia and infertility.13, 14
In women, BRCA 1 mutations have been shown to increase the risk of cumulative breast cancer in patients up to 70 years old from 40% to 87% while the risk of cumulative breast cancer is increased in BRCA 2 carriers from 27% to 84%. Hence, BRCA 1 mutations have a stronger association with breast cancer in women.23
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 35.15 In addition, MRI is used to screen women with known BRCA mutations or those with first degree relatives who have a BRCA mutation.16 Note that MRI is much more sensitive for the detection of breast cancer compared to mammography. However, it is not specific. There are specific criteria which 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.
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 first surgical dressing change is usually performed by the surgical team. If the patient is discharged home in the immediate postoperative setting, the dressing is usually removed by the patient at home with specific instructions from the physician.
In the postoperative setting, bleeding from the surgical site is usually a bigger issue in patients who are post-mastectomy. 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. It is important for nurses 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 are laying 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 as well as 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 in order to increase vasodilation to the nipple and periareolar tissue. This intervention is used to prevent skin flap necrosis.
You are the nurse in a post-operative 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?
Patients who have undergone 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 side of the mastectomy. After the incision has completely healed, the patient is able to use deodorant on the side of the mastectomy. Contrary to common belief, it is okay for a patient to wear a watch on the side of the mastectomy. 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. When it is unclear, this information should be clarified with the clinical team especially for patients who must return to a job where they are expected to lift heavy objects as part of their duties.
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 on the forefront of patient care and are heavily relied upon to educate or reinforce education for patients who are; at risk for breast cancer, diagnosed with breast cancer, currently receiving treatment for breast cancer and finally those who are breast cancer survivors.