Breast Cancer

Breast Cancer RISKS,TREATMENT, PERIOPEKA1'IVE

PATLENT C A R E

Parricia S t e i n , RN; Richard T. Zera, MD

I

n the United States, breast cancer occurs in

one out of 10 wo1neii.l It is estimated that there would be approximately 15 1,000 new cases of breast cancer in 1990, and more than 44,000 of those women would die from the disease. Until the age of 54, the leading cause of cancer-related deaths in women is breast cancer. The toll of breast cancer is exceeded only by lung cancer i n women aged 55 to 74 and colorectal cancer in women older than 75 as a malignancy-related cause of death. Given these facts, a nurse can expect to take care of'patients with breast cancer frequently or even find oneself with the disease. This article provides an overview of measures for early detection of breast cancer, diagnosis, and treatment. It also provides nursing diagnoses and a nursing care plan for the breast cancer patient.

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any factors are evident in the etiology of breast cancer. Geuetic, hormonal, dietary, and environmental factors influence each case. Familial factors clearly identify some patients at higher risk. A woman with a first-degree relative (ie. mother or sister) with breast cancer is estimated to have a two to three times higher rish than the general population.' The menopausal status at which the relative is diagnosed is important. Higher rish is ;it t r i but a b 1e t o a p re m e 11o p a u 5 ;i 1 d i ag 11o s i s . Additional risk is noted if both the relative's breasts are involved. For example, the sister of a preinenopausal woniaii with bilateral breast ciliiceI is estimated to have a 30% risk of devel-

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The causative role of exogenous estrogen (ie, birth control pills or postmenopausal estrogen) remains controversial.

oping breast cancer by age 70. Her risk is reduced to approximately 17% if her sister developed a postmenopausal unilateral cancer.’ Hormonal influences also are implicated in the development of this disease. A woman with breast cancer is more likely to have had an early menarche and to be nulliparous or to have had her first full-term pregnancy after age 35. In addition, the late onset of natural menopause is considered a risk factor. Pregnancy before the age of 20 appears to offer some protection against breast cancers. This suggests that early full differentiation or “maturing” of breast e p i t h e l i u m i s i m p o r t a n t , a n d that later endocrine stimulation of this tissue may be a secondary promoter of cancer development. Removal of the ovaries either surgically or with radiotherapy before age 40 has been found to diminish the potential for breast cancer by as much as 75%. The causative role of exogenous estrogen in breast cancer (ie, birth control pills [BCPs], postmenopausal estrogen) remains controversial. Most BCPs contain both estrogen and progesterone. This balanced hormonal influence at worse appears to have no net effect on the incidence of breast cancer.(’ One study suggests that BCPs may offer a protective e f f e ~ t The . ~ postmenopausal use of estrogen/progesterone combinations continues to appear safe.x Unopposed estrogen use (ie, without progesterone) appears to be more of a problem. Estrogen, when used alone, appears to increase the risk of breast cancer by 2.5 times.’ As a rule, women who have had breast cancer should not receive estrogen. Dietary influence on the development of breast cancer centers primarily on high fat intake. In animals this has been shown to increase the incidence of chemically induced m a m m a r y c a r c in o m as. 1n h u m an s , both intake of dietary fat and excess body weight

in postmenopausal women have been shown to correlate positively with the risk of mortality from breast cancer.Io These results, however, have been considered inconclusive because other major studies dispute these findings. I I If an increased risk exists. it may be related to the increased activity of the enzyme aromatase. Aromatase is present to a large extent in peripheral adipose tissue. This enzyme converts precursors derived from the adrenal gland into estrogenic compounds. Obesity, therefore, may be associated with increased conversion of these precursors to an unopposed estrogenic compound. In addition, obesity is associated with increased output of these adrenal precursors. This suggests a causal link between diet, obesity, and breast cancer via these abnormalities and the presence of unopposed estrogens from an endogenous source. Preliminary results suggest that dietary influences also may prevent breast cancer. Certain foods (eg, some types of soy beans) contain phytoestrogens, which are plant-derived compounds with weak anti-estrogenic (ie, estrogen blocking) effects.” In animals, these agents decrease the incidence of chemically induced mammary cancer. Environmental factors that may contribute to breast cancer include radiation and certain chemical compounds. Although therapeutic radiation to the chest wall and breast has been associated with an increase of breast cancer, diagnostic mammography has not been shown to carry an increased risk. This is particularly true with improvements in current techniques and a lack of observed risk for radiation after the age of 40.” No discussion of breast cancer risk would be complete without a discussion of benign breast disease. T h e American College of Pathologists Consensus Statement discusses 939

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fibrocystic disease and the risk of invasive breast c a n ~ e r . The ’ ~ term fibrocystic disease covers a broad range of histologic diagnoses that include diagnoses with no added risk such as sclerosing adenosis, florid adenosis, apocrine metaplasia, duct ectasia, fibroadenoma, mild hyperplasia (ie, two to four epithelial cells in depth), mastitis, and periductal mastitis Diagnoses with slightly increased risk (ie, 1.5 to 2 times) include moderate, florid, solid, or papillary hyperplasia, and papilloma with fibrovascular core. Diagnoses with moderately increased risk (ie, up to 5 times) include atypical hyperplasia, ductal hyperplasia, and lobular hyperplasia. These catagories can be divided into proliferative lesions and nonproliferative lesions. Proliferative lesions are associated with an increased risk of subsequent invasive carcinoma. Where proliferation of ductal or lobular breast epithelium occurs in association with atypia, the risk of breast cancer increases to 5 times that of the “normal” female population.I5 Some authors would include a high risk category that includes lobular carcinoma in situ and ductal carcinoma in situ, although these are not considered benign fibrocystic disease. Many issues under the broad definition of fibrocystic disease have not been settled. For example, although apocrine metaplasia is in the “ n o increased risk” c a t e g o r y , when found in women older than 45 the associated risk of subsequent carcinoma increases 2.7 times.I6 Other nonfibrocystic conditions also may cause breast lumps. Inflammatory conditions, such as breast abscesses, fat necrosis, lipomas (ie, benign fatty tumors), and lesions of the skin (eg, sebaceous cysts) also

may cause breast lumps.”

Diagnosis reast cancer is a histologic diagnosis. Physical or mammographic findings may strongly suggest this diagnosis, but examination of tissues either as cytologic or histologic specimens is necessary for confirmation. T h e physical examination of a patient involves inspection and palpation. With careful attention, it is not unusual to see contour changes, nipple retraction or skin dimpling related to a n u n d e r l y i n g mass. Occasionally, the entire breast may be elevated relative to the opposite breast. Skin erythema may be the hallmark of inflammatory breast cancer. In more advanced cases, edema of the skin may be visible. Palpation of the breast is done in both sitting and supine positions. Inspection and palpation should be done with the arms at the sides as well as with arms raised above the head. The most common physical finding is a lump or mass which generally is hard and nontender. Examination of the cervical, supraclavicular, and axillary lymph nodes is important and should include attention to the number of nodes palpable, the nature of the nodes (ie, hard versus rubbery), and whether the node is fixed to underlying structures or to the skin. Arm edema is an ominous sign usually associated with advanced nodal involvement. The use of screening mammography (ie, xray examination of the breasts in asymptomatic women) has increased dramatically the number of patients who have no significant physical findings. Screening mammography increases survival rates in all women over 40.’* Sadly, mammography is not used enough in the United States. Much of the blame lies with physicians who fail to recommend the test to their patients. l9 Features shown on mammography that merit further evaluation and clinical correlation are 941

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asymmetry of the breasts, a discrete mass or density, particularly if it distorts the breast, calcifications within a mass, and 0 clusters of microcalcifications. Evaluation of physical or mammographic findings may include ultrasonography. This procedure can reliably determine if a mass is solid or cystic and generally is considered more useful in premenopausal women. If a mass is palpable, an alternative may be the use of fine needle aspiration (FNA). Fine needle aspiration using a 22- or 25gauge needle is rapid, inexpensive, and diagnostic as well as therapeutic for cysts. In addition, cytologic examination of the aspirate can be a highly accurate adjunct to the evaluation of a breast lump. This may obviate the need for a formal biopsy.*O The physician performing FNA should be familiar with its limitations. A suspicious mass and/or suspicious mammogram requires formal biopsy if FNA is negative for cancer. A small number of centers now have stereotactic FNA available that may allow cytologic evaluation of nonpalpable mammographic lesions. A special unit is required to perform FNA under radiographic control. The current expense of these installations, however, may limit their wider use. Biopsy techniques for mammographic lesions that are not palpable have evolved from blind biopsy of a general area in a given quadrant of the breast to “wire localization.” In the latter method, measurements taken from scout mammograms allow placement of a smallgauge needle through which a hooked wire can be passed. After confirming adequate placement by repeat mammograms with the needle and wire in place, the needle is removed leaving the wire as a guide for biopsy. After biopsy, a specimen radiograph is then taken to confirm removal of the lesion. It is our practice to approach palpable lesions by FNA. If this is not diagnostic and the lesion is suspicious on x-ray or physical examination, biopsy by Tru-cut needle or by incisional or excisional techniques should be done depend0

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Table 1

Types of Breast Cancer Carcinomas Infiltrating ductal Papillary Intraductal Mucinous Tubular Adenoid tuba1 Metaplastic Squamous cell Apocrine Secretory Giant cell Lobular carcinoma in situ Infiltrating lobular carcinoma Inflammatory Paget’s Disease Sarcomas Cystosarcoma phyllodes Stromal Fibrosarcoma Liposarcoma Angiosarcoma ing on the size of the lesion. Involvement of a pathologist is critical in handling specimens properly. It is important for the surgeon to orient excised lesions so specimens can be inked before fixation. This allows the pathologist to assess the margins of resection. In addition, proper handling of the specimen is necessary for measurement of estrogen and progesterone receptor contents, and deoxyribonucleic acid (DNA) flow cytometry. These measurements are all integral parts of the full evaluation of breast cancer specimens.

Types, Staging of Breast Cancer

B

reast cancer must be considered a generic term because there are at least fifteen histological subtypes of the disease (Table 1).*’ Infiltrating ductal carcinoma

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Table 2

The TNM Staging Systemfor Breast Cancer Stage I TINoMo Tumor size less than 2 cm May extend into pectoral fascia or muscle No distant metastasis No positive nodes Stage I1 T2NoMoor T10r2N1Mo Tumor size 2 to 5 cm May or may not extend into pectoral fascia or muscle No distant metastasis Mobile axillary nodes

Stage 111 T1or2N1Wor T1-3N2M0or T3N0M0 Tumor size greater than 5 cm May or may not extend into pectoral fascia and muscle Skin edema, infiltration or ulceration may be present Nodes fixed to skin, deeper structures, supraclavicular nodes No distant metastasis Stage IV Any TN3 any M or T4 any N any M Any TN plus M’

Definitions

T = primary tumor T 4= Tumor extension to the chest wall or skin N = regional lymph nodes NO = no growth N l = movable nodes with tumor growth N2 = homolateral axillary nodes fixed to one

represents more than 50% of histologic diagnoses. A specific subtype diagnosis offers an improved prognosis over that of infiltrating ductal carcinoma. In addition to carcinomas, there are five different sarcomas of the breast. Breast cancer is classified into four stages. Staging describes tumor size, lymph node involvement, and distant metastasis. In the “TNM’ system, T equals tumor size, N equals lymph nodes, and M equals metastasis (Table 2).

Patient Care

T

ypes of breast lesions, either cancerous or benign, can be classified into categories; Patients who have these lesions

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another or other structures and containing growth N3 = homolateral infra or supraclavicular nodes containing growth A4 = distant metastasis iW=absent MI= present, includes skin beyond the breast

cannot. The nurse must approach each patientindividually in terms of diagnosis and treatment. Several nursing diagnoses may be used to guide perioperative interventions. Potential for body image disturbance. This seems obvious, however, there are some women who feel the fear of recurrence they would experience by not having the breast removed outweighs a body image change. Although the age of a patient would seem to be a factor in considering body image issues, some younger women facing 30 to 40 years of monitoring a breast elect to have a total mastectomy. Conversely, many older women share feelings and concern about how surgery will affect their body image.22

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The perioperative nurse needs to be sensitive to issues of sexuality and femininity when working with a patient who has breast cancer. The patient who has elected a less radical procedure to preserve her breast needs support for that decision as she enters the operative suite. Potential for decisional conflict regarding cancer treatment options. This may be more fitting in some cases. There are several choices and decisions about treatment that the patient with breast cancer must make. Weighing the choices can be very stressful. 23 Potential for ineffective individual coping. This exists regardless of the patient’s age. When a woman enters her physician’s office or clinic to undergo a breast examination she often has an underlying fear that a lump found at home will be cancerous. This fear alone can cause the woman to delay seeking diagnosis and treatment because she may not be able to cope with the findings. The patient may avoid care until she is in an active problem-solving mode. This may not occur until the anxiety aroused by the discovery is recognized and acknowledged. If the patient is in denial, that denial may be controlling her anxiety and allowing the patient time to develop some means for problem solving. The shock, disbelief, and confusion associated with a diagnosis of breast cancer directly affects the patient’s receptivity to any preoperative or postoperative teaching. When preparing to do preoperative teaching, the perioperative nurse should assess the patient for signs of coping that signal a readiness to learn. Coping has been described as the way in which a patient manages to retain her courage and fighting spirit. Potential for anticipatory grieving. This can be related to concern that the patient may have had something to do with being diagnosed with breast cancer and can lead to feelings of If the patient delays going to her physician, and as a result, delays diagnosis and treatment, she may not show signs of grief until after the surgery. The patient may feel a certain amount of depression and hopelessness. The nurse should be aware that a patient who consents for 946

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surgery may not understand the full consequences of that surgery until it has occurred. Potential for altered role performance. The perioperative nurse must be sensitive to the feelings of helplessness, depression, fatigue, and insomnia that a patient may experience and how they affect the patient’s return to presurgical activities. Any woman may find her role in life greatly changed for a time. For the woman who is used to being self-sufficient, asking for and accepting help can be stressful. A woman who felt helpless and powerless before surgery may be at a complete standstill when faced with breast cancer. In a study of 43 breast cancer patients, however, 80% believed that the illness had made them grow as human beings, and 90% said it had taught them to understand others. There is no doubt that having a life-threatening illness will change a woman’s relationship with the rest of the world. The perioperative nurse needs to understand that the intraoperative phase of care is small in terms of the time spent actually dealing with the problem. (See “Nursing Care Plan for the Patient with Breast Cancer.”)

Preoperative Care

A

fter the diagnosis of breast cancer has been made, the preoperative workup .should include a history and physical examination, complete blood count, electrolyte evaluation, liver function tests, and a chest x-ray. Any signs or symptoms of metastatic disease require further evaluation that may include a total body bone scan, x-rays andlor computerized axial tomography of the head, lungs or abdomen. Surgery should be delayed until the workup is complete. Surgical options should be discussed at length with the patient. Breast conservation surgery (ie, lumpectomy with axillary dissection) is indicated for women with tumors less than 5 cm in size and those whose altered

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Nursing Care Plan for the Patient with Breast Cancer Nursing diagnoses

Patient outcomes

Nursing interventions

Potential for body image disturbance

Patient will be able to express self freely regarding postsurgical experience.

Elicit patient’s fears regarding changed body image. Acknowledge patient’s anxiety, sense of panic, and despair. Practice active listening.

Potential for decisional conflict regarding cancer treatment options

Patient will be able to make informed and intelligent decisions regarding type of surgery and adjuvant therapy as needed.

Assess patient’s ability to take in clinical information about breast cancer and treatment. Allow for questions that may be repeated often. Offer support for whatever choice the patient makes about her body and life.

Potential for ineffective coping

Patient will be able to regain and retain her courage and fighting spirit.

Acknowledge that anxiety may prevent effective coping. Acknowledge that denial may allow time to develop problem solving skills. Assist with explanations to the family about breast cancer. Allow patient to go through grieving process.

Potential for anticipatory grieving

Patient will be able to freely express grief over condition.

Assure patient that cancer is not a punishment for acts committed before the diagnosis. Allow for anger and disbelief to surface about diagnosis. Refer questions about recurrence to physician. Provide referral if needed to assist patient in grieving process.

Potential for altered role performance

Patient will be able to perform activities of daily living independently.

Assist patient with arm and hand exercises. Provide referral to Reach to Recovery for support. Teach alternative ways of meeting needs at home. Encourage patient to use arm and hand of affected side early in recovery.

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breast size following lumpectomy is acceptable cosmetically. Conversely, where breast size is so large as to preclude postoperative radiation therapy (RT), lumpectomy is contraindicated. Other contraindications to breast conservation surgery include the inability to obtain negative margins with lumpectomy, diffuse microcalcifications or density, making mammographic follow-up impossible, unavailability of RT facilities, or a patient unwilling to undergo RT. The use of postoperative RT for patients undergoing lumpectomy is important because local recurrence is significantly reduced with this therapy.25 There is as yet no well-defined group that does not require RT. The National Surgical Adjuvant Breast and Bowel Project (NSABP) is undertaking a study to determine whether patients with intraductal carcinoma may be such a group. Total mastectomy (TM) or a modified radical mastectomy with or without reconstruction remains an option that many women choose even if they are suitable candidates for breast conservation. Within some current NSABP t i als, only 25 to 30% of the patients undergo lumpectomy, yet half of the participants may be candidates for this type of surgery. Although TM is considered by many to be the gold standard of surgical therapy, within a NSABP trial that compared lumpectomy with or without radiation to TM, there were no significant differences in survival at a median of eight years follow-up.~6 Patients scheduled for surgical treatment of breast cancer are given preoperative instructions similar to those given any patient undergoing surgery. Most often, patients are admitted the morning of their surgery, and then go to an assigned room after they leave the postanesthesia care unit. Generally, each patient would be told the following: do not eat 'or drink anything after midnight or on the morning of surgery, avoid smoking at least 24 hours before surgery,

take no aspirin o r aspirin-containing medicines at least o n e week before surgery, check with your doctor about talung prescribed medications the morning of surgery, remove all makeup and nail polish, leave all valuables including jewelry, at home, do not consume alcohol for at least 24 hours before surgery, and 0 notify your physician of any change in your physical condition or if you have questions. The nurse or physician gives the patient specific written instructions about the time and date of surgery and where to report. A history and physical examination can be done in the clinic, as can the preoperative teaching. All mammograms, pathology reports, lab results, and the history and physical, should be assembled before the patient's arrival on the day of surgery. The penoperative nurse gives the patient an overview of what she can expect from the time she comes in until she is admitted to her room. The nurse instructs the patient in early ambulation, coughing and deep breathing, clinical follow-up, physical therapy, if necessary, and postmastectomy support groups such as Reach to Recovery. The nurse must assess the amount of information the patient is able to take in. Too many details or too much information can be overwhelming. When the patient arrives in the holding area, the nurse sees that all items required for surgery are assembled. The consent form is especially important. The consent can delineate several surgical options based on what might happen in relation to pathology findings, but more likely spells out exactly what is to be done. For example, the lumpectomy, mastectomy or other definitive treatment would be specified on the consent form, and an axillary dissection would be listed as a possibility. It is necessary for the nurse and surgeon to 0

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verify with the patient which breast will be operated on. The patient needs to be sure that she understands what the consent specifies and that she agrees with the planned procedure. It is helpful for the nurse to elicit the patient’s impressions about the surgery. The patient’s anxiety may be peaking at this point, and the nurse may have an opportunity to correct misunderstandings or reassure the patient. The anesthesiologist and surgeon ensure that laboratory values are within normal limits preoperatively. The nurse assists anesthesia personnel with starting an intravenous line on the unaffected side to maintain fluid volume and administer necessary medications. The anesthesiologist may order preoperative medications to allay anxiety and decrease secretions. The nurse administers a preoperative antibiotic at the surgeon’s request and fits the patient with thigh-high antiembolism stockings or automatic compression sleeves as ordered.

Inti-aoperative Patient Care

W

hen the perioperative nurse finishes an assessment of the patient and c h a r t , he o r s h e transports the patient to the operating suite. If able, the patient can move onto the operating room bed with guidance. The nurse covers the patient with a warm blanket. The patient may be asked to extend both arms on padded arm boards with palms up so the nurse can secure them with safety straps. A safety strap also is placed around the patient at least 2 inches above her knees. After the patient is induced and positioned, the nurse ensures the patient’s arms are not abducted more than 90 degrees to prevent brachial plexus injury. The nurse assesses the patient’s age, size, nutritional status, and skin condition and provides extra padding for the coccyx, heels, and other pressure points. When prepping, it is important not to scrub vigorously or with too much pressure over the tumor site. In some cases, the surgeon will request only an antiseptic paint. For the surgeon to drape the arm free for the

axillary node dissection, the nurse suspends the patient’s arm with finger traps. The nurse then preps the arm circumferentially, prepping the axilla last. The surgeon uses towels to square off the breast and axilla, and he or she may use a combination of laparotomy sheets and drape sheets to create a sterile surgical field. A sterile elastic bandage can be used to drape the distal arm.

Surgical Procedure

A

lumpectomy involves excision of the tumor with a 1- to 2-cm margin of .normal tissue surrounding it. This is generally done by sharp dissection, although s o m e s u r g e o n s m a y use e l e c t r o c a u t e r y . Following hemostasis of the biopsy site, it is recommended that the surgeon not close deep tissue. He or she may close the skin in a subcuticular fashion. Axillary d i s s e c t i o n m a y p r e c e d e t h e lumpectomy, depending on whether the surgeon has been able to diagnosis cancer preoperatively by FNA. Generally, the surgeon performs axillary dissection through a transverse incision approximately 1 cni below the axillary hairline. The incision extends from the pectoralis major muscle anteriorly to the latissimus dorsi muscle posteriorly. The surgeon removes lymphoareolar tissue between t h e two muscles. T h e dissection includes Level I a n d I1 l y m p h n o d e s ( i e , lymph nodes that extend up to the point of the medial margin of the pectoralis minor muscle). S o m e surgeons prefer to perform the lumpectomy first, reprep, redrape, and follow with the axillary dissection. The surgical team uses a separate set of instruments for each procedure to avoid possible tumor contamination of the axilla. Performing the axillary dissection second allows time for the pathologist to check the margins of lumpectomy tissue while the surgical team prepares for the second procedure. If necessary, the surgeon can re-excise the affected breast margins later. If a total mastectomy is to be done, it is gen951

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erally done on the basis of FNA diagnosis or incisional biopsy. The surgeon can perform the mastectomy immediately after the biopsy, however, many women prefer that a mastectomy be done as a separate procedure. The surgeon performs a total mastectomy through an elliptical incision that includes the nipple and areolar complex of the breast. He or she makes the incision transversely, occasionally obliquely, on the breast and develops skin flaps either with a knife, electrocautery, or laser to remove all the breast tissue and the axillary contents down to Level I1 lymph nodes. With the arm draped free and mobile, the surgeon can dissect high in the axilla by bringing the arm over the patient’s head. When the surgeon has removed the breast, the nurse must ensure that it is handed directly to the pathologist for further diagnostic studies. The circulating nurse should check with the surgeon about placing the specimen in saline or formalin. Formalin prohibits performing some studies on the breast. If estrogen and progesterone receptors or frozen sections are to be done, the tissue must be moistened with saline only. Axillary nodes may be handled similarly, although these generally are sent for permanent sections only. After a mastectomy, the surgeon places drains in the axilla and over the pectoralis muscle to eliminate dead space. He or she uses a closed suction drain with reservoirs, brings the tubes out through separate stab wounds, and sutures them in place. The surgeon closes the flaps using a two-layer closure with a deep layer and either a subcuticular stitch or skin staples. He or she uses large, loose gauze pads completely opened and bunched to create extra padding and holds them in place with foam or paper tape. The anesthesia personnel stop administering anesthetic gases, reverses any medication given in addition to the anesthesia, and monitor the patient’s emergence until extubation is possible. The nurse removes the grounding pad and checks the skin for burns, redness, or any break in skin integrity. He or she washes all prep solution off the patient and provides her with a 952

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fresh gown and warm blankets before the surgical team takes the patient to the postanesthesia care unit. The surgeon, in collaboration with a plastic surgeon, may perform breast reconstruction after the mastectomy. It is our practice to limit reconstruction at this time to women with noninvasive disease or women having a mastectomy done for prophylaxsis. Nonetheless, some surgeons believe that reconstruction is indicated for all patients and best done at the time of the original mastectomy. Reconstruction of the breast may be done by inserting silicone- or saline-filled implants in the subpectoral space. More commonly, inflatable tissue expanders placed under the pectoralis major muscle are used for reconstruction of the breast. Tissue expanders allow the surgeon to more closely match the opposite breast when the patient’s brassiere cup size is larger than a B. Separate, clean instruments are required for this portion of the case if done immediately a f t e r m a s t e c t o m y . Use of t i s s u e expanders requires a subsequent procedure to substitute an implant for the expander. Implants are indicated when there is adequate post-mastectomy skin and soft tissue and the opposite breast is relatively small (ie, <300 mL, an A or B cup. ) An alternative to implants or expanders is the use of myocutaneous flaps. The two most commonly used flaps are the latissimus dorsi flap, from the posterior aspect of the axilla, and the transverse rectus abdominis myocutaneous (TRAM) flap. These flaps generally are used when there is need for additional skin coverage (eg. after radical mastectomy). The bulk of the muscle flap itself may be sufficient for reconstructing the breast; however, with the latissimus dorsi flap, implants are often required. The TRAM flap has a major advantage because of the amount of subcutaneous fat that can be moved with the skin and muscle, which obviates the use of an implant. If the thorocodorsal nerve or vessels are injured in the original mastectomy, the latissimus dorsi muscle may not be satisfactory for transfer. These two flap procedures typically are done

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well after the original mastectomy. The use of microvascular techniques may allow a patient without available local flaps to have an adequate reconstruction using a free flap, such as the superior gluteal myocutaneous flap. Using this flap, the surgeon anastomoses the vessels of the muscle flap to the internal mammary or axillary vasculature.

Postoperative Care

T

he patient can anticipate a hospital stay between two and four days, depending on drain output, temperature, vital signs, and postoperative condition. Postoperative complications include infection, development of seroma, brachial plexus injury from over abduction of the arm intraoperatively, bleeding, and deep vein thrombosis. The patient may experience lymphedema in the affected arm due to interference with lymphatic drainage. This is more likely in obese patients or when an extensive lymph node dissection has been done, If the patient keeps her hand in a dependent position for an extended period of time, an increase in postoperative edema may occur. Collateral lymphatic drainage will develop over time; however, the patient should continue exercises of the affected arm for up to four months following surgery. If lymphedema persists, the patient can be fitted with an elastic compressive sleeve to minimize debilitation. Muscle tone will gradually return if the patient can exercise her arm consistently. The nurse should reassure the patient that no surgery was done to the muscles of the arm. Exercise of the affected arm should begin within 24 hours after surgery, and activity should increase gradually so that the patient is able to perform activities of daily living independently. We ask volunteers from the American Cancer Society’s Reach to Recovery to see nearly all of our patients within two to five days postoperatively. 954

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In general, patients rarely require lengthy rehabilitation. For some patients return to normal function can be prolonged; however, it is important for these patients to realize that normal function will return. The surgeon typically schedules an appointment for follow-up care within one week of discharge. If the surgeon leaves the drains in place at the time of discharge, he or she makes arrangements for the nurse to teach the patient drain site care before discharge. If the patient is unable to care for herself, the surgeon can make arrangements for home visits by a nurse. The surgeon generally removes the drains when their output is 50 mL or less per day.

Adjuvant Therapy

T

he use of chemotherapy or hormonal therapy after surgery is known as adjuvant therapy. The optimal adjuvant therapy regime has not yet been defined. Tamoxifen is an estrogen-blocking agent or estrogen antagonist and is the mainstay of hormonal therapy for breast cancer. It binds to proteins or estrogen receptors within tissue sensitive to estrogen (eg, many breast cancers) and can prevent many of the effects of estrogen that lead to cells dividing and growing. Thus tamoxifen is believed to be a cytostatic agent that prevents estrogen-induced cell growth rather than a cytotoxic agent that would cause cell death. In 1985, the National Institutes of Health consensus conference developed recommendations for adjuvant therapy (Table 3).27These recommendations were updated in 1990.28In 1985, it was believed that premenopausal nodepositive patients obtained clear benefit from chemotherapy. If they were postmenopausal and estrogen receptor positive, then tamoxifen was the adjuvant therapy of choice. Node-negative patients could not be said, at that time, to have any clear benefit from adjuvant therapy. In May 1988, this issue became controversial when the National Cancer Institute (NCI), announced a “clinical alert.”29At that time, the NCI recommended that all women with breast

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Table 3

National Institutes of Health Adjuvant Chemotherapy Recommendations Condition

Premenopausal Node positive Node negative ER positive ER negative

Recommended treatment 1985

Recommended treatment 1990

Chemotherapy

Chemotherapy

Adjuvant therapy trials

Tamoxifen with or without chemotherapy Chemotherapy trials

Adjuvant therapy for high risk patients in trial settings only$

P~stme~opausal Node positive Tamoxifen ER positive ER negative Node negative ER positive ER negative

chemotherapy trials Adjuvant treatment trials Adjuvant therapy for high risk patients in trial settings only

Tamoxifen with or without chemotherapy trials chemotherapy trials Tamoxifen Chemotherapy trials

ER = estrogen receptor +Breast conservation surgery was endorsed for this catagory. More research is needed for conclusive statements regarding adjuvant chemotherapy in node negative patients. The use of chemotherapy and tamoxifen for node positive postmenopausal women also requires further study. $.High risk patients are defined as ER negative, with large tumors that are aneuploid in a high S-phase.

cancer be offered some form of adjuvant therapy. This recommendation was based on unpublished studies and caused understandable skepticism. Since then, studies have been published detailing early results from adjuvant treatment of node-negative patients.30These studies showed a significant improvement in diseasefree survival, although the results are immature (ie, average patient follow-up of approximately three years). These disease-free survival advantages have not translated into an overall survival advantage, however, because of the relatively short follow-up. There remains considerable debate as to the wisdom of subjecting all women to the risks and expense of cytotoxic therapy o r tamoxifen.31 We encourage patients to participate in 956

ongoing NSABP trials through our institution. Current trials include 0 dose intensification for node positive patients, 0 tamoxifen alone or with chemotherapy in ER positive patients with negative nodes, tamoxifen versus placebo for lesions less than 1 cm where data on hormone receptors are not available, and 0 preoperative or “neoadjuvant” versus postoperative chemotherapy for lesions diagnosed by fine needle aspirate. Patients who are considered at relatively low risk for developing recurrence are those with tumors less than 1 c m in size with a well differentiated histology or good nuclear

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Fig 1. Cosmetic appearance of patient 18 months after lumpectomy for breast cancer followed by irradiation. grade.” Patients who do not require adjuvant therapy are those with noninvasive disease. In addition, receptor status and the DNA histogram provide additional prognostic information that may place the patient in a low risk category. A DNA histogram is an analysis of the status of DNA or chromosomal material contained in the tumor specimen. Typically, cell populations will be classed as diploid (ie, containing paired chromosomal material as in normal cells), or aneuploid (ie, containing more or less than the normal DNA complement). An aneuploid tumor is considered to have a worse prognosis. Additionally, an estimate of the percentage of cells that are actively synthesizing DNA (ie, S-phase) is reported and implies cells that are preparing to grow and divide. In our institution, an S-phase population greater than 1 1% is used as marke r of a more aggressive tumor that has a greater likelihood of recurrence. Further definition of these high versus low risk groups is necessary and may include evaluation of features such as the evidence of lymphatic or venous invasion within the $58

s p e c i m e n a n d m e a s u r e m e n t of a n e w e r marker of risk, cathepsin D.

Case Report

M

s. BD is a 67-year-old woman who had a palpable mass in the right breast. She had no family history of breast cancer, and no history of hormone use. She was gravida 111, para 111, and her first pregnancy was at age 20. She was postmenopausal for approximately 18 years and had a normal mammogram two years previously. On physical exam, she had a 2-cm mass in the upper outer quadrant of the right breast. She had no axillary node involvement clinically, and there were no signs of distant metastasis. Her physician recommended fine needle aspiration, and the results were reported as suspicious for carcinoma. Because FNA was nondiagnostic, the surgeon discussed plans for a biopsy with the patient and described the surgical options. After these discussions, the patient elected to proceed with a lumpectomy. If that was positive on frozen section, she wished to proceed

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Fig 2. Side \iiew of patient who appears in Figure 1. immediately with axillary dissection. The patient was taken to the operating room, and under general anesthesia, the surgeon performed a lumpectomy of what appeared to be a medullary carcinoma with negative margins on frozen section. The surgical team reprepped and redraped the patient, and the surgeon performed an axillary dissection. The lymph nodes were negative. The surgeon presented the patient’s case to the institutional tumor board at which time further information regarding her negative hormone receptor status was available. The surgeon elected, after discussion with the tumor board, not to recommend adjuvant therapy because of t h e i m p r o v e d prognosis of medullary carcinoma. the patient’s lymph node status, and negative hormone receptors. The patient underwent radiation therapy of 5,000 rads to the breast with an additional 750 rad boost to the tumor site. Postoperatively, the patient has been followed for approximately 18 months at threemonth intervals and continues to be free of recurrence. She is quite happy with the cosmetic results (Figs 1 and 2).

This patient had strong feelings about preserving her breast, and this illustrates that age is not a factor in decisions regarding body image. The notion that an older woman will naturally elect to have the breast removed needs to be rethought. In addition. she had cytologic features on FNA that precluded a definitive diagnosis of carcinoma, although raising the strong possibility of this diagnosis. This situation allowed the surgeon to discuss surgical options ranging from incisional biopsy alone with subsequent definitive therapy of the axilla, total mastectomy, and lumpectomy with axillary dissection at the same sitting. The histologic features of a relatively small tumor (ie, less than 2 cm) and negative axillary nodes have a good prognosis. Radiation therapy was indicated for this patient to prevent local recurrence.

Early Detection Recornrnendutions

B

reast cancer detection is a team effort that should involve patients, nurses, primary care physicians, radiologists, surgeons, and pathologists. Each woman has a 959

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Performing a Breast Self-Examination1 Sit or stand in front of a mirror with arms relaxed at your sides. Look carefully at your breasts. Look for any changes in sue and shape, and any puckering or dimpling of the skin. Squeeze the nipple gently to detect abnormal discharge or change in the appearance of the nipple. Look for the same things listed in number 1 when you raise both arms over your head, after placing hands behind head and tensing arms, and with hands on hips tensing arms and pressing arms forward. See if any changes have occured. Lie down with a towel or pillow under your left shoulder. Place your left hand under your head. With your right hand held flat, fingers together, press gently but firmly with small circular motions to examine the upper inner quadrant of your left breast. Start at the ster-

4.

5. 6.

7.

8.

num moving outward toward the nipple line. Feel the area around the nipple. Feel for any lump or thickening. Palpation in the shower with wet, soapy skin aids in breast examination. With the same pressure and methd described in number 3, examine the lower inner part of the breast. Feel for any lump or thickening. It is normal to feel a ridge of firm tissue or flesh. Bring your left arm down to your side. Feel in the axilla with the flat part of your fingers (same as number 3 and 4). With arms still at your side, palpate the upper outer quadrant of your breast 60m the nipple line to where your arm is resting. Palpate the lower outer quadrant of the breast going from the outside in toward the nipple. Repeat the entire procedure on the right breast, again feeling for any lump or thickening.

1. L S Brunner, D S Suddarth, Textbook of Medical Surgical Nursing sixth B Lippincott Co, 1988) 1131.

responsibility to herself to practice breast selfexamination (BSE) after appropriate instruction. (See “Performing a Breast SelfExamination.”) Monthly exams are encouraged, and it is helpful if a patient is familiar with the changes in her breasts throughout her menstrual cycle. Therefore, w e encourage the premenopausal woman to vary the time within the cycle for BSE until she is comfortable with these changes. The most reliable part of the cycle to examine for new findings is the week after a menstrual period and patients are encouraged to perform BSE at this time. Women (especially postmenopausal women) are encouraged to choose a day of the month when it is easy to remember to add BSE to their daily routine, such as payday or when the phone bill arrives. This reinforces the practice and can improve patient BSE reliability as well. A yearly exam by a physician familiar with

ed

(Philadelphia: J

breast pathology also is encouraged as part of a general health maintenance program. For many women, this is included as part of their yearly gynecologic exam. For high risk patients or those whose breasts are difficult to examine, because of dense benign disease, prior surgery, or size, more frequent physician exams may be necessary. The physician has a responsibility to have an appropriate index of suspicion on each patient he or she sees and be willing to act on suspicious findings with the vigor required to diagnose cancer early. Mammography is an integral part of the evaluation of any suspicious exam and in breast cancer screening. This should be a part of the annual evaluation of all women over 50 years old. The American Cancer Society recommends a baseline mammogram sometime around the age of 35 years, every one to two years between age 40 and 50, and then yearly thereafter. Patients at high risk should have individualized 961

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screening programs sometimes starting much younger than the recommended guidelines. Efforts to educate more physicians on the value of mammography are clearly needed. Women should insist on having m a m m o grams or insist on a n explanation why the p h y s i c i a n b e l i e v e s it is not a p p r o p r i a t e . Nurses play a major role as patient advocates in this regard by promoting wider use of mammography. It is critical to remember that mammography is only part of the breast evaluation, and a negative mammogram may be reported in 10% to 15% of breast cancer cases. A suspicious lump with a nondiagnostic or negative mammogram requires further evaluation by FNA or biopsy.

Conclusion reast cancer therapy is an evolving process. Surgery will likely be a part of that therapy for t h e foreseeable future. Although the role of radical surgery has diminished, many patients continue to choose total mastectomy as their definitive surgical therapy. Nurses play a vital role in patient advocacy perioperatively. In addition, female nurses may find themselves as patients. An awareness of the treatment options available and nursing diagnoses should allow the perioperative nurse to develop care plans that address the special needs of these patients. -

Editor’s note. The impetus for Ms. Stein to write this article came after Mary Dahl, a close friend. died of breast cancer. Notes 1 . E S Silverberg, C C Boring, T S Squires, “Cancer statistics, 1990,” Ca-A Cuncer. Jour~rzalfor C1iniciari.s 40 (January/February 1990) 9-26. 2. J S Spratt, W L Donegan, R A Greenberg, “Epidemiology and Etiology” in Cuncer of the Breast, third ed, W L Donegan, J S Spratt, eds (Philadelphia: W B Saunders, 1988) 46-73. 3. R Ottman et al, “Practical guide for estimating risk for familial breast cancer,” The Lanwt 2 (Sept 3, 1983) 556-558. 4. B MacMahon, P Cole, J Brown, “Etiology of human breast cancer: A review,” Joirrnal of’ the

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National Cancer Insriricte SO (January 1973) 2 1-42. 5 . M Feinleib, “Breast cancer and artificial menopause: A cohort study,” Journal of’ rhe Nariorzal Cancer Institute 41 (August 1968) 315329. 6. Centers for Disease Control, “Cancer and hormone study. Long-term oral contraceptive use and the risk of breast cancer,” Joui~nulof the Aniericxn Medical Association 249 (March 25. 1983) 1591-1595. 7. M P Vessey, R Doll, P M Sutton, “Investigation of the possible relationship between oral contraceptives and benign and malignant breast disease,” Cancel. 28 (December 1971) 1395-1399. 8. Centers for Disease Control, “Cancer and hormone study. Long-term oral contraceptive use and the risk of breast cancer,” 1591; R D Gambrell, Jr, R C Maier, B I Sanders, “Decreased incidence of breast cancer in post menopausal estrogen progesterone users,” Ohstetvics arid Cynec,ology 62 (October 1983) 435-443. 9. R K Ross et al, “A case control study of menopausal estrogen use and breast cancer,” Joumul of the American Medical A ~ ~ o c i ~ t i 243 otz (April 1980) 1635-1639. 10. K K Carroll, “Experirnental evidence of dietary factors and hormone dependent cancers,” Cunc,er Research 35 (November 1975) 3374-3383; F dewadrd, “Breast cancer incidence and nutritional status with particular reference to body weight and height,” Cancer. Research 35 (November 1975) 335 1-3356. 1 I. W C Willett et al, “Dietary fat and the risk of breast cancer,” T h e N e w England JournuI o j Medicine 316 (Jan 1, 1987) 22-28. 12. R Brylowski, “Tofu chic.” Oncology Times 12 (July 1990) 14; Spratt, Donnegan, Greenberg, “Epidemiology and Etiology,” 46-73. 13. MacMahon, Cole, Brown, “Etiology of human breast cancer: A review.” 21. 14. D P Winchester, “The relationship of fibrocystic disease to breast cancer,” B~rllerinof rlze Anwricwn CollcJge qf Surgeons 7 I (September 1986) 29-31; D L Page et al, “Relation between component parts of fibrocystic disease complex and breast cancer,” Journal of the National Cuncer Instirirte 61 (October 1978) 1055-1063. 15. de Waard, “Breast cancer incidence and nutritional status with particular reference to body weight and height,” 3351. 16. Page et al, “Relations between component parts of fibrocystic disease complex and breast cancer,” 1055-1063. 17. L E Hughes, R E Mansel, D J T Webster, Beriign Disorders and Diseuses qf the Breast: Conceprs and Clinical Mtrriagenierit (London: Bailliere Tindall. 1989) 27-39. 963

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18. A S Morrison, “Review of evidence on the early detection and treatment of breast cancer,” Cancer 64 no 12 supplement(Dec 15, 1989) 26512656. 19. The National Cancer Institute Breast Cancer Screening Consortium, “Screening mammography: A missed clinical opportunity? Results of the NCI breast cancer screening consortium and national health interview survey studies,” Joiirtzal of the American Medical Associarion 264 (July 4, 1990) 5458. 20. M Kaufman, D Bider, D Weissberg, “Diagnosis of breast lesions by fine needle aspiration biopsy,” The American Surgeon 49 (October 1983) 558559. 21. C D Haagensen, Diseases of the Breast, third ed (Philadelphia: W B Saunders, 1986) 719-843. 22. K Krause, “Responding to breast cancer,” Nursing Times 83 (March 1987)63-65. 23. W H Wohlberg et al, “Factors influencing options in primary breast cancer treatment,” Joiri-nu1 of Clinical Oncology 5 (January 1987) 6874. 24. K Krause, “Responding to breast cancer,” Nursing Times 83 (March 1987) 63-65; B Fisher et al, “Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer,” The N e w England Journal of Medicine 320 (March 1989) 822-828. 25. S Ward, S Heidrich, W H Wolberg, “Factors women take into account when deciding upon type of surgery for breast cancer,” Cancer Nursing 12 (December 1989) 344-35 1. 26. Fisher et al, “Eight year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer,” 822-828. 27. Consensus Conference, “Adjuvant chemotherapy for breast cancer,” Journal of rhe American Medical Associarion 254 (Dec 27, 198.5) 3461-3463. 28. K Smigel, “Consensus on treatment of early stage breast cancer: Less surgery. more research,” Journal ofthe National Cancer Institiire 82 (July 18, 1990) 1180-1181. 29. National Cancer Institute, “Clinic Alert,” (Letter to clinicians) (May 1988). 30. B Fisher et al, “A randomized clinical trial evaluating sequential methotrexate and Fluorouracil in the treatment of patients with node negative breast cancer who have estrogen-receptor-negative tumors,” The New England Journal of Medicine 320 (Feb 23, 1989) 473-478; B Fisher et al, “A randomized clinic trial evaluating tamoxifen in the treatment of patients with node-negative breast cancer who have estrogen receptor-positive tumors,” The New, England Journal of Medicine 320 (Feb 23,

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1989) 479-484; E G Mansour et al, “Efficacy of adjuvant chemotherapy in high-risk node-negative breast cancer: An intergroup study,” The N e w England Journal of Medicine 320 (Feb 23, 1989) 485-490; The Ludwig Breast Cancer Study Group, “Prolonged disease-free survival after one course of perioperative adjuvant chemotherapy for nodenegative breast cancer,” New England Journal of Medicine 320 (Feb 23, 1989) 491-496. 31. W L McGuire, “Adjuvant therapy of nodenegative breast cancer,” The N e w England Journal Medicine 320 (Feb 23, 1989) 525. 32. D Rosner, W W Lane, “Node-negative minimal invasive breast cancer patients are not candidates for routine systemic adjuvant therapy,” Cancer 66 (July 1990) 199.

Enrollments Decrease in Master’s Programs The National League for Nursing (NLN) reports a decrease in the number of enrollments and graduations in master’s level nursing programs for the first time. Enrollments in 1989 decreased by 1.4% from 1988 and graduations decreased 2.6%, according to a Jan 7, 1991, NLN news release. This data has serious implications in light of the shortage of nursing faculty in the United States. Many nursing schools have waiting lists of students who can not be admitted because of the shortage of faculty members. The recent improvement in the nursing shortage may be temporary if there are not enough advanceddegree nurse educators to teach new nursing school entrants. The news release stated that nursing education programs continue to attract the smallest group of master’s degree students. Most nursing graduate students are preparing for advanced clinical practice or jobs in administration or management. This data was released in the latest volume of Nursing Datasource: A Research Report, published by NLN.

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-Examination . *

Horn STUDYPROGRAM

1. Breast cancer occurs in a. one out of two women b. one out of 10 women c. one out of five women d. one out of 20 women 2. What factors are involved in the etiology of breast cancer? a. research is inconclusive b. dietary and hormonal c. genetic, environmental, and hormonal d. genetic, hormonal, dietary, and environmental 3. A woman with a first-degree relative who was diagnosed with premenopausal bilateral breast cancer has a higher risk of having breast cancer than a woman with no family history of the disease. What percent does that risk represent? a. 10% b. 15% c. 20% d. 30% 4. Which hormonal factors are thought to increase the risk of breast cancer? 1. nulliparity or first pregnancy after age 35 2. early menarche 3. late menopause 4. surgical removal of the ovaries before age 40 a. all of the above b.2and3 c. 1,2, and 3 d. 1 and 3 5. Which of the following statements are true? 966

1. In animals, high-fat diets increase the incidence of chemically induced mammary cancers, but this has no relation to human cancer development. 2. In humans, intake of dietary fat and excess body weight in postmenopausal women is not healthy, but does not represent an increased risk of breast cancer. 3. Obesity may be associated with the increased conversion of adrenal precursors by aromatase to unopposed estrogenic compounds that are thought to contribute to breast cancer. 4. The presence of unopposed endogenous estrogen suggests a link between diet, obesity, and breast cancer. a. 1 only b. 1 and2 c. 2 and 3 d. 3 and 4 6 . Breast cancer is a histologic diagnosis. This means a. It is easily diagnosed by a complete patient history. b. Diagnosis can be suggested by physical and mammographic findings, but confirmation of the diagnosis must be made by histologic or cytologic examination of the tissue specimens. c. Physical examination and mammograms can diagnose breast cancer definitively. d. A routine screening mammogram is the diagnostic tool of choice. 7. The most common physical finding in breast

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cancer is a breast lump. Other physical findings that may be present include 1. breast contour changes 2. nipple retraction or discharge 3. skin dimpling or erythema 4. lymph node changes a. 1 only b. 1 and4 c. 1,2, and 3 d. all of the above 8. Diagnostic tests used to evaluate a patient for breast cancer include a. fine-needle aspiration andlor biopsy b. mammography c. ultrasonography d. all of the above 9. When evaluating a mammogram, what features would indicate the need for further clinical evaluation of the patient? 1. asymmetry or distortion of the breasts 2. a discreet mass or density 3. calcification within a mass of microcalcifications 4. cystic areas within the breast a. 1 and2 b. 1, 2, and 3 c. 3 only d. all of the above 10. Fine-needle aspiration (FNA) is rapid, inexpensive, diagnostic, and therapeutic for breast cysts, however, a suspicious mass requires formal biopsy if FNA is negative for cancer. a. true b. false 11. Breast cancer is considered a generic term. Why? a. because there is no specific type of patient who is diagnosed with breast cancer. b. because there are generic drugs that can be used to treat it. c. because it is a term that describes the different histological subtypes of carcinoma and sarcoma of the breast d. all of the above 12. Of all breast cancer, infiltrating ductal carcinoma represents what percentage of 968

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diagnoses? a. 10% b. 33% c. 50% d. 75% 13. Breast cancer is classified into four stages. What do these stages describe? a. tumor size b. lymph node involvement c. distant metastasis d. all of the above 14. Radical or modified radical mastectomy are the only recommended treatments for breast cancer. a. true b. false 15. Breast conservation surgery (ie, lumpectomy with axillary dissection) followed by radiation therapy is indicated for which patients? 1. patients with tumors < 5 cm in size 2. patients whose breast size would result in acceptable cosmetic results following lumpectomy and permit radiation therapy postoperatively 3. patients who have concerns about body image 4. This treatment has not proven to be effective and should not be used. a. 4 only b. 1 and2 c. 2 only d. 1,2, and 3 16. Many people assume that total mastectomy is the only safe choice in treating breast cancer. What have the National Surgical Adjuvant Breast and Bowel Project (NSABP) clinical trials shown regarding total mastectomy versus lumpectomy followed by radiation therapy? a. This opinion is correct. b. There is no difference in eight-year follow up survival rates. c. No conclusive evidence can be shown that either treatment works. d. Women who opt for lumpectomy have lower survival rates but have fewer body image problems.

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17. The use of postoperative radiation therapy for patient undergoing lumpecfomy is important. Why? a. Radiation therapy is considered palliative therapy only. b. Local recurrence is significantly reduced with this therapy. c. Radiation therapy is not important. d. The effects of radiation therapy are unknown. 18. The use of chemotherapy or hormonal therapy is a. known as adjuvant therapy b. used as a means to prevent spread or recurrence of breast cancer c. controversial area because recommendations vary on which women should receive it and what its benefits are d. all of the above 19. Only 25% to 30 % of all patients in NSABP trials undergo lumpectomy even though at least half of the participants may be candidates for this surgery. Why? 1. Many women choose total mastectomy rather than worry about surveillance of a breast over the rest of their lives. 2. The statistics regarding lumpectomy with radiation therapy are not encouraging. 3. Some physicians still feel that total mastectomy offers the best treatment. 4. Only 25% to 30% of eligible women choose lumpectomy because on the whole, patients are uneducated. a. 2 only b.2and3 c. 1 and 3 d. 4 only 20. Tamoxifen is an estrogen-blocking agent commonly used in adjuvant therapy. How does it work? 1. It is a cytostatic agent that prevents estrogen-induced cell growth. 2. Tamoxifen binds to proteins or estrogen receptors within tissue sensitive to estrogen (eg, breast cancer cells). 3. Tamoxifen is a chemotherapeutic agent. 4.It is not known how it works. 970

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a. 4 only b. 3 only c. 1 and2 d. 1 only 21. When caring for a patient with breast cancer, the perioperative nurse should assess the patient for body image disturbance, conflict over treatment options, ineffective coping, grief, and the potential for altered role performance. a. These nursing diagnoses will affect the patient but do not affect the OR nursing care. b. The perioperative nurse must be sensitive to these nursing diagnoses and how they affect each patient with breast cancer. c. Nursing diagnoses are figments of the collective nursing consciousness. d. These nursing diagnoses do not apply to the breast cancer patient. 22. When caring for the patient having a total mastectomy or lumpectomy with axillary dissection, the nurse must take care to 1. provide a quiet supportive atmosphere before induction to reduce patient anxiety 2. avoid hyperextending the arm on the surgical side to avoid brachial plexus injury 3. avoid undue pressure over the breast lump while prepping 4. provide separate instruments and drapes for the axillary dissection to avoid contamination of the axilla by tumor cells a.2and3 b. 4 only c. 1,2,3, and 4 d. 1 only 23. Proper handling of breast tissue specimens is very important. Why? 1. All tissue removed from a patient should be handled in the same manner. 2. Many of the studies performed on breast cancer specimens affect postoperative therapy. 3. How the specimen is preserved and sent to the pathologist has no bearing on

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anything. 4. Estrogen and/or progesterone receptor studies, DNA f l o w cytometry, and frozen sections can be performed only if the specimen is moistened with saline. a. 1 only b. 2 and 4 c. 3 only d. 4 only 24. T h e perioperative nurse who cares for patients undergoing total mastectomy also should be familiar with breast reconstruction. What are some of the common techniques used to reconstruct the breast? a. tissue expanders b. silicone or saline-filled implants c. myocutaneous flaps d. all of the above 25. The perioperative nurse must be aware of common postoperative complications of mastectomy. These include a. minor complications, usually related to infection b. bleeding, deep vein thrombosis, infections, and seromas c . infection, seromas, brachial plexus injury, bleeding, and deep vein thrombosis d. all of the above Professional t i ~ r s e sare invited to sirhniit clinical in' matiagerial maniiscripts for the home study program. Manuscripts or queries should be sent to the Editor, AORN Journal, 10170 E Mississippi AIV, Denwr., CO 80231. As with all manuscripts sent to the J o u i m l , papers submitted for. honie study progrunis should tiot have h e m previously puhlislred or submitted siniulianeorrsly to any other puhlicatioti.

AORN JOURNAL

HIV Infection on College Campuses A recent study concluded that human immunodeficiency virus (HIV) infection exists on college campuses in the United States and the potential for further spread clearly exists. According to research results published in the Nov 29, 1990, issue of The New England Journal of Medicine, positive specimens were found at nine of the 19 schools investigated. The survey was conducted by the Centers for Disease Control, Atlanta, in collaboration with the American College Health Association. The researchers found 30 samples that were positive for antibodies to HIV among the more than 16,000 blood samples tested. The blood that was tested was collected for routine medical purposes at the student health centers of the institutions. This gave a seroprevalence of 0.2%, or one positive sample per 500 students tested. Seroprevalence increased with age. All positive results were from students more than 18 years old and 19 were from students more than 24 years old. Twenty-eight of the positive samples were from men. The seroprevalence rate was 0.5% for men and 0.02% of women. The researchers listed several limitations to the study. The survey was not a random sample of all colleges or of all the students at the surveyed colleges. Schools from all geographic areas were not included. Students who seek medical attention at health centers and have blood drawn may not be representative of all students. The results demonstrate that HIV infection and the potential for its transmission are present on many college campuses. According to this article, studies have shown that many students engage in behavior that could place them at risk of HIV infection. The researchers concluded that education measures to change unsafe behaviors are needed to prevent the further spread of HIV infection in the college student population. 97 1

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Answer Sheet BREASTCANCER

P

lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, C O 80231 Session #5496 Event #915007 Program offered April 1991 The deadline for this program is Oct 31,1991.

Mark only one answer per question

1 2

3 4 5 6 7

1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70%correct is required for credit. 4. Record the time required to complete the program 5. Enclose fee: Members $7; Nonmembers $14. AORN (ID) # If nonmember, please provide Social Security

8 9 10

11 12 13 14 15

#

16

Name Address

17

City

18

State

Zip

RN license and state

19 20

Florida license # (Required for Florida CE Credit)

21

PhoneNo. (

22

Fee enclosed or bill the credit card indicated 0 Mastercard 0 Visa Card # Expiration date Signature

23 24 25 (Turn Over)

(for credit card aulhorizauon)

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Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. 1. Objectives. To what extent were the following objectives of this home study program achieved? (1) Identify the incidence and etiology of breast cancer. (2) Identify the means of diagnosing breast cancer. (3) Describe the classification and staging of breast cancer. (4) Identify treatment modalities for breast cancer. (5) Discuss the role of the perioperative nurse.

(Low)

2. Content. (1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? (5) Was the content of the article relevant to the objectives? 3. Test question/answers. (1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address important points? 4. What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s):

Author names and addresses:

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