Breast Cancer

Pathophysiology Assignment: Education Project

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College of Nursing Pathophysiology Assignment

“The purpose of this project is to develop a presentation of some sort that would be appropriate to give to either a new nurse or a patient diagnosed with the assigned disease process. It should include all of the areas below. Note that the format should be something that could logically be provided to someone.”


We will be discussing the pathogenesis, risk factors, diagnostics, treatments, and clinical manifestations of breast cancer. Each section will be discussed, and supplemental resources will be available throughout the flyer.


Group members include:

Mendi Chen

Samantha Ernst

Acacia Leslie

Kimberly Lohbeck

Jessica Luong

Martina Pineda

A Few Facts:

Breast Cancer is the most common cancer in American women.

It is the leading cause of death in women 40 years old to 44 years of age.

More than 2/3rds of breast cancer cases occur in women older than 55 years old.

The median age for breast cancer diagnosis: 61 years of age.

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Pathogenesis

“Breast cancer” refers to several types of neoplasm arising from breast tissue. The most common neoplasm neoplasm would be adenocarcinoma of the cells lining the terminal duct lobular unit. Breast cancer has different aspects to it--this includes hormonal cancer and hereditary cancer. Breast cancer requires a hormonal supply to develop (like the breast tissue it comes from) The risk of breast cancer increases with lifetime estrogen exposure.


With the hormone-sensitive aspect of this particular cancer, breast cancers express estrogen receptors and proliferate (reproduce rapidly) in response to estrogen stimulation.

  • note the relationship of this statement to the treatment section and how there are endocrine therapies inhibit estrogen production, which is why it’s effective in treating hormone-sensitive breast cancer


With the hereditary portion of it, approximately 5-10% of breast cancers are hereditary. Being hereditary implies that there is a known genetic mutation causing increased cancer risk in the patient’s family.


There’s a syndrome called HBOC syndrome--HBOC syndrome is caused by mutations in two genes, which are BRCA1 and BRCA2. These genes code for a DNA repair pathway & protect against mutations. Loss of either of the two leads to a high risk of breast cancer (and others).


Normal breast stem cells or progenitor cells can transform into breast cancer cells.

There are two different estrogen receptors – Erα, which is alpha and ERβ, which is beta. They both carry DNA binding domains and exist in the nucleus and cytosol. When estrogen enters the cell, it is supposed to bind to the ER—or estrogen receptors I mentioned above—and that complex travels into the nucleus, leading to the production of transcription proteins that induces cell changes. Because estrogen has proliferative properties, it cellular simulation can lead to negative consequences if a patient has too many of these estrogen receptors.


There are different types of breast carcinomas - they are noted below.


Carcinoma of Mammary Ducts:

Papillary

Intraductal (comedo)


Infiltrating Carcinoma:

Ductal (no specific type, NST)

Mucinous

Medullary

Tubular

Adenoid Cystic

Metaplasmic

Squamous Cell


Carcinoma of Mammary Lobules:

Lobular carcinoma in situ

Infiltrating lobular

Paget Disease

Inflammatory Carcinoma


Sarcoma of the Breast:

Cystosarcoma phyliodes

Fibrosarcoma


As you can see, there are lots of different types of breast cancer. That's why there are many diagnostic tests to determine proper treatment and care plans.


Breast cancer is a heterogenous disease - this means there are lots of molecular, phenotypic, and pathological changes that happen in someone's body.


There are however, traits that are central to the pathogensis, of breast cancer: these include motility, invasiveness, and self-renewal of the cancerous cells. Another important trait for pathogensis includes the resistance of the cancer cell to apoptosis, or regulated self-destruction of a cell.


DCIS (ductal carcinoma in situ) is the most common type of non-invasive breast cancer. It I s the presence of abnormal cells inside a milk duct in the breast. DCIS is considered the earliest form of breast cancer. Noninvasive means it hasn't spread out of the milk duct to invade other parts of the breast.


LCIS (lobular carcinoma in situ) is an area (or areas) of abnormal cell growth that increases a person's risk of developing invasive breast cancer later on in life. Lobular means that the abnormal cells start growing in the lobules, the milk-producing glands at the end of breast ducts.

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Breast cancer staging is determined during the surgical removal of the cancer, or using blood tests and imaging techniques to assess the extent at which cancer has spread. The stage of cancer is based on:

  1. the cancer size

  2. whether the cancer is invasive or non-invasive

  3. whether the cancer is present in lymph nodes

  4. whether the cancer has spread to body parts other than the breast


Some words commonly associated with cancer staging are: local- meaning the cancer is confined within the breast; regional- the lymph nodes are involved, primarily those in the armpit; and distant- the cancer is found in other parts of the body as well. Breast cancer staging assists in understanding prognosis, and making decisions about treatment.


The stages range from least to most severe, expressed on a number scale of 0 through IV


  • Stage 0- Noninvasive, no evidence of cancer cells or other abnormal cells anywhere but the breast tissue where they originated.


  • Stage I- Invasive, cancer cells are invading the normal surrounding breast tissue.This stage has two subcategories: IA & IB.

  • IA- the tumor measures up to 2cm AND has not spread outside of the breast tissue.

  • IB- there’s no tumor in the breast; small groups of cancer cells--larger than 0.2mm but not larger than 2mm-- are found in lymph nodes, OR there is a tumor in the breast no larger than 2cm, and there are small groups of cancer cells (0.2mm-2mm) in the lymph nodes.


*In Stage I, microscopic invasion of the tissue outside the lining of the duct or lobule is possible, but these invading cancer cells can’t measure more than 1mm.


  • Stage II- Has two subcategories: IIA & IIB.

  • IIA- Invasive; no tumor in breast, but cancer larger than 2mm is found in 1 to 3 axillary lymph nodes, or in the lymph nodes near the breastbone. OR, the breast tumor measures 2cm or smaller and has spread to axillary lymph nodes. OR, the breast tumor is 2cm to 5cm, but has not spread to lymph nodes.

  • IIB- Invasive; breast tumor is 2cm to 5cm, and small groups of cancer cells (0.2-2mm) are found in lymph nodes. OR, breast tumor is 2 to 5cm, and cancer has spread to 1-3 axillary nodes or the lymph nodes near the breastbone. OR, the breast tumor is larger than 5cm but has not spread to axillary lymph nodes.


  • Stage III- Has three subcategories: IIIA, IIIB, and IIIC.

  • IIIA- Invasive; no tumor is found in the breast or the tumor may be any size, but cancer is found in 4 to 9 axillary lymph nodes or in the nodes near the breastbone. OR, the tumor is larger than 5cm, and small groups of cancer cells (0.2mm-2mm) are found in lymph nodes. OR, tumor is larger than 5cm and cancer has spread to 1-3 axillary lymph nodes or the nodes near the breastbone.

  • IIIB- Invasive; the tumor may be any size and has spread to the chest wall and/or skin of the breast and caused swelling or an ulcer AND may have spread to up to 9 axillary lymph nodes OR may have spread to the nodes near the breastbone.

  • IIIC- Invasive; there may be no tumor in the breast, or one of any size, and may have spread to the chest wall and/or skin of the breast AND cancer has spread to 10 or more axillary lymph nodes, OR spread to lymph nodes above or below the collarbone.


  • Stage IV- Invasive breast cancer that has spread beyond the breast and nearby lymph nodes to other organs of the body. This stage of cancer may be described as “advanced” or “metastatic”.

Risk Factors

Modifiable:


· Having Children: Women who have had no children or who had their first child after age 30 have a slightly higher breast cancer risk overall.

· Birth Control: Studies have found that women using oral contraceptives (birth control pills) have a slightly greater risk of breast cancer than women who have never used them. This risk seems to go back to normal over time once the pills are stopped.

· Hormone therapy after Menopause

· Breastfeeding: may slightly decrease breast cancer risk

· Drinking alcohol: women who consume 1 alcoholic drink a day have a very small increase in risk. Excessive alcohol consumption is also known to increase the risk of developing several other types of cancer.

· Smoking tobacco: long-term heavy smoking is linked to a higher risk of breast cancer.

· Being overweight or obese

· Physical activity: In one study from the Women's Health Initiative, as little as 1.25 to 2.5 hours per week of brisk walking reduced a woman's risk by 18%.


Non-modifiable:


· Gender: Women are 100 times more common among women than men, though men can get breast cancer as well

· Aging: As you age, your risk for breast cancer increases.

· Genetics: mutations of the BRCA1 and BRCA2 genes increases risk of getting cancer in general by about 65%-80%. Mutations of other genes can increase the risk of cancer as well.

· Family and Personal History of breast cancer

· Race and Ethnicity: Overall, white women are slightly more likely to develop breast cancer than are African-American women, but African-American women are more likely to die of this cancer. However, in women under 45 years of age, breast cancer is more common in African- American women. Asian, Hispanic, and Native-American women have a lower risk of developing and dying from breast cancer.

· Menstrual periods: Women who have had more menstrual cycles because they started menstruating early (before age 12) and/or went through menopause later (after age 55) have a slightly higher risk of breast cancer. The increase in risk may be due to a longer lifetime exposure to the hormones estrogen and progesterone.

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Diagnostics

There are a multitude of tests used to help health professionals diagnosis breast cancer. Receiving an accurate diagnosis of breast cancer will help develop a proper breast cancer treatment plan and will help increase your survival rate and decrease side effects.


The tests include lab tests, biopsy, ultrasound, mammography, MRI, PET/CT scan, miraluma breast imaging, bone scan, and metastatic cancer detection.

Physical exam and health history: You will receive a full physical exam and subjective data collection of your health history. The main focus of the physical exam will be a breast exam to check for enlarged lumps, nodules, swelling or thickening, and enlarged or tender lymph nodes in the axilla and supraclavicular area.


Lab Tests: CBC (complete blood count) measures red and white blood cell count circulating in the bloodstream,hemoglobin, and hematocrit levels. Genomic tumor assessment examines the genetic mutations of the tumor to help determine the cause of the tumor which allows for more accurate treatment. Oncotype DX is a 21-gene test that determines the benefits of chemotherapy for a specific patient and also the likelihood of recurrence of cancer. Mammaprint+Brluprint is a genomic lab test used to decode a breast tumor’s unique characteristics and mutations to help target the best method of treatment for the specific tumor. Tumor molecular profiling tests the tumor cells for specific enzymes, proteins, and genes to identify the best drug therapy that will be most effective in treating the cancer. Nutrition panels analyze the patient’s nutrient levels to determine any deficiencies especially in vitamin D and iron.


Biopsy: A sample of tissue or fluid is removed from the tumor. The cells are then examined under a microscope and determined if cancerous or benign. Sentinel lymph node biopsy helps determine if cancer has spread to the lymph nodes. Dye is injected near tumor site. Once a lymph node has picked up the dye, part of the tissues are removed to be examined for presence of cancer cells. MRI-guided breast biopsy is an image-guided procedure that utilizes MRI technology to target precise locations for cell removal for diagnosis and treatment planning.


Ultrasound: A form of imaging technology that utilizes high-frequency sound waves to produce images of organs and tissues. This source helps detect the smallest abnormalities such as a lump, cyst, or a solid mass especially in dense breast tissue. It can also be used to locate the precise position of a tumor to guide a biopsy procedure.


Mammography: X-ray of the breast that helps detect and diagnose breast cancer tumors. It produces sharp, digital images of the breast with low radiation exposure that help determine precise location and extent of the disease. It helps detect breast cancer in its early stages which will result in lower radiation doses, reduced breast compression pressure, and improved breast cancer detection rates.


MRI: Imaging tool that creates cross-sectional images of the internal organs of the body. It can differentiate normal and diseased tissue by using radiofrequency waves, powerful magnets, and a computer. This can often detect tumors that may have been missed during a mammogram.


PET/CT scan: Nuclear imaging technique that can reveal information about the structure and function of cells and tissues in the body. It provides a detailed computerized picture of the breasts which show abnormal activity and gives a precise location of the activity.


Miraluma breast imaging: A non-invasive nuclear medicine that produces pictures of malignant lesions hidden in dense fibrous breast tissue. Small amounts of radioactive substance is injected into the patient. A Gamma camera takes a picture of the breast. The radioactive substance helps to highlight cancerous tissue from non-cancerous tissue based on how it accumulates around the tissue.


Bone scan: It is an image scan that detects cancerous cells, evaluates bone fractures, and monitor bone conditions. A small dose of a radioactive substance is injected into the vein to be delivered to the bloodstream. The substance accumulates in the bone and is detected by a scanner via nuclear imaging. This will reveal cell activity and function in the bone. This will detect cancer that has metastasized to the bone from its primary site such as from breast tissue.


Metastatic cancer detection: Common locations for metastatic breast cancer to spread are the bone, liver, lungs, skin, and brain. Radiofrequency ablation may be used to treat metastatic breast cancer to the liver. Endobronchial ultrasound system (EBUS) is used to treat metastatic breast cancer to the lungs. Kyphoplasty is used to treat metastatic breast cancer to the bone.


On top of all these diagnostic tests and procedures used by health professionals, it is highly recommended that women perform monthly-self breast exams. This can help catch breast cancer early by detecting any abnormalities which can be confirmed as cancerous or benign by your doctor by utilizes the test above.


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Treatments

Surgery: removing the tumor and nearby margins

  • Goal: To remove not only the tumor, but also enough of the margin to be able to test for the spread of cancer.

  • Lumpectomy (Most common)/partial mastectomy: Removes the cancerous tumor along with a rim of potentially healthy tissue around it (known as the margins) without removing the entire breast.

    • Diff.: Lumpectomy: removes the least amount of breast tissue--cancer and small portion of the surrounding tissue

    • Partial Mastectomy: removes a larger portion of the breast than in lumpectomy--whole segment or quadrant of tissue--in order to eliminate the cancer--remove some of lining over the chest muscles.

  • Mastectomy: removes entire breast(or as much of the breast tissue as possible)

    • Partial Mastectomy: Remove larger portion of the breast--whole segment or quadrant of tissue. May remove some lining of the chest muscles as well

    • Skin-Sparing Mastectomy: Removal of breast, nipple, areola, and sentinel lymph node(s)but not the breast skin--usually done w/ women who intend to have breast reconstruction

    • Simple/Total Mastectomy: Removal of breast, nipple, areola, and sentinel lymph node(s)--leaves the chest wall and more distant lymph nodes intact

    • Modified Radical Mastectomy: Removal of entire breast, nipple, areola, and axillary lymph nodes but leaves chest wall intact.

    • Radical Mastectomy:(or as much of the breast tissue as possible), chest wall, and all axillary lymph nodes


Chemotherapy: Uses drugs to either destroy or slow down growth of cancer cells

  • Prescribed usually with hormonal or targeted therapies

  • can be used to shrink tumor

  • Uses Cytotoxic drugs--given orally or intravenously

  • Affects whole body

Radiation Therapy

  • Uses radiation to kill cancer cells

  • Used to destroy undetectable cancer cells & reduce risk of cancer recurring

  • May be used to destroy any remaining cancerous cells after surgery

    • Affects nearby skin/cells only in the part of the body treated with radiation

    • Begins 3-4 weeks after surgery

    • Usually for people who have Stage 0 and or Stage 1 with invasive cancer and higher

  • External Beam Breast Cancer Radiation-Traditional/whole breast radiation uses an external beam that is highly focused and targets the area for 2-3minutes.

  • Internal Radiation/Partial Breast Radiation: a radioactive liquid is inserted into the area to target where the cancer originally began to grow and tissue closest to the tumor


Hormone therapy: Uses hormone inhibitor/blocker drugs--help kill cancer cells by removing supply of hormone

  • Most common is Tamoxifen (prior and after menopause)-blocks estrogen-shaped openings in cell-> preventing estrogen-fueled cancers from growing. Can be taken daily up to 5 years after surgery. Helps prevent the development of new cancers.

  • The hormone inhibitor target the hormone receptors on the breast cancer cells--reducing the the body’s hormone production

  • Often used together with chemotherapy.

  • LH-RH Agonist-Prevents ovaries from making estrogen.

    • Ex: Leuprolide & Goserelin

  • Surgery to remove ovaries: Source of estrogen is removed

  • Aromatase inhibitor (after menopause): Prevents body from making estradiol (form of estrogen)

    • Ex: anastrazole, exemestane, and letrozole

Targeted therapy: Uses drugs that block the growth of breast cancer cells

  • Trastuzumab (Herceptin) or lapatinib (TYKERB) block the action of a protein called HER2 which stimulates growth of breast cancer cells--finds the cells, bind to them, and blocking the action of the receptor

  • Bevacizumab: Prevents tumors from angiogenesis

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Clinical Manifestations

Monthly breast self-exams should be done, because it is the most convenient and simple way of keeping up to date with one’s own body.

Furthermore, the individual is able to identify any changes in the breasts that were not present a month or two ago.


Abnormalities upon palpation: tenderness of the nipple, a lump or mass on or around the breast.


The lateral upper quadrant of each breast is where most masses appear.

This is called The Tail of Spence; it is an extension of the tissue of the breast that extends into the axilla, or armpit


Enlargement of pores, or the texture of the skin changing is also abnormal. A mass felt does not always mean it is cancerous, but still should be checked by a doctor.


Abnormalities upon inspection: Any significant changes in breast size or shape. This does not mean the normal fluctuations that follow with the menstrual cycle. This includes things like any recent nipple retractions.


As noted in the image included above, dimpling, asymmetrical swelling or shrinking, or notable change in color of the breast, areola, or nipple also can manifest.


The change in skin may often appear like the skin of an orange.

If one breast has recently appeared larger than the other, it should be checked.

Nipple discharge (especially not breastmilk) in a woman who is not pregnant or breastfeeding should be checked.

Peeling or flaking of nipple skin may also be present.

Itching, irritation may also be common.

Breast cancer symptoms can also be present in the lymph nodes or in the axillary area; these include swelling or lumps.

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Resources

There are some short animations below that can help visually explain some of the things we talked about. Also found below are links to websites with even more information and detail for questions patients may ask. Earlier we noted that it is recommended they see a doctor if there are any abnormalities noted, but these websites will lead them to other resources such as support groups, further research, and advances in medicine.
Breast Cancer Animation
Breast Cancer Therapy - Medical Animation by Watermark

Works Cited

"About Breast Cancer: Treatment." National Breast Cancer Foundation, Inc. National Breast Cancer Foundation, Inc. Web. 4 Dec. 2015.


"Breast Cancer Diagnostics and Treatment." Cancer Treatment Centers of America. Rising Tide. Web. 4 Dec. 2015.


"Breast Cancer: Treatment Options." Cancer Network. American Society of Clinical Oncology (ASCO). Web. 4 Dec. 2015.


Huether, Sue E., and Kathryn L. McCance. "Chapter 32: Alterations of the Reproductive Systems."Understanding Pathophysiology. 5th ed. St. Louis: Mosby/Elsevier, 2012. Print.


"Symptoms and Signs: The National Breast Cancer Foundation." Www.nationalbreastcancer.org. National Breast Cancer Foundation. Web. 4 Dec. 2015.



    "Cancer stages are based on four characteristics: the size of the cancer, whether the cancer is invasive or non-invasive, whether cancer is in the lymph nodes, whether the cancer has spread to other parts of the body beyond the breast."