1. Breast Cancer
Awareness
Conversation Starters

2. By the Numbers: Stats
and demographics for
breast cancer.
Genetics:
Predispositions and
available tests
Risk Factors: Drugs,
hereditary, diet,
reproductive, more.
The Down-Low: What
breast cancer is, how
it’s classified.
Staging: Criteria for the
4 stages of breast
cancer.
Self-Breast Exam:
Timing, processes, key
points for teaching.
Clinical Exam: Timing,
purpose, who provides
the examination.
Mammogram: Timing,
methods, diagnostic vs.
screening.
Public Health: The
purpose and goals of
the nurse.
Early Detection:
3 Tiers, overview of
each.
Take-Away Points
Nursing Care Planning:
Diagnoses, interventions,
outcomes.
References: Scholarly
journal articles that
totally rock!
Men: Remembering the
1%, consequences of
being ill-informed.
Diagnostics: Lab tests,
imaging, biopsy, patho
report, immunoassay.
Treatment: Forms,
surgery, chemo,
radiation, endocrine.

3. Cell growth involves a system of
checks-and-balances. When an
error occurs in a cell’s
development, it’s usually killed
through apoptosis, or cellular
suicide. When this mechanism
malfunctions, unhealthy cells are
able to continue growing. Breast
cancer develops when cells
begin to proliferate, or multiply,
abnormally… unchecked.
A tumor is classified based upon
its relationship with the basement
membrane. Non-invasive (in-situ)
forms are anchored to the
membrane. Invasive (infiltrating)
masses may to spread to other
tissues, such as the lymph nodes.
A tumor is staged according to
the diameter of the mass and the
amount of surrounding tissue
that’s invaded.
Classifying & StagingWhat is Breast Cancer?
The Down-Low on Breast Cancer

4. Tumor is limited
to the areas
within the
breast tissue
and the mass is
small, no more
than 2 cm in
diameter.
Tumor is > 5 cm
but limited to
breast tissue, or
< 2 cm in lymph
nodes of the
arm, or 2-5 cm
in lymph nodes
of the breast
only.
Tumor has
metastasized
beyond the
breast and
spread to
external lymph
nodes, tissue
groups and
organs.
Tumor is > 5 cm
and has spread
beyond the
breast tissue,
invading the
lymph nodes
located under
the arm.
STAGE 1 STAGE 2 STAGE 3 STAGE 4
Staging Breast Cancer
One Two FourThree

5. 99% 2nd Three
Million
Breast Cancer by the Numbers
Number
One

6. Advanced
age. History of
ovarian
cancer.
Previous
radiation
therapy in the
breast or chest
region.
Nulliparity (no
children) and
having children
but not
breastfeeding
increases
lifetime
estrogen
exposure.
Reproductive
Age/History
Carriers of the
BRCA 1 or 2
gene. 1st
degree
relatives
(mother or
sister)
diagnosed with
breast cancer.
Genetics
Leading
theories
speculate that
high glucose
levels act as
“fuel” that
triggers growth
of cancerous
cells.
Use of certain
hormonal
contraceptives
or hormonal
replacement
therapy
increases
estrogen
exposure.
Hormones
Diet/Obesity
Risk Factors for Breast Cancer

7. GENETIC TESTING
Can Help To
Better Understand
Risks
And Take Action!
CancerTYPE
ID
Oncotype
Dx
MammaPrint
Predispositions
Ashkenazi
Jewish
heritage
1st degree
relatives
BRCA-1 or
BRCA-2 gene
carrier
Genetic Tests

8. Early detection is associated
with higher patient outcomes!

9. Identifying
women at high
risk and
increasing
surveillancePrognosis is
higher when the
cancer is
detected early,
preferably
before it
metastasizes.
Efforts are focused on
educating the public about
methods for early
detection, such as
performing monthly self-
breast exams.
Nurse’s Role in the Community
help women understand benefits
public
awareness
health
promotion
Early detection
surveillance
identify
high risk
improve
access

10. The Three Tiers of Early Detection
Early Detection = Better Outcomes!
Self-Breast Exam Mammogram Clinical Exam

11. PointsforTeaching Self-Breast Exam
Mammogram
Clinical Breast Exam
Schedule 1st screening mammogram at the age of
40, and then once again every 5 years. If high risk,
schedule 1st imaging between the ages of 25-30
and then once again every year.
Schedule 1st clinical breast exam with a clinician
beginning at the age of 20 and then once every 2-
3 years until the age of 40. Following 40, increase
frequency to once a year.
Perform the self-breast exam once a month, 2 days
after menstruation. If post-menopausal, perform on
the same day, each month. Consistent
performance promotes familiarity!

12. Hormonal fluctuations alter the way
the breasts look and feel. They’re
most consistent 2 days after
menstruation ends.

13. Self-breast examination involves
both breasts (plus the nipples),
the axillary regions, and the
surrounding tissue (from the
sternum, extending to the
underarm region, and up to the
clavicles). Women are
encouraged to exam their
breasts on a monthly basis in
order to identify early changes.
 The breasts are both visualized
and palpated.
 Size, shape, and texture of the
breasts, axillary, and
surrounding tissue are
examined.
 The breasts are palpated using
3 levels of pressure: light,
medium, and firm; in order to
cover the entire tissue span.
How to ExamineWhat, When, & Why
About the Self-Breast Exam

14. Teaching Points: Self-Breast Exam
Gently squeeze each
nipples to assess for
drainage.
Examine up to the
clavicles (AKA: collar
bones).
Visualize with arm over
head, arms down, and
arm propped under a
pillow.
Common approaches
include the checker-
board, circle, and
square methods.
Palpate using 3 levels
of pressure: Light,
medium, and firm.
The axillary, or
underarm regions
contains lymph nodes.
The upper left quadrant
is the most common
area for breast cancer
to originate!
Feel and look at both
breasts, nipples, axillary,
and surrounding tissue,
up to the clavicles.
Palpate using 3 levels
of pressure: light,
medium, and firm.
Gently squeeze each
nipple to assess for
drainage.
3 visualizations: arms
over head, arms down,
and pillow propped
under the shoulder.
Technique and Pattern:
1) Up and Down, 2)
Circle 3) and Wedge.
Chose one to use.
Examine breasts ↑ to
the clavicles (AKA:
collar bones).
The axillary (AKA:
underarms/pits)
contain lymph nodes.
The upper left quadrant
is the most common
area for breast cancer
to originate!
Feel and look at both
breasts, nipples, axillary,
and include all of the
surrounding tissue.
Goal: Identify Changes!

15. Stand in front of a mirror
and examine the
appearance.
Stand in the shower.
Palpate breasts using 3
levels of pressure.
Lay down, prop up
shoulder on a pillow
and feel the breasts.
3 Main Steps of the Self-Breast Exam

16. Standing in front of a mirror, view
breasts from a forward position.
Observe the symmetry, shape, color,
and size of each breast, checking for
any new changes.
Inspect in Front of a Mirror
Next, change the perspective: raise
arms over the head, and press palms
together. Be sure to also look in the
underarm region and visualize the
nipples.In the Mirror

17. Look and Feel in the Shower
This allows the breasts to be visualized
from a different angle. Standing in the
shower ensures that the same position
will be used every month.
Examine the breasts in the shower.
Place the hand on the side of the
breast to be examined behind the
head. Look down at the breasts to
observe the same characteristics as
before.
In the Shower

18. Palpation Pattern Technique
With hand still above head, palpate
the breast with the free hand. Using
the Up and Down pattern technique,
feel the breast with the finger pads of
the first three fingers.
Palpate from the outer side to the
inner side of the breast; then up and
down in order to cover the entire tissue
span. Continue by palpating up the
axillary regions. Repeat on other side.
Up-and-Down

19. Be Thorough and Consistent
Cover All Areas
It helps to get into the habit of starting
on the same side each time.
Remember to raise the arm on the
same side to be examined.
When palpating, be sure to cover the
entire span, including the nipple,
breast tissue to the collar bone, the
upper chest area, and underarm
region.

20. Remember the Nipples!
Nipples Included
Be sure to include the nipples. Inspect
them for changes in size, color, texture,
symmetry, or shape. Feel for lumps,
bumps, thickening, or other changes.
With the thumb and ring finger, gently
squeeze the nipple to access for fluid
leakage. Discharge is an abnormal
finding and must be reported.

21. Lay Down and Pillow Prop
On a Pillow
Lay down and place a pillow under
one shoulder to prop up the breast to
be examined first. Use the same
techniques as before and include all
areas. Repeat for the other breast.
This position allows the breast tissue to
be felt from a different angle. It also
enables a deeper level of palpation.

22. 2 versions:
Screening
(standard) and
diagnostic
(when a mass is
detected).Considered to
be the “Gold
Standard” for
early detection
of breast
cancer.
Provides an image to
visualize the breast tissue
by evaluating the
density. Epithelial and
stromal cells, collagen,
and fat tissue all
influence the breast
density.
Screening Mammograms
breast imaging
screening reduces mortality rates
Gold
Standard
diagnostic
version is
more
detailed

23. Provides an
extra “check” in
addition to the
self-breast
exam.
The clinician
observes and
feels the breasts.
Involves visualization
(external) and palpation of
the breast, surrounding
tissue, and the
nipple…similar to the self-
exam.
Clinical Breast Exams
once a year starting at 40
exam by
clinician
remind
your
provider to
examine
palpate
start at
age of 20
extra
check
Identify palpable masses
observe

24. Diagnosed… Now What?
Individualized Treatment Plan.

25. Portrays a
complete
picture of the
case by
providing
information
such as grade,
size, and
margin of the
tumor.Diagnostic
technique used
to measures
the level of
certain
molecules such
as androgens
(sex hormones)
and antibodies.
Immunoassay
PathoReport
The diagnostic
mammogram,
ultrasound
tomography
(UST), and
magnetic
resonance
imaging (MRI)
provide internal
visualization.
Imaging
A tissue sample
is obtained and
then analyzed.
Several types
are available.
This is the only
method for a
definitive
diagnosis.
Blood samples
monitor factors
such as serum
tumor markers,
calcium levels,
hormones, and
alkaline
phosphatase.
LabWork
Biopsy
Labs and Diagnostic Procedures

26. Chemo
Endocrine
Treatment Options
Surgery
Radiation
A regimen of powerful drug
combinations that may be
thought of as ‘cell poison.’
Various forms are available.
All or part of the breast
tissue is removed. May
include the nipple, lymph
nodes, or only select tissue.
A high dose is delivered in
fractions to kill cancerous
cells while allowing healthy
ones time to recover.
Drugs that inhibit or alter
the effects of hormones.
Used for estrogen-receptor
positive breast cancer.

27. TreatmentModalities Primary Treatment
Adjuvant Treatment
Palliative Treatment
The method used as the main form of curative
treatment. This usually involves surgery, but may also
be another form, such as radiation or chemo.
Therapies that complement or enhance the primary
treatment. Chemo and endocrine therapy are
often used as adjuvants to surgery.
Purpose is not curative; rather, it’s to slow tumor
growth. It’s used to promote comfort and enhance
quality of life by providing relief of symptoms.

28. Mastectomies are named based
upon the portion of the breast
removed (if the nipple and
areola are left intact) and
involvement of surrounding
tissues, such as the lymph nodes.
Major post-op considerations
include incision site infection, fluid
balance, and the impact on the
woman’s body image.
 Lumpectomy: Only the lump is
removed (“conservative”).
 Partial mastectomy: Only part
of the breast is removed.
 Simple mastectomy: Breast
removed, but the nipple/
areola remains intact.
 Radical (Halsted) mastectomy:
Breast, nipple/areola, and the
lymph nodes are removed.
Major Procedure TypesSurgery Down-Low
Mastectomies

29. The minimal amount of radiation
is used to accomplish the desired
therapeutic response. The goal is
to kill cancerous cells while
allowing enough time for healthy
ones to recover between
treatments. Treatment itself is not
painful, but rays can irritate the
skin, causing a sunburn-like
reaction. Fatigue is also common.
 As the total radiation dose is
fractionated rather than given
all at once, each treatment is
called a fraction.
 Average length/frequency: 2-8
weeks; 4-5 times per week.
 Average time: 20 minutes per
fraction…up to several hours,
including prep and post-
treatment monitoring.
Radiation ConceptsWhat, How, Why
Radiation Therapy

30. Cell-cycle specific drugs target a
particular phase of cellular
replication while non-cell-cycle
specific drugs use other
mechanisms. Many chemo drugs
destroy cells that replicate
quickly. Alopecia and
gastrointestinal disturbances are
common as hair and mucosal
cells replicate rapidly.
 The risk of infection increases
as immune system function is
compromised.
 Maintaining hydration and
general nutritional status are
priorities.
 Nausea and vomiting must be
proactively managed through
administration of antiemetic
drugs and dietary adjustments.
Chemo-ConceptsMechanism of Action
Chemotherapy

31. Actions: Drugs that inhibit or alter
the effects estrogen. Indications:
adjuvant therapy, prophylactic
treatment, or active treatment of
metastatic cancer of estrogen-
receptor positive tumors. Major
classes: GnRH agonists,
aromatase inhibitors, and
selective estrogen receptor
modulators (SERMs), and
antiestrogen agents.
A SERM drug that antagonizes
(inhibits) the effects of estrogen
while agonizing/mimicking the
hormone’s actions in select
tissues. May be used for
prophylaxis in high-risk cases, as
an adjuvant therapy for up to 5
years following primary
treatment, or for metastatic
tumors. Avoid use with SSRIs as
toxicity may occur.
Tamoxifen (Nolvadex)What, How, Why
Endocrine Therapy

32. Antineoplastic
Agents
Hormones
Alkylating
agents
Antimetabolites
Antitumor
antibiotics
Nitrosoureas
Topoisomerase
I inhibitors
Drugs that Fight Cancer
Major Drug Classifications

33. Post-Op Mastectomy
Nursing Care Plan.

34. 1. Risk for infection, related to surgical incision.
2. Ineffective tissue perfusion, related to edema.
3. Acute pain, related to surgery.
4. Disturbed body image, related to loss of breast.
5. Interrupted family processes, related to altered roles,
relationships, and functions secondary to illness and treatment.
6. Fear, related to disease process/prognosis.
Nursing Diagnoses
Nursing Care Planning
Mastectomy

35. Nursing Interventions
 Infection: Monitor incision site. Provide
wound care, as ordered. Educate
patient on symptoms of infection and
other signs that warrant action.
 Pain: Assess on a 1/10 scale including
characteristics. Identify the level that’s
tolerable (example: 3/10). Administer
medications and reassess response.
 Perfusion: Position on non-affected side
to promote lymphatic drainage. Monitor
for signs of lymphedema, such as arm
pain.
 Body Image: Establish a therapeutic
patient-nurse relationship and supportive
environment that promotes expression of
response to body changes.
 Role: Assess family dynamics and support
system. Aid in developing a plan that
addresses the need for changed roles
and functions throughout recovery.
 Fear: Encourage expression of fears
about diagnosis, treatment, and
mortality. Arrange access to spiritual
services as appropriate.

36.  The patient doesn’t experience any signs of infection.
 Adequate tissue perfusion is maintained.
 Pain remains at or below tolerable levels throughout recovery.
 A positive body image is maintained, independent of decision for
reconstructive breast surgery.
 New family member roles are acknowledged and effective
adjustment methods are identified.
 Sources of fear are identified and explored. A plan that addresses
effective coping methods is established.
Anticipated Outcomes
The Goals of Nursing Care

37. What about
the 1%?

38. Consequences of Being Ill-Informed
metastasis
Delayed detection
Myth perpetuation that’s it a
“girl” disease
Unaware of risk factors, such as carrying
the BRCA-1/2 gene
shame Among those diagnosed
isolation
And higher mortality rates

39. For any woman reading this, I hope it helps
you to know you have options. I want to
encourage every woman, especially if you
have a family history of breast or ovarian
cancer, to seek out the information and
medical experts who can help you through
this aspect of your life, and to make your
own informed choices.
Angelina Jolie, in a statement made to the
New York Times.
Angelina is reported to be a carrier of
the BRCA gene. She underwent a
prophylactic double mastectomy.
Lessons from Pop Culture
Image by Michael Cook and MercatorNet.com
“

40. Many Thanks to these Amazing Sources…
1 Hamilton, R. (2012). Being young, female, & BRCA positive. American Journal of Nursing, 112(10), 26-31. Retrieved
from http://www.nursingcenter.com/lnc/cearticle?tid=1436197
2 Lieberthal, R. D. (2013). Economics of genomic testing for women with breast cancer. American Journal of Managed Care, 19(12),
1024-1031. Retrieved from http://www.ajmc.com/publications/issue/2013/2013-1-vol19-n12/Economics-of-Genomic-Testing-for-
Women-With-Breast-Cancer
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http://www.nursingcenter.com/lnc/CEArticle?an=00006527-201210000-00004&Journal_ID=496448&Issue_ID=1470639
5 Opdahl, S., Alsaker, M. D., Janszky, I., Romundstad, P. R., & L J Vatten, L. J. (2009). Joint effects of nulliparity & other breast cancer risk
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6 Pelusi, J. (2006). Sexuality & body image: Research on breast cancer survivors documents altered body image & sexuality. American
Journal of Nursing, 106(3), 32-38. Retrieved from http://www.nursingcenter.com/lnc/journalarticle?Article_ID=630712
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Retrieved from http://www.americannursetoday.com/article.aspx?id=8310
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http://www.americannursetoday.com/radiation-therapy-101/
9 Thomas, E. (2010). Men’s awareness & knowledge of male breast cancer. American Journal of Nursing, 110(10), 32-40. Retrieved from
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