A Journey with Breast Cancer

The body is made up of many types of cells. Normally, cells grow and divide to produce more cells only when the body needs them. This is an orderly process which keeps the body healthy. Sometimes cells keep dividing when new cells are not needed. They may form a mass of extra tissue called a growth or tumor. Benign tumors are not a threat to life but malignant tumors are cancer. Cells in these tumors can invade and damage nearby tissues and organs. The fear is that cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. That is how breast cancer spreads and forms other tumors in the body. The spread of cancer is called metastisis. (Dollinger, Rosenbaum and Cable, 1991).

Each breast has 15 to 20 overlapping sections called lobes. There are many smaller lobules, which end in dozens of tiny bulbs that can produce milk. The lobes, lobules and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple in the center of a dark area of skin called the areola. Fat fills the spaces around the lobules and ducts. The breast does not have muscles tissue but muscles lie under each breast and cover the ribs. Each breast contains blood vessels and vessels that contain lymph. The lymph vessels lead to small bean shaped organs called lymph nodes. Clusters of lymph nodes are found near the breast under the arm, above the collarbone and in the chest. They are also found in other parts of the body. (Dollinger, Rosenbaum and Cable, 1991).

According to Dollinger, Rosenbaum and Cable (1991), the most common type of breast cancer begins in the lining of the ducts It is called ductal carcinoma. Lobular carcinoma arises in the lobules. They explain that when breast cancer spreads outside of the breast, cancer cells are often found in the lymph nodes under the arm. If it reaches these nodes it may mean that cancer cells have spread to other parts of the body, other lymph nodes or other organs. It may have spread to the bones, liver or lungs.

When cancer spreads, it is called metastatic breast cancer. The median duration of survival for women with metastatic disease is two to three years. Malignant cells are transported via the lymphatic system. Distant metastasis occurs when the cancerous tumor cells break away from the primary tumor and spread to other sites in the body. (McEvilly and Hassey, 1998).

According to the National Cancer Institute (1999), research has shown that the following conditions place a woman at increased risk for breast cancer:

Personal history of breast cancer – Women who have had breast cancer face an increased risk of getting breast cancer again.

Genetic alterations – Changes in certain genes (BRCA1, BRCA2, and others) make women more susceptible to breast cancer. In families in which many women have had the disease, gene testing can show whether a woman has specific genetic changes known to increase the susceptibility to breast cancer.

Family history- A woman’s risk for developing breast cancer increases if her mother, sister, daughter or two or more other close relatives, such as cousins, have a history of breast cancer, especially at a young age.

Certain breast changes – Having a diagnosis of atypical hyerplasia or lobular carcinoma in situ (LCIS) or having had two or more breast biopsies for benign conditions may increase a woman’s risk for developing cancer.

Breast density – Women age 45 and older whose mammograms show at least 75 per cent dense tissue are at increased risk. Dense breasts contain many glands and ligaments, which makes breast tumors difficult to see and the dense tissue itself is associated with developing breast cancer.

Radiation therapy – Women whose breasts were exposed to radiation during their childhood, especially those who were treated with radiation for Hodgkin’s disease, are at an increased risk.

Late childbearing – Women who had their first child after the age of 30 have a greater chance of developing breast cancer than women who had their children at a younger age. Early menstruation – Women who started menstruating at an early age (before age 12), experienced menopause late (after age 55), never had children, or took hormone replacement therapy or birth control pills for long periods of time. Each of these factors increases the amount of time a woman’s body is exposed to estrogen. The longer this exposure, the more likely she is to develop breast cancer.

In most cases, doctors cannot explain why a woman develops breast cancer. Studies show that most women who develop breast cancer have none of the risk factors listed above. Also, women with known risk factors may never develop breast cancer (Dollinger, Rosenbaum and Cable, 1991).

When breast cancer is found and treated early, the chances for survival are better. Women can take an active part in the early detection by having regular mammograms and breast exams. Self examination is also very important. Mammograms can often detect cancer before it is felt. It can also show calcium deposits which may be an early sign of cancer. There are some limitations because a mammogram may miss some cancers or may find things that turn out not to be cancer at all. Detecting a tumor early does not guarantee that a woman’s life will be saved. Some fast growing cancers may have already spread to other parts of the body before being detected. (Dollinger, Rosenbaum and Cable, 1991). The National Cancer Institute recommends that women in their forties and older have mammograms on a regular basis, every one to two years.

Early breast cancer does not cause pain as a rule. In fact, when breast cancer first develops, there may be no symptoms at all. According to Dollinger, Rosenbaum and Cable, 1991), as cancer grows it can cause many changes that women should watch for:

A lump or thickening in or near the breast or in the underarm area;

A change in the size or shape of the breast;

Nipple discharge or tenderness, or the nipple pulled back into the breast;

Ridges or pitting of the breast (looks the skin of an orange);

A change in the way the skin of the breast, areola or nipple looks or feels.

The physician is able to tell a lot about a lump by its size, texture and whether is moves easily. He/she does this by feeling the lump and the tissues around it. Apparently, benign tumors have a different feel. The physician finds out a lot of information by reading the mammogram. Ultrasonography is also used to tell whether a lump is solid or fluid filled. The following procedures may be performed to make a diagnosis according to Dollinger, Rosenbaum and Cable, (1991):

Fine needle aspiration. A thin needle is used to remove fluid from a lump. If it is fluid filled it is not cancer. If it is solid it may or may not be cancer.

Needle biopsy. Tissue can be removed with a needle from an area that is suspicious on a mammogram and cannot be felt.

Surgical biopsy. The surgeon cuts out part or all of a lump or suspicious area.

The pathologist can tell what kind of cancer it is, if it is invasive, whether the cancer is sensitive to hormones, if it grows slowly or rapidly. The patient will be referred to an oncologist who specializes in the treatment of cancer. Generally, treatment will begin within a few weeks after diagnosis. This is the time to get a second opinion, prepare self and loved ones.

There are more treatment options and hope for survival than ever before. The options depend on the size and location of the tumor, the results of lab test and hormone receptor tests, and the stage of the disease. The women’s age, menopausal status, general health and size of her breasts are considered. This is the time to learn all that is possible about the disease, the treatment choices and to take an active part in decisions about medical care and options.

There are many resources where a patient can learn about breast cancer. Calling the National Cancer Institute’s Cancer Information Service a 1-800-4-CANCER is a great way to gather the most current up to date treatment information, including information about current clinical trials. A cancer specialist can provide answers to questions about breast cancer treatment. They can also make referrals to other resources. There is so much to learn about breast cancer and its treatment. As I described in my personal journey, this is a very difficult time to remember all of the information heard and understand all of the answers at once. I suggest keeping a journal to refer to when things seem a lot clearer.

Methods of treatment are local or systemic. Local treatments are used to remove, destroy, or control the cancer cells in a specific area. Surgery and radiation therapy are local treatments. Systemic treatments are used to destroy or control cancer cells throughout the body. Chemotherapy and hormonal therapy are systemic treatments. A patient may have one form of treatment or both (McEvilly and Hassey, 1998).

Surgery is the most common treatment for breast cancer. An operation to remove the breast or as much of the breast as possible, is a mastectomy. Breast reconstruction is often an option at the same time as the mastectomy, or later on. An operation to remove the cancer but not the breast is called breast sparing surgery. They usually are followed by radiation therapy to destroy any cancer cells that may remain in the area. In most cases, the lymph nodes under the arm are removed to help determine whether cancer cells have entered the lymphatic system (Dollinger, Rosenbaum and Cable, 1991).

In lumpectomy, the breast cancer and surrounding tissue is removed. Some of the lymph nodes under the arm are removed.

In segmental mastectomy, the surgeon removes the cancer and a larger area of normal breast tissue around it. Occasionally, some of the lining over the chest muscles below the tumor is removed as well. Some of the lymph nodes under the arm may also be removed. (Dollinger, Rosenbaum and Cable, 1991).

In total (simple) mastectomy, the whole breast is removed with some of the lymph nodes. In modified radical mastectomy, the whole breast is removed, the lymph nodes under arm and often the lining over the chest muscles. The smaller of the two chest muscles is also taken out to help in removing the lymph nodes (Dollinger, Rosenbaum and Cable, 1991)..

In radical mastectomy, also called Halsted radical mastectomy, the breast is removed, the chest muscles, all of the lymph nodes under the arm and some additional fat and skin. This operation was considered standard procedure for many, many years. Thank goodness, it is only used rarely these days and only in cases where the cancer has spread to the chest muscles. (Dollinger, Rosenbaum and Cable, 1991).

Breast reconstruction is surgery to rebuild a breast’s shape. This option should be discussed with a plastic surgeon prior to having a mastectomy (Fraker and Edwards, 1998).

Radiation therapy is the use of high energy rays to kill cancer cells and stop them from growing . These rays can come from radioactive material outside the body and be directed at the breast by a machine. It can also come from radioactive material placed directly in the breast in thin plastic tubes. Some women receive both kinds (McEvilly and Hassey, 1998).

Chemotherapy is the use of drugs to kill cancer cells. It is usually in a combination of drugs. They may be given orally or by injection. Either way, it is a systemic therapy because the drugs enter the blood stream and travel throughout the body.

Treatment choices depend on a number of factors. These include age, menopausal status, general health, the size, location, stage of the tumor, lymph node involvement and size of the breast. Certain features of the tumor cells, such as whether or not they depend on hormones to grow are considered. But, the most important consideration is the stage of the disease. The stage is based on the size of the tumor and whether the cancer has spread.

The following is a brief description of the stages of breast cancer and the treatments often used at each stage according to (Dollinger, Rosenbaum and Cable, 1991):

Stage 0 is sometimes called noninvasive carcinoma or carcinoma in situ. Lobular carcinoma in situ, or LCIS, refers to abnormal cells in the lining of the lobule These abnormal cells seldom become invasive cancer. They mean there is an increased risk for developing breast cancer. The risk is increased for both breasts. Some women with LCIS may choose to take a medication called tamoxifen in an attempt to prevent cancer or may do nothing at all and have regular check ups.

Ductal carcinoma in situ is called intraductal carcinoma or DCIS. This refers to the cancer cells in an area of abnormal tissue in the lining of a duct that have not invaded the surrounding breast tissue. If DCIS lesions are left untreated, over time cancer cells may break through the duct and spread to nearby tissue. Patient with DCIS may have a mastectomy or breast sparing surgery followed by radiation therapy. Underarm lymph nodes are not usually removed.

Stage I , the cancer cells have not spread beyond the breast and the tumor is no more than an inch across.

Stage II, the tumor in the breast is less than one inch across and the cancer has

spread to the lymph nodes under the arms, the tumor is between 1 and 2 inches with or without spread to the lymph nodes under the arms or the tumor is larger than 2 inches but has not spread to the lymph nodes under the arm.

Stage III is called locally advanced cancer. The tumor is large, more than 2 inches across and the cancer is extensive in the underarm lymph nodes or it has spread to other lymph nodes or issues near the breast. Inflammatory breast cancer is this type. Usually local and systemic treatment are given to stop the disease from spreading.

Stage IV is metastatic cancer. The cancer has spread from the breast to other parts of the body. Chemotherapy and/or hormonal therapy is given to destroy the cancer cells and control the disease. Recurrent cancer means it has come back in spite of the initial treatment. Even when a tumor seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained in the area after treatment or the disease had already spread before treatment. Most recurrences appear within the first 2 to 3 years after treatment, but breast cancer can recur many years later. Side effects of treatment

The side effects are different for each person or even one treatment to the next. It is hard to limit the effects so that only the cancer cells are removed. Healthy cells and tissues are both damaged and the treatment can cause many side effects.

The most common side effect of radiation is fatigue. Resting is important. The skin in the treated area becomes red, dry, tender and itchy. Toward the end of treatment the skin may become moist and “weepy”. Exposing the area to air helps aid healing. There may be a permanent change in the skin color (Dollinger, Rosenbaum and Cable, 1991).

Chemotherapy has many side effects but vary from person to person. In general, anti- cancer drugs affect rapidly dividing cells. These include blood cells, which fight infection, cause the blood to clot and carry oxygen to all parts of the body. When these cells are affected the patient is more prone to infections, bruising and bleeding easily, and my have less energy during treatment. Patients may lose their hair, have loss of appetite, nausea, vomiting, diarrhea or mouth sores. These side effects are generally short term problems and go away after treatment is over (Dollinger, Rosenbaum and Cable, 1991).

Tamoxifen is a form of hormonal therapy. This drug blocks the body’s use of estrogen but does not stop estrogen production. It may cause hot flashes, vaginal discharge and irritation, and irregular periods in some women. Serious side effects are rare but are noted to be blood clots in the veins, especially in the legs and sometimes causes cancer in the lining of the uterus (McEvilly and Hassey, 1998).

Surgery causes short term pain and tenderness in the area of the operation. Any surgery carries a risk of infection, poor wound healing, bleeding or reactions to medications and anesthesia according to Fraker and Edwards, (1998). Removal of a breast can cause a woman’s weight to shift and be out of balance. This can cause discomfort in a woman’s neck and back. The skin in the breast area may be tight and the muscles of the arm and shoulder may feel stiff. After a mastectomy, some women have some permanent loss of strength in these muscles, but for most, reduced strength and limited movement are temporary. Exercises are of benefit to improve and maintain range of motion. Nerves may be injured or cut during surgery and they may be a numbness and tingling in the chest, underarm, shoulder and arm. These feelings usually go away within a few months but some women have permanent numbness (Fraker and Edwards, 1998).

Loss of appetite can be a problem when feeling uncomfortable or tired. Nausea, vomiting and mouth sores can make it hard to eat. However, good nutrition is important. Getting enough calories and protein helps to prevent weight loss, regain strength and rebuild normal tissues (Monson and Harwood, 1998).

After mastectomy a woman may decide to wear a breast form (prosthesis). Others may prefer breast reconstruction. What is right for one woman may not be right for another. There are many choices to be considered. Various procedures are used to reconstruct the breast. Some use implants or tissue moved from another part of the body. A woman’s age, body and type of cancer treatment will all play a role in deciding what treatment would be best. According to Fraker and Murray (1998), some women think the reconstructed breast may improve marital or sexual relations. It may make a woman feel more feminine and I described earlier, “whole again”. There is more freedom in wearing clothing. The prosthesis is difficult to wear at times. Other factors play a role in choosing reconstruction or not. Such as, age, fear of more surgery, fear of the outcome, more pain and fear of not finding a local recurrence. Some reconstruction takes place right away, others are delayed because of the type of procedure. The reconstruction process can be long and grueling according to my own experience but it can be one of the most important parts of the rehabilitation process if a woman chooses this option.

Recovery will be different for every woman, depending on the extent of the disease, the type of treatment and other factors.

Exercising after surgery helps to regain motion and strength in the arm and shoulder. It can also reduce pain and stiffness in the neck and back. Gradually, exercising can be more active and regular exercise should become part of the daily routine (Fraker and Edwards, 1998).

Often, lymphedema after surgery can be prevented or reduced with certain exercises and resting the arm on a pillow. An elastic sleeve can be worn, medication prescribed or manual lymph drainage (massage) can be tried. A physical therapist may be a helpful referral (Dollinger, Rosenbaum and Cable, 1991).

Regular follow up care is important after breast cancer treatment. A woman will have regular checkups to be sure that the cancer has not returned. This includes examinations of the breasts, chest, underarm and neck. From time to time there will be a complete physical examination and additional tests. Any unusual symptoms should be reported to the doctor such as pain, loss of appetite or weight changes, unusual vaginal bleeding or blurred vision. A woman should be alert to signs of dizziness, coughing or hoarseness, headaches, backaches or digestive problems that are unusual and do not go away. These symptoms may be a sign that cancer has returned but could be a lot of other things (Dollinger, Rosenbaum and Cable, 1991).

This diagnosis can change a woman’s life and the lives of people close to her. These changes can be very hard to handle. There are feelings of fright, anger and depression. These are normal reactions when someone faces a serious health problem. It helps to share thoughts and feelings with others. It can open the way for others to show their concern and offer support.

Sometimes women who have had breast cancer are afraid that changes to their body affect not only how they look but how other people feel about them. They may be concerned that breast cancer and its treatment will affect their sexual relationships. It is helpful to seek counseling or a couple’s support group (Monson and Harwood, 1998).

Cancer patients may worry about holding a job, caring for their families or starting new relationships. Worries about tests, treatments, hospital stays and medical bills are common. Doctors, nurses, members of the health care team and the rehabilitation counselor can help calm fears and ease confusion about these issues. The patient should be provided with information and resources (Monson and Harwood, 1998).

Employers must be educated to understand breast cancer and its treatment. Flexible work schedules, rest periods, time off for doctor appointments and treatments will be necessary. Depending on the extent of the disease, an employer may need to make reasonable accommodations for the returning employee. If the patient, for example is suffering from lymphedema, it may be necessary to adapt the work station or place the worker in a different position where no lifting is involved. Since cancer is a disease outlined in the American Disabilities Act, it may be necessary for the rehabilitation counselor to discuss making reasonable accommodations and review the laws with the employer.

In conclusion, it can be very helpful to talk with others who are facing similar problems. It is beneficial to get together in support groups and self help groups to share what has been learned about cancer, its treatment and coping with the disease. Several organizations have trained volunteers who have had breast cancer themselves, such as Kaiser Permanente’s Breast Buddy program or The American Cancer Society’s, Reach for Recovery program. Volunteers may telephone or visit patients, provide information and lend emotional support before and after the treatment. Their own experiences are often shared with the patient which helps to put things into perspective during a very confusing, lonely and frightening time.

Bibliography:

References

Ault, Susan R., BSN, OCN and Ferrell, Betty R., Ph.D., FAAN (1999). From victim to victor: Taking control of breast cancer, The American Journal of Nursing, 46-51

Dollinger, Malin, M.D., Rosenbaum, Ernest N., M.D., and Cable, Greg (1991). Everyone’s guide to breast cancer therapy, New York; Universal Press

Fraker, Teresa R., BSN, RN, OCN and Murray Edwards, Denise, MA, MED, RNCS, NTS (1998). After mastectomy: Restoring cosmesis via breast reconstruction, The American Journal of Nursing, (Suppl. 6), 40-45.

McEvilly, Jan Marie, MS, RN and Hassey Dow, Karen, Ph.D., RN, FAAN (1998). Treating metastatic breast cancer; Principles on current practice, The American Journal of Nursing, (Suppl. 6), 26-29.

Moffa Barse, Patty, MSN, OACN, RN and Masney, Agnes, MPH, MSN (1990). Adjuvent therapy and breast cancer treatment, The American Journal of Nursing, (Suppl. 6), 21-25.

Monson, Mary Ann, MSN, RN and Harwood, Kerry, MSN, RN, (1998). Helping women select primary breast care treatment, The American Journal of Nursing,, 3-7.

The National Cancer Institute, (1999). Understanding breast cancer treatment; A guide for patients, Chicago: Author.





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