ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING

NCM112 RLE

CASE STUDY NO: 5

BREAST CANCER

Submitted by:
GROUP 2

EUSEBIO, SHIELA MAE A.

FORRO, SHIEHAN MAE
FURIO, KEILAH EVE L.
GALACHE, KOLEEN ERICKA M.
GARILLOS, ANGEL MAY G.
HUESCA, YZEL JAN E.
ILUSTRE, NICA JADE T.
JULLEZA, CYRINE
LADINES, RUFFA MAE B.
LANES, AYLA CLARISSA C.
LAUREA, KYRO LUIGI C.
LASTIMOSO, DINA M.
PRAIRE, KURT BRIXTER C.
PUNO, JOHN BENLIAM E,

Clinical Instructor:
Eleanor Tupas Cabangal
CASE SCENARIO
Mrs. C.B. is a 55-year-old woman who noticed a lump in her left breast during her
monthly breast self-exam two weeks ago. She made an appointment with her
gynecologist who documents a fixed round lump with irregular borders palpated in the
upper outer quadrant of left breast at 2:00. Left axillary edema noted. There is symmetry
of the breasts with no puckering or nipple discharge. The client denies pain. Mrs. C.B.
began having her menstrual period at 10 years of age. She has two children ages 25
and 22 years old, both of whom she breastfed for approximately twelve months. Mrs.
C.B.'s oldest sister died of breast cancer. Due to patient's family history of breast
cancer, her doctor performed clinical breast examination followed by a mammogram
and fine needle biopsy. Tumor was found in left breast tissue but has not spread to
lymph nodes or other surrounding organs. The doctor recommends continuing with
surgical treatment to remove tumor through mastectomy. Patient followed-up with
physical therapist with doctor's diagnosis of Stage 2A Breast Cancer. A Jackson-Pratt
(JP) drain will be in place postoperatively. Following surgery, tamoxifen is prescribed.
The doctor has written orders for post-op patient to manage wound care, swelling, and
functional limitations. Also requests multiple rounds of radiation (5 days a week for 5
weeks) to ensure that abnormal cell growth has been ceased. Patient and caregiver
were educated on possible side effects of radiation therapy including, skin irritation,
redness, soreness, swelling, fatigue, and Lymphedema. After being discharged from
acute physiotherapy, patient was advised to go to outpatient physical therapy and
received Lymphedema treatment along with functional training. Upon discharge from
outpatient physiotherapy, patient was instructed to continue with physical activity
through exercise groups or community programs. Support group information was
administered to patient as well.
 I. INTRODUCTION AND OBJECTIVES

A. INTRODUCTION

Cells are the basic structure and functional unit that makes up an organism. The
human body is composed of trillions of cells, all with their own specialized functions.
Including the growth and
reproduction of new cells as the body needs. If cells die, they are usually replaced
by new cells.

Cancer is a broad term of a class of diseases characterized by abnormal cells that

grow and invade healthy cells in the body. Cancer begins when genetic changes
interfere with this orderly process. These cells may form a mass of tissue called a lump,
growth, or a tumor. A tumor can be either malignant or benign.

Breast cancer starts in the cells of the breast as a group of cancer cells that can then
invade surrounding tissues or spread to other areas of the body. These cells can spread
by breaking away from the original tumor and entering blood vessels, which branch into
tissues and organs, the process called metastasis. The most common histologic type of
breast cancer is infiltrating ductal carcinoma (80% of cases), whereby tumors arise from
the duct system and invade the surrounding tissues. Infiltrating lobular carcinoma
accounts for 10% to 15% of cases. These tumors arise from the lobular epithelium and
typically occur as an area of ill-defined thickening
in the breast. Infiltrating ductal and lobular carcinomas usually spread to bone, lung,
liver, adrenals, pleura, skin, or brain. However, there is no one specific cause of breast
cancer; rather, a combination of genetic, hormonal, and possibly environmental events
may contribute to its development.

Staging of Breast Cancer

Classifying tumors as stage 0, 1, 2, 3, or 4. Stage 2 and 3 tumors represent a wide

spectrum of breast cancers and are subdivided into stage 2A, 2B, 3A, 3B, and 3C. The
stage 2 is subdivided into groups: Stage 2A and 2B. The differences are determined by
the size of the tumor and whether the breast cancer has spread to the lymph nodes.

Stage 2A Breast Cancer

● No actual tumor is associated with the cancerous cells and less than four axillary
lymph nodes have cancer cells present.
● The tumor is less than 2 centimeters and less than four axillary lymph nodes
have cancer cells present.
● The tumor is between 2 and 5 centimeters and has not yet spread to lymph
nodes.

Stage 2B Breast Cancer

 ● The tumor is between 2 and 5 centimeters and has spread to less than four
axillary lymph nodes.
● The tumor is larger than 5 centimeters, but has not spread to any axillary lymph
nodes.

Modifiable Risk Factors:

● Gender (female)
● Family history
● Gene mutation
● Hormonal factors
● Other factors: ionizing radiation during adolescence and early adulthood obesity,
alcohol intake and high-fat diet

B. OBJECTIVES

1. GENERAL OBJECTIVES:

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2. SPECIFIC OBJECTIVES:

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KNOWLEDGE:
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SKILLS:
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ATTITUDE:
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II. PATIENT’S DATA

A. Biographic Data
Patient Name: Mrs. Reyes
Address: -
Age: 35 years old
Sex: Female
Marital Status: Married
Occupation: Laborer
Religion: -
Source of Information: Patient Herself
Attending Physician: -
Date of Admission: -
Time of Admission: -
Admitting Impression/Diagnosis: Pulmonary Tuberculosis

Chief Complaint
Mrs. Reyes complained of low grade fever, night sweats and loss of appetite.
She also complained of chest tightness.

Physical Examination
Patients looks pale, with dry and flushed skin and looks older than her age. Upon
auscultation both lungs sound revealed crackles breath sound. She also complained of
chest tightness but upon auscultation heart has no significant abnormalities. During
palpation, there are enlarged lymph nodes and she has a distended abdomen

Vitals signs revealed:

Pulse rate : 90 bpm
Respiratory rate : 25 com
Temperature: 38°C
02sat: 90%

III. PAST AND PRESENT MEDICAL HISTORY

A. History of Present Illness

Patients experiencing hemoptysis and have a low grade fever, night sweats and
loss of appetite

B. Past Medical History

Month prior to admission, she experience easy fatigability, nocturnal sweats and
weight loss. She sought consultation and she was able to have an apicolordotic X- Ray
result of PTB and Genexpert result of POSITIVE.
.
C. Family History
Her mother died of TB disease and her father constantly experienced chronic
asthma attack

D. Lifestyle And Health Practices

During her teenage years she was a smoker, alcohol drinker and a drug user .
Since then she manifested a smoker cough. The patients work as a laborer who ask her
neighbors to let her clean the house or even wash their laundry and she is also work as
street cleaner or sweeper in their barangay.
 IV. PATHOPHYSIOLOGY

ANATOMY & PHYSIOLOGY

Target Organ: BREAST

 Are art of the female and male sexual anatomy.
 For females, breasts are both functional (for breast feeding and sexual (bringing
pleasure).
 The visible arts of breast anatomy include the nipples and areolae
WHAT ARE BREASTS MADE OF?
 Several kinds of tissue form female breasts. Muscle connects breasts to ribs, but
they aren’t part of the breast anatomy. The different types of breast tissue
include:
o Glandular: also called lobules, glandular tissue produces milk.
o Fatty: This tissue determines breast size.
o Connective or fibrous: this tissue holds glandular and fatty breast tissue
in place.
PARTS THAT MAKE UP BREAST ANATOMY
 Lobes: each breast has between 15 to 20 lobes or sections. These lobes
surround the nipple like spokes on a wheel.
 Glandular tissue (lobules): these small sections of tissue found inside lobes
have tiny bulblike glands at the end that produces milk.
 Milk (mammary) ducts: these small tubes, or ducts, carry milk from glandular
tissue (lobules) to nipples.
 Nipples: the nipple is in the center of the areola. Each nipple has about nine milk
ducts, as well as nerves.
 Areolae: the areola is the circular dark-colored area of skin surrounding the
nipple. Areolae have glands called Montgomery’s glands that secrete a
lubricating oil. This oil protects the nipple and skin from chafing during
breastfeeding.
 Lymph vessels: part of the lymphatic system, these vessels transport lymph, a
fluid that helps your body’s immune system fight infection. Lymph vessels
connect to lymph nodes, or glands, found under the armpits, in the chest and
other places.
 Nerves: nipples have hundreds of nerve endings, which makes them extremely
sensitive to touch and arousal.

A. ETIOLOGY

Breast cancer invades locally and spreads through the regional lymph nodes,
bloodstream, or both. Metastatic breast cancer may affect almost any organ in the body
—most commonly, lungs, liver, bone, brain, and skin. Most skin metastases occur near
the site of breast surgery; scalp metastases are uncommon.
Pathology of Breast Cancer
Most breast cancers are epithelial tumors that develop from cells lining ducts or lobules;
less common are nonepithelial cancers of the supporting stroma (eg, angiosarcoma,
primary stromal sarcomas, phyllodes tumor).
Cancers are divided into carcinoma in situ and invasive cancer.
Carcinoma in situ is proliferation of cancer cells within ducts or lobules and without
invasion of stromal tissue.

There are 2 types:

Ductal carcinoma in situ (DCIS): About 85% of carcinoma in situ are this type.
DCIS is usually detected only by mammography. It may involve a small or wide
area of the breast; if a wide area is involved, microscopic invasive foci may
develop over time.

Lobular carcinoma in situ (LCIS): LCIS is often multifocal and bilateral. There
are 2 types: classic and pleomorphic. Classic LCIS is not malignant but increases
risk of developing invasive carcinoma in either breast. This nonpalpable lesion is
usually detected via biopsy; it is rarely visualized with mammography.

Invasive carcinoma is primarily adenocarcinoma. About 80% is the infiltrating ductal

type; most of the remaining cases are infiltrating lobular.

Inflammatory breast cancer is a fast-growing, particularly aggressive, and often fatal

cancer. Cancer cells block the lymphatic vessels in breast skin; as a result, the breast
appears inflamed, and the skin appears thickened, resembling orange peel (peau
d’orange). Usually, inflammatory breast cancer spreads to the lymph nodes in the
armpit. The lymph nodes feel like hard lumps. However, often no mass is felt in the
breast itself because this cancer is dispersed throughout the breast.
Paget Disease of the Nipple

Paget disease of the nipple (not to be confused with the metabolic bone disease also
called Paget disease) is a form of ductal carcinoma in situ that extends into the skin
over the nipple and areola, manifesting with a skin lesion (eg, an eczematous or a
psoriaform lesion). Characteristic malignant cells called Paget cells are present in the
epidermis. Women with Paget disease of the nipple often have underlying invasive or in
situ cancer.

Risk Factor for Breast Cancer

Age: The strongest risk factor for breast cancer is age. Median age at diagnosis is
about 60 years (1).
Family history: Having a 1st-degree relative (mother, sister, daughter) with breast
cancer doubles or triples risk of developing the cancer, but breast cancer in more
distant relatives increases risk only slightly. When ≥ 2 1st-degree relatives have breast
cancer, risk may be 5 to 6 times higher.
Personal history: Having had in situ or invasive breast cancer increases risk. Risk of
developing cancer in the contralateral breast after mastectomy is about 0.5 to 1%/year
of follow-up.
Gynecologic history: Early menarche, late menopause, or late first pregnancy
increases risk. Women who have a first pregnancy after age 30 are at higher risk than
those who are nulliparous.
Breast changes: History of a lesion that required a biopsy is associated with a slightly
increased risk. Women with multiple breast masses but no histologic confirmation of a
high-risk histology should not be considered at high risk. Benign lesions associated with
a slightly increased risk of developing invasive breast cancer include complex
fibroadenoma, moderate or florid hyperplasia (without atypia), sclerosing adenosis, and
papilloma. Risk is about 4 or 5 times higher than average in patients with atypical ductal
or lobular hyperplasia and about 10 times higher if they have a family history of invasive
breast cancer in a 1st-degree relative. Increased breast density seen on screening
mammography is associated with a 1.2- to 2.1-fold increased risk of breast cancer (5).
Lobular carcinoma in situ (LCIS): Having LCIS increases the risk of developing
invasive carcinoma in either breast by about 7 to 12 times (6); invasive carcinoma
develops in about 1 to 2% of patients with LCIS annually.
Use of oral contraceptives: Study results vary regarding the use of oral contraceptives
and risk of breast cancer. Some studies have found a small increased risk in current or
recent users (7).
Hormone therapy: Menopausal hormone (estrogen plus a progestin) therapy appears
to increase risk modestly after only 3 years of use (8). After 5 years of use, the
increased risk is about 7 or 8 more cases per 10,000 women for each year of use
(about a 24% increase in relative risk). Use of estrogen alone does not appear to
increase risk of breast cancer (as reported in the Women's Health Initiative). Selective
estrogen-receptor modulators (eg, raloxifene) reduce the risk of developing breast
cancer.
Radiation therapy: Exposure to radiation therapy before age 30 increases risk. Mantle-
field radiation therapy for Hodgkin lymphoma about quadruples risk of breast cancer
over the next 20 to 30 years.
Diet: Diet may contribute to development or growth of breast cancers, but conclusive
evidence about the effect of a particular diet (eg, one high in fats) is lacking. Obese
postmenopausal women are at increased risk, but there is no evidence that dietary
modification reduces risk. For obese women who are menstruating later than normal,
risk may be decreased.
Lifestyle factors: Smoking and alcohol may contribute to a higher risk of breast cancer.
Women are counseled to stop smoking and to reduce alcohol consumption. In
epidemiologic studies, alcohol intake is associated with a higher risk of breast cancer;
however, causality is difficult to establish. The American Cancer Society recommends
no more than one alcoholic drink a day for women.

Women should be screened for breast cancer. All professional societies agree on this
concept, although they differ on the recommended age at which to start screening and
the precise frequency of screening.
Screening modalities include
Mammography (including digital and 3-dimensional)
Clinical breast examination (CBE) by health care practitioners
Magnetic resonance imaging (MRI) for high-risk patients
B. DISEASE PROCESS
 C. SYMPTOMATOLOGY
The following are the patient’s positive pertinent assessment /diagnostic
• The patient noticed a lump on her left breast during her monthly breast self exam
two weeks ago.
• Upon documentation fixed round lump with irregular borders palpated in the
upper outer quadrant of left breast at 2:00. Left axillary edema noted and there is
symmetry of breast with no puckering or nipple discharge
• Performed mammogram and fine needle biopsy. Tumor was found in left breast
tissue but has not spread to lymph nodes or other surrounding organs
• Also request multiple rounds of radiation therapy
Management: To ensure that abnormal cells growth has been ceased.

V. DIAGNOSTIC EXAMINATION RESULTS

VI. NURSING CARE PLAN
VII. DRUG STUDY
 VIII. DISCHARGE PLAN

EVALUATION
 Patient is due for discharge and has been advised to patient was advised to
go to outpatient physical therapy and received Lymphedema treatment along
with functional training. Continue radiation therapy as prescribed.
DISCHARGE PLAN

DIET:
 Encourage patient to have a Mediterranean diet.
 Encourage patient to limit coffee and other caffeinated drinks.
 Encourage increased fluid intake at least 8 or more glasses per day.
EXERCISE:
 Encourage patient to move and do stretching to promote muscle and bone
activity. Do light exercises to be able to do daily living activities.
OUTPATIENT FOLLOW-UP CARE:
 Strategize with health care team or family to ensure adequate nutritional
intake and availability of nutritious foods and high-calorie nutritional
supplements.
 Instruct about medications, schedule, and side effects.
 Instruct client to continue radiation therapy as prescribed
 Instruct patient to be religious on lymphedema treatments
 Instruct patient how to take care with the Jackson-Pratt Drain
 Instruct patient to consult with the physician as scheduled.
HEALTH TEACHING:
 Teach client to avoid smoking activities or alcohol intake since this acts can
put her at increased risk.
 Demonstrate and stress good hand hygiene.
 Encourage patient to attend in support groups to boost mental health
IX. REVIEW OF RELATED LITRETURE

Breast cancer is the most commonly occurring cancer in women, comprising

almost one third of all malignancies in females. It is second only to lung cancer as
a cause of cancer mortality, and it is the leading cause of death for American
women between the ages of 40 and 55.1 The lifetime risk of a woman developing
invasive breast cancer is 12.6 % 2 one out of 8 females in the United States will
develop breast cancer at some point in her life. The death rate for breast cancer
has been slowly declining over the past decade, and the incidence has remained
level since 1988 after increasing steadily for nearly 50 years.3 Twenty-five
percent to 30% of women with invasive breast cancer will die of their disease. But
this statistic, as grim as it is, also means that 70% to 75% of women with invasive
breast cancer will die of something other than their breast cancer. Hence, a
diagnosis of breast cancer, even invasive breast cancer, is not necessarily the
‘‘sentence of death’’ that many women (and their insurance companies) imagine.
Mortality rates are highest in the very young (less than age 35) and in the very
old (greater than age 75). It appears that the very young have more aggressive
disease, and that the very old may not be treated aggressively or may have
comorbid disease that increases breast cancer fatality.5 Although 60% to 80% of
recurrences occur in the first 3 years, the chance of recurrence exists for up to 20
years.
Breast cancer incidence is highest in North America and Northern Europe and
lowest in Asia and Africa. Studies of migration patterns to the United States
suggest that genetic factors alone do not account for the incidence variation
among countries, as the incidence rates of second-, third- and fourth-generation
Asian immigrants increase steadily in this country. Thus, environmental and/or
lifestyle factors appear to be important determinants of breast cancer risk.
Gender is by far the greatest risk factor. Breast cancer occurs 100 times more
frequently in women than men. In women, incidence rates of breast cancer rise
sharply with age 45 to 50, when the rise becomes less steep. This change in
slope probably reflects the impact of hormonal change (menopause) that occurs
about this time. By ages 75 to 80, the curve actually flattens and then decreases.
Despite the steepness of the incidence curve at younger ages, the more
important issue is the increasing prevalence of breast cancer with advancing age,
and the take home message for physicians and underwriters alike is that any
breast mass in a postmenopausal woman should be considered cancer until
proven otherwise. Genetics plays a limited but important role as a risk factor for
breast cancer. Only 5% to 6% of breast cancers are considered hereditary.
BRCA-1 and BRCA-2 account for an estimated 80% of hereditary breast cancer,
but again, this only represents 5% to 6% of all breast cancers. BRCA-1 and/or
BRCA-2 positive women have a 50% to 85% lifetime risk of developing breast
cancer and a 15% to 65% risk of developing ovarian cancer, beginning at age 25.
Familial breast cancer is considered a risk if a first-degree relative develops
breast cancer before menopause, if it affected both breasts, or if it occurred in
conjunction with ovarian cancer. There is a 2-fold relative risk of breast cancer if
a woman has a single first degree relative (mother, sister or daughter). There is a
5-fold increased risk if 2 first-degree relatives have had breast cancer. A woman’s
hormonal history appears to be a risk factor, as the relative risk of breast cancer
seems to be related to the breast’s cumulative exposure to estrogen and
progesterone. Early menarche (onset of menstruation, age 13), having no
children or having them after age 30, and menopause after age 50 and especially
age 55—all these mean more menstrual cycles and thus greater hormone
exposure. The Women’s Health Initiative (WHI), a randomized controlled trial of
16,608 postmenopausal women comparing effects of estrogen plus progestin
with placebo on chronic disease risk, confirmed that combined estrogen plus
progestin use increases the risk of invasive breast cancer.14 Hormone
replacement therapy (HRT) users have a breast cancer risk that is 53% higher for
combination therapy and 34% higher for estrogen alone, especially if used for
more than 5 years.
References:
1. Harris J, Lippman M, Veronesi U, et al. Breast Cancer (3 parts). N Engl J Med.
1992:327:319–479. 2. Greenlee RT, Hill-Harmon MD, Murry T, Thun M.
Cancer Statistics, 2001. CA Cancer J Clin. 2021;51: 15.