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Prevention & Treatment of Breast Cancer: New Rays of Hope

Course Material Valid Through August 2015

About the Author

Denise Warren, RN, BSN, has been a nurse educator in a hospital setting. In this capacity, she has authored continuing education materials for nursing staff as well as training and competency manuals for oncology and med/surg units. She has also worked several years in a hospital oncology unit administering chemotherapy and providing care to cancer patients. She has worked closely and counseled patients on a variety of topics in an outpatient setting. She continues to write health-related articles and continuing education courses.

About the Editor

Cheryl Duksta, RN, ADN, M.Ed., is currently a critical care nurse in an intermediate care unit in Austin, Texas. She is an active member of the American Association of Critical-Care Nurses (AACN) Greater Austin chapter. A master's prepared teacher and former public school teacher, Ms. Duksta frequently serves as a continuing education facilitator. She has 15 years of experience in education and medical publishing, including writer and editor at the National Center of Continuing Education, Inc.

Purpose and Goals

This course is designed to provide the nurse or other healthcare professional with timely information on breast cancer treatment and prevention. It covers the physiology of the breast, risk factors for development of breast cancer, and diagnostic procedures, with special emphasis on cultural issues and patient education.

Instructional Objectives

At the end of this course, you will be able to:

1. Explain basic breast physiology.
2. Compare the normal breast changes that occur throughout the life course.
3. Contrast benign and malignant breast conditions.
4. Name the major risk factors for developing breast cancer.
5. Summarize specific lifestyle factors that may contribute to the development of breast cancer.
6. Describe the major concepts in breast cancer prevention
7. Evaluate the major diagnostic tools currently used in detecting breast cancer.
8. Recognize the components of a good breast cancer early detection program.
9. Write the steps for breast self-exam.
10. Describe treatment options currently available to women with breast cancer.
11. Summarize the various complimentary and alternative therapies available to patients with breast cancer
12. Describe appropriate nursing interventions surrounding the treatment of breast cancer.
13. Identify barriers that prevent women from accessing the health care system for diagnosis and treatment of breast cancer.
14. Relate the cross-cultural considerations inherent in the early detection and screening process.
15. Describe patient education strategies that lead to improved breast health.

Introduction

At a woman's health clinic in Cleveland, Ohio, Monica, a registered nurse, is preparing to see her first patient, a 27-year-old who has come in for an annual examination. Quickly reviewing the patient's chart, Monica sees that the young woman has a significant familial history of breast cancer: Her mother died after being diagnosed with Stage 4 breast cancer at age 54, and her sister had a single mastectomy after a lump was discovered in her right breast. Monica thinks about the patient waiting in the examination room. What information does her patient need to know to protect herself from the same fate as her mother? How can Monica advocate for this woman, who may need significant help now or in the future in dealing with cancer?

Monica is not alone in her concern for her patient. Because the incidence of breast cancer is so high, many nurses encounter patients just like this young woman and confront the same concerns as Monica. According to the American Cancer Society, breast cancer is the most common cancer among women in the United States, excluding skin cancer. Almost 230,000 American women are diagnosed with breast cancer annually, accounting for about one in every three cancers diagnosed. About 12% of women in America will develop breast cancer during their lifetime. Second to lung cancer, breast cancer is the leading cause of death for women in America and kills almost 40,000 women every year. While there are no guaranteed prevention methods, research shows that early detection—through regular breast self-exams, regular clinical breast exams, and regular mammography—is the best way to reduce mortality. In other words, women who detect the disease in its early stages are less likely to die.

Certain risk factors increase the chances of a person developing breast cancer, and these risks are discussed in this course. The primary risk factor, however, is being female, which makes every woman a potential target. Although men can develop breast cancer, the risk is 100 times less than for women. In 2010, breast cancer was responsible for approximately 390 deaths in men compared to almost 40,000 in women. It is believed that the primary biological factor that makes women more susceptible than men to breast cancer is women's greater number of mammary cells. In addition, women's breast cells are stimulated during pregnancy and lactation; obviously, men's breasts can never be stimulated in this manner.

The apparent capriciousness of breast cancer and the uncomfortable diagnostic and treatment methods serve to increase fears about developing the disease. Although there is no cure, in recent years breast cancer research has undergone a positive attitude shift as experts discover new rays of hope for the prevention and the treatment of the disease. Statistics are no longer dominated by rising incidence rates and newly discovered risk factors.

Every nurse has a role to play in the prevention and treatment of breast cancer. Health professionals are often in a unique position to teach patients and the public about the risk factors, the latest prevention methods, and recent discoveries in treating the disease. They, too, must stay informed about the American Cancer Society's recommendations for the early detection of breast cancer. Current evidence suggests that women in their 20s and 30s should undergo a clinical breast exam (CBE) at least every 3 years. Women over 40 years of age should have a breast exam every year along with a mammogram. Recent revised screening guidelines also suggest that women can perform self-exams; however, these exams should be done in conjunction with other screening methods, such as the clinical breast exam.

Often women encounter barriers to regular screening exams. These barriers may be cultural, economic, or emotional. For example, some women state they do not perform regular self-exams because they are afraid they will find a lump. Other barriers may be due to a knowledge deficit about the risk of developing the disease. These barriers and the nurse's role in helping women overcome them are discussed throughout this course.

Anatomy and Physiology

The breast lies on top of the pectoralis major muscle. Fibrous stroma provide the background structure of the breast, and ligaments connect the skin to the pectoralis muscle. The axillary lymph nodes function to drain the breast tissue. Although good arterial blood supply to the breast tissue is usually present, venous drainage may vary in quality.

All developed breasts are an intricate network of ducts and lobules (which contain the mammary glands) cushioned by a layer of fat. The basic component of the breast lobule is the hollow alveolus or milk gland lined by a layer of milk-secreting epithelial cells. A crisscross of myoepithelial strands and a rich network of capillaries surround each alveolus. The alveolus is connected to an intralobular duct via a thin nonmuscular duct. The intralobular ducts, lined with contractile muscle cells, reach the exterior of the body through openings in the areola. This intricate breast tissue normally extends from the bra line to the clavicle bones and into the armpit.

Normal Breast Changes

Beyond basic anatomy and physiology, there is no "standard" female breast. Breasts vary from one woman to another, and even from one girl to another, throughout life.

Breast tissue begins to develop around the 6th week of fetal gestation. Prepubescent breasts are in a resting state with ducts present but nonfunctional. The first major changes in the breast occur at puberty and are the result of estrogen influence. The first response to pubertal estrogen stimulation (about age 11 to 14 years) is the formation of a mass of breast tissue just under the areolae as well as a change in areola pigmentation and size. If left untreated, these lumps usually disappear in about 6 months.

Once menstruation begins, a girl may notice swelling and tenderness in the breasts before and sometimes during her menstrual period. This tenderness and swelling is caused by the collection of extra fluids in the breast tissue as a direct result of hormonal changes associated with the menstrual cycle. Some girls may notice fibrocystic changes that make the breasts feel ropy, lumpy, or granular. This condition is most often benign.

As the pubescent breast changes into a more mature breast, the ducts elongate and side branches of the ducts and lobular elements form. After many ovulatory cycles, the breasts become pendulous, with mature lobular elements remaining in a resting state until pregnancy occurs.

Breasts vary among women in adulthood. One woman may seem to have breasts that are filled with fine, granular material, whereas another woman's breasts may feel like they contain pea-sized gravel. An individual woman's breasts, at different times in her life and even at different times in her menstrual cycle, may undergo normal changes that cause her breasts to feel very different from how they felt previously or how they will feel in the future.

During pregnancy a woman may notice breast changes such as enlargement, increased sensitivity, or darkening of the areolae. In late pregnancy the nipples may secrete a protein-rich fluid known as colostrum. During this time and immediately after giving birth, breast changes take place to prepare for lactation. Proximal ducts grow and branch, while increased mammary blood flow leads to vascular engorgement and the lobules become dilated and engorged with milk. Growth of this milk-producing system depends on hormonal stimulation that typically occurs in two sequences, first at puberty and again with each pregnancy.

At menopause, a reduction in hormonal stimulation once again causes changes to take place in breast composition as ductal tissue is replaced by fatty and fibrous tissues and the breasts are rendered unable to produce milk. Because the fatty tissue is less dense than the ductal and globular tissue, lumps are easier to feel and easier to see via mammogram than they are on a younger woman or on a woman taking postmenopausal hormone replacement therapy (the dense breast tissue of younger women and those on hormones provides a white background against which tumors are difficult to detect).

Benign Conditions

Several conditions may lead to the formation of a benign breast lump:

Cysts. Classified as simple and complex, cysts are typically seen in women in their 40s, but can be found at any age. A simple cyst is described as a thin, fluid-filled capsule that may become enlarged and tender during the menstrual cycle. It usually disappears without treatment. A complex cyst has a thicker wall and contains both fluid and tissue. Both types of cysts are often referred to as fibrocystic changes in the breast, and they occur in 40–50% of women. They do not increase a woman's risk of developing breast cancer. Cysts usually call for needle aspiration followed by microscopic evaluation to determine whether the fluid is suspicious. Solid lumps usually require outpatient biopsy to determine if they are benign or malignant. Sometimes the biopsy will indicate a precancerous condition that merits further monitoring.

Fibroadenomas. Mobile, rubbery lumps, fibroadenomas usually occur in women about 20–30 years of age, although they can occur at any age. Studies have shown that the risk of developing fibroadenomas increases in women who use birth control before age 20. Fibroadaenomas usually resolve on their own. However, if they continue to enlarge or if the diagnosis is uncertain, they may need to be surgically removed.

Fat necroses. These hard, round lumps of fat often occur with age as the fat in the breast is broken down. These lumps, which are more common in women with large breasts, may develop after a hard blow to the breast or at the site of a previous breast biopsy. They can also occur after radiation therapy or surgery. A woman's chance of developing breast cancer does not increase because she has fat necroses. However, a biopsy is often needed to rule out malignancy.

Oil cysts. These cysts occur when fat cells die and release their contents instead of forming scar tissue, resulting in an accumulation of greasy fluid that collects in a saclike formation in the breast. These fluid-filled cysts can be treated with fine-needle aspiration.

Sclerosing adenosis. This condition consists of benign excessive growth of breast tissue. As in breast cancer, mineral deposits can form in sclerosing adenosis, which can sometimes result in confusing mammogram studies. For this reason, a biopsy is often required to distinguish sclerosing adenosis from cancer. Some studies show that women with sclerosing adenosis have approximately 1.5 to 2 times greater risk of developing breast cancer.

Intraductal papillomas. These small, wartlike growths occur in a milk duct, usually near the nipple. They consist of dense, fibrous tissue and may occur as a single growth (usually in women nearing menopause) or as multiple lumps (usually in younger women). They may cause bloody nipple discharge; therefore, a biopsy is necessary to rule out cancer. The presence of papillomas does not significantly increase one's risk of developing breast cancer.

Calcifications. Usually discovered by mammography and not through self-exam, calcifications form as calcium crystals collect in the breast tissue. The small deposits form for many different reasons, most of which are benign. However, calcifications may also be associated with some types of premalignant lesions and certain cancers, so they are usually biopsied to rule out the possibility of malignancy.

Mastitis. Usually caused by the obstruction of a mammary duct during lactation, mastitis is an infection in one or both breasts. The area around the clogged duct may become inflamed, swollen, warm to touch, and painful. Other symptoms of mastitis include nausea, fever, lack of appetite, fatigue, and blood-tinged discharge from the nipple. Often mastitis is the result of bacteria entering the breast through cracks that develop in the nipple during breast-feeding. Antibiotics are the treatment of choice for this condition. In some cases, a breast abscess can form, which needs to be drained. While this condition can sometimes be painful, it does not increase the risk of developing breast cancer.

Mammary duct ectasia. This condition affects perimenopausal women and women who smoke. Ducts near the nipple become thin and dilated and may accumulate secretions leading to the formation of an abscess if the duct becomes infected. Antibiotics and the application of warm compresses can be used to treat mammary duct ectasia.

Galactorrhea. This condition results in the continued flow of milk from the breasts at times other than breast-feeding. It may happen in nulliparous women and even in men. It is usually caused by medication.

Discharges. It is normal for the nipples to pass a little fluid if they are squeezed. Spontaneous discharges, however, may occur during times of increased prolactin production, such as puberty and menopause. Some drugs may cause increased prolactin as well, including birth control pills, antihypertensives, and some tranquilizers. Underlying conditions such as hyperthyroidism or a pituitary tumor can also increase prolactin levels. Nipple discharges are seen more often in women who jog several miles a day or those who supplement their aerobic workout with weight lifting. This may be due to clothing that irritates the nipples or to stimulation of the chest muscles. Bilateral nipple discharge is usually benign, whereas unilateral discharge may have a more serious underlying cause.

Hyperplasia. An excessive accumulation of cells that line the lobules or the ducts, hyperplasia is referred to as lobular hyperplasia when present in the lobule; when located in the duct, the condition is known as ductal hyperplasia. Three classifications of hyperplasia may pose an increased risk of breast cancer:

• mild hyperplasia—no measurable risk for breast cancer
• usual hyperplasia—approximately 1.5 to 2 times greater risk for breast cancer
• atypical hyperplasia—approximately 4 to 5 times greater for breast cancer

Hyperplasia is diagnosed with core needle or surgical biopsy. Women with atypical hyperplasia should get annual mammograms due to the increased risk of developing breast cancer.

Benign phyllodes tumors. These tumors often appear similar to fibroadenomas and are usually felt as painless lumps, but in rare cases they can be painful. These tumors, which are caused by an overgrowth of connective tissue and glandular tissue, are usually benign. In rare cases, they can be malignant. Most commonly seen in women in their 30s and 40s, benign phyllodes tumors can reoccur in the same area of the breast. They are treated by removing the mass along with a 0.5–0.75 inch of surrounding breast tissue.

Benign breast lumps (about 80% of all breast lumps) should be reported to a physician, even if a woman discovers the lump on self-examination. A physician should check all lumps and determine whether further screening is necessary. A woman's age plays a major role in determining the type of screening she gets. Because younger women have denser breasts, mammography may not be particularly helpful; however, ultrasound can detect lumps even in dense breast tissue.

Just how much treatment benign breast changes require depends on several factors, including the type of tissue involved, a woman's personal breast cancer risk, the amount of pain the condition is causing, and the woman's desire to be rid of the anxiety-producing lump. Some normal breast changes are easily treated. For example, fibrocystic changes, at times uncomfortable, usually require analgesia only. Anecdotal evidence suggests that eliminating caffeine, taking evening primrose oil, or increasing one's intake of vitamin E can ease symptoms.

Malignant Conditions

Breast cancer is not a homogeneous disease but instead may differ in histologic, biologic, and immunologic characteristics. Cancerous lumps differ in many ways from benign lumps. For example, cancerous lumps are much harder than benign masses; they are also fixed and stationary, whereas benign lumps are more movable. The following list discusses various malignant breast conditions:

Intraductal carcinoma or ductal carcinoma in situ (DCIS). A common form of breast malignancy, DCIS is the most common type of noninvasive breast cancer, accounting for about 1 in 5 cases. Considered an early-stage breast cancer, DCIS is usually detected by mammogram. It does not develop as a lump but instead fans out along the milk ducts so that early detection by the woman is much harder (often the diagnosis is made during screening mammography, where it shows up as calcifications). Because it is confined to the ducts, DCIS is a curable condition if caught early and if it is completely excised. However, if left untreated it will progress to invasive cancer at the site of the biopsy in more than half of the cases, usually within 5 to 8 years. For this reason, providers are encouraged to treat the disease somewhat aggressively. Treatment options for women with a diagnosis of DCIS are more ambiguous than the options for women with other breast cancer diagnoses. Mastectomy is recommended only for women with large and especially virulent patches of DCIS. Lumpectomy is the treatment of choice for most women diagnosed with this condition. There is controversy over whether the lumpectomy should be followed by radiation. For years, radiation was part of the standard of care, but recent studies suggest that radiation may not be necessary for some women diagnosed with DCIS. Margin width, the distance between the edge of the lesion and the edge of the excised specimen, may be an important determinant of recurrence and, therefore, determine the need for postoperative radiation. The size and character of the cells also play a role the prescription of radiation.

Infiltrating ductal carcinoma (IDC). Another form of breast cancer, IDC is the most prevalent type of invasive breast cancer, with about 8 out of 10 invasive breast cancers falling into this category. IDC begins in the milk duct and eventually metastasizes into the breast's fatty tissue. It can also spread through the lymphatic system into other parts of the body.

Infiltrating lobular carcinoma (ILC). This form of breast cancer occurs in approximately 1 in 10 cases of breast cancer, making this cancer the second most common type of invasive cancer. ILC typically occurs later in life than does IDC, affecting women in their 60s. In classic ILC, cancerous cells invade the stroma, which includes the fatty tissue and lymph vessels of the breasts. ILC occurs in breast tissue between the ducts or elsewhere in mammary tissue. It may be multifocal and is more likely to be bilateral rather than intraductal carcinoma.

Inflammatory breast cancer (IBC). IBC is a particularly virulent form of malignancy. It is characterized by breast enlargement, general breast redness with a purple area over the tumor, and sections of induration caused by subdermal spread of the disease. Usually there is no palpable lump. Symptoms tend to progress rapidly, and often the disease is not diagnosed until there is lymph node involvement and even gross distant metastasis. Inflammatory cancer is most common in women ages 45 to 55. This type of invasive malignant cancer only accounts for about 1–3 % of breast cancers. IBC is sometimes mistaken for mastitis (infection in the breast) and treated with antibiotics, which fail to improve the symptoms. Because there are no lumps associated with IBC, mammograms can fail to diagnose this type of breast cancer; a breast biopsy is needed to locate cancerous cells. The prognosis is worse for IBC than for ductal or lobular cancers due to the increased risk of metastasis. The 5-year median survival rate for IBC is about 40%.

Paget disease of the nipple. A rare type of breast cancer, accounting for about 1% of breast cancers, Paget disease of the nipple is associated with DCIS or IDC. It starts in the breast ducts, spreads to the skin of the nipple, and eventually to the areola, causing the nipple and areola to become red, crusted, and scaly. Women who suffer from this type of breast cancer usually complain of itching and burning in the affected areas.

Breast cancer metastasizes both by lymphatic drainage and by hematologic involvement. Although breast cancer is a multicentric disease, almost half of all breast tumors occur in the upper outer quadrant of the breast. These tumors tend to drain to the axillary lymph node, which is why, until recently, removing not only the affected breast but also the axillary lymph nodes treated most diagnoses of breast cancer. The likelihood of axillary node involvement increases with the size of the tumor.

Sometimes, however, the axillary nodes are bypassed, and the tumor drains into the supraclavicular and infraclavicular nodes. Secondary drainage patterns may extend from the axillary nodes into the nodes at the base of the neck. Medial lesions tend to drain into the internal mammary nodes as well as the axillary nodes. The incidence of disease recurrence is higher in women with internal mammary node involvement, and the prognosis for these women is not as good as it is for women with axillary node involvement alone.

Breast cancer may metastasize widely and unpredictably either early in the course of the disease or much later, sometimes years after a woman appears to be disease free. Factors affecting the speed of distant metastasis include the size of the tumor, the number of positive nodes, and the histologic grade of the tumor.

The pulmonary system is a common site of metastasis. Once pulmonary metastasis occurs, the tumor cells get into arterial circulation, and metastasis spreads easily to the brain and liver. A second common site of metastasis is the skeletal system, particularly the ribs, thoracic vertebrae, skull, pelvis, and upper femurs. The disease may also spread to the pleura, the kidneys and adrenal glands, the ovaries, the pituitary gland, and the thyroid.

When breast cancer is detected in its early stages, the chances of survival increase dramatically. The goal of most early detection programs is to diagnose the condition within 3 months of discovery of a lump. If early diagnosis is made, 98% of cancers can be effectively treated.

Risk Factors

Experimental and clinical data indicate that the development of breast cancer is not a chance event. Rather, it is a process involving many factors that are influential in an ongoing battle between tumor growth and individual resistance level. As a result, experts find it difficult to determine all of the factors involved. It appears, however, that in all cases but those of hereditary, genetic abnormalities, there must be direct damage to the cell DNA. Even though experts do not know everything that causes this damage, they do know that most cancers begin growing as much as 10–20 years before they are detected, which is why so much emphasis is placed on early detection.

Being female and having breasts are the two major risk factors for the development of breast cancer. Other known risk factors include:

• increased age
• first degree relative with breast cancer (i.e., a mother or a sister)
• personal history of atypical hyperplasia (usually from a previous breast biopsy)
• early menses or late menopause (both of which mean longer bombardment of the body with estrogen)
• first pregnancy after the age of 30 years
• a history of ovarian cancer
• a diagnosis of globular carcinoma in situ
• never having been pregnant or never having breast-fed (research suggests that premenopausal women who breast-feed, especially those who lactate at a younger age and for a longer period of time, have a significantly reduced risk for developing breast cancer; laboratory observations show that human breast milk kills breast cancer cells through the use of a protein called alpha-lactalbumin, a substance that scientists have genetically engineered in lab settings, have had good results with in animal testing, and perhaps may be used for breast cancer treatment)

Other factors may also can increase a woman's risk for breast cancer:

Estrogen replacement therapy (ERT). Hundreds of studies have tried to determine whether estrogens are initiators, promoters, or neutral as causal agents in the development of breast cancer, but these studies have failed to reach a consensus. Although some studies suggest that those on ERT have an increased risk for breast cancer, other studies do not show this. One study, the Million Women Study, tracked women between the ages of 50 and 64. The results of this investigation indicated that women who took any form of estrogen for 10 years or longer had an increased risk of breast cancer. Certain barriers prevent studies from reaching consensus. For example, various estrogens affect the body differently—some are endogenous, while others are exogenous—and can cause variances in study results. Some experts believe that the problem may not be the estrogens themselves but the way some women's bodies metabolize the hormone (estrogen metabolites and their influence on estrogen receptors in the breast may play a role in the development of the disease). In 2004, a large, randomized, controlled, double-blind study (the kind of study researchers think is the most reliable), the Women's Health Initiative, showed an increase in strokes in women who had used ERT for 5 years or longer but no significant increase in heart disease or breast cancer. Experts now recommend that women who want to relieve the most troublesome menopause symptoms be on ERT for only the shortest amount of time necessary.

Estrogen/progestin combined hormone replacement therapy (HRT). The Iowa Women's Health Study indicated that HRT may not raise the risk for developing the most common cancer types but that it may increase the risk for developing rarer (and less virulent) forms of the disease. These cancers are slow growing with orderly cell patterns when compared to the more common forms of breast cancer. Although this study is encouraging for long-term prognosis, these cancers are still treated the same way as the more common forms, and, as a result, the woman diagnosed with them may face surgery, radiation, and postoperative drug treatment. Another recent study showed that women taking combined HRT for 6 months or more were more than twice as likely to develop lobular tumors as women who did not use HRT. Lobular tumors are harder to detect via mammography or physical exam, but they do have higher survival rates. The Women's Health Initiative, cited earlier, found strong evidence that HRT is linked to an increase in breast cancer risk and heart disease in those who used it for 5 or more years. As a result, experts recommend HRT for menopausal symptoms only and strongly encourage women to stop therapy as soon as possible. The National Heart, Blood, and Lung Institute recommends that if women decide to take HRT, they should be administered the lowest dose possible for the shortest amount of time. Additionally, the need to take hormones should be reevaluated every 6 months.

Abortion. This highly controversial and emotional procedure does not have a proven link to breast cancer. However, given the number of abortions performed each year and because some past research suggests evidence to support a possible link, a discussion of this theory is warranted. The physiology behind this theory stresses that during pregnancy the increased hormonal stimulation causes many changes in the composition of the breast as the body prepares for the process of lactation. At this time, more breast cells are vulnerable to cancer. A pregnancy carried to term results in a natural evening out of hormonal stimulation by the third trimester, leaving the delivered woman with fewer cancer-vulnerable cells than she had before she was pregnant. This is why pregnancy is believed to have a protective effect on the breast. However, an unnatural interruption of these hormones in the first trimester (such as occurs with elective abortion) leaves the body with estrogen levels 20 times what they would be in her nonpregnant state, without a chance for gradual evening out of hormones. As a result, the woman is left with more cancer-vulnerable cells than she had in her prepregnant state, with an overall 30% increased risk of breast cancer, according to some studies. Interestingly, women who miscarry do not appear at increased risk for breast cancer development. Experts suggest that miscarriages often occur because of disturbances in the hormonal system of the pregnancy, leaving the spontaneously aborted woman with few vulnerable cells. One issue with past studies of the abortion–breast cancer link is the personal matter of the subject; many women were reluctant to talk about the issue. A more recent study, which included more than 100,000 women, ages 29 to 46, suggests no direct link between abortions and breast cancer, and the American College of Obstetricians and Gynecologists (ACOG) recently stated that current scientific evidence does not support the abortion–breast cancer link. The ACOG added that past studies were methodologically flawed due to participant recall bias.

Radial scars. A specific type of benign breast lesion, radial scars may double a woman's chances of developing a malignant lesion. A fibroelastic core from which ducts and lobules radiate characterizes them microscopically. These ducts and lobules often exhibit various alterations, including cysts and proliferative lesions. Radial scars are usually discovered incidentally during diagnosis and treatment of other possible breast anomalies. However, larger radial scars are now being detected more frequently on mammogram. According to some researchers, a correlation exists between the size of the scar and the risk of developing cancer: The larger the scar, the higher the risk of developing breast cancer. Another correlation occurs between the number of scars and the risk of developing cancer: The more scars a woman has, the higher the risk. Because of their morphologic similarities to cancer, as well as the detection of some malignant cells in the radial scars themselves, these lesions may represent a very early stage of some cancers. The data to back up this suspicion were ambiguous until 2010, when some researchers found that percutaneous biopsies are not reliable because radial scars are associated with malignancy. These researchers suggest that women with radial scars undergo surgical excision instead.

Obesity and high dietary fat intake. A link may exist between breast cancer and dietary fat intake. An analysis of several observational studies indicated that as fat consumption increases so does the risk for breast cancer. However, researchers in the ongoing Nurses Health Study found no such link; in fact, they found that breast cancer risk fell slightly with increased fat consumption. However, high-fat diet may have a deleterious effect in postmenopausal, obese women. High-fat diets create a modest risk of breast cancer in women ages 50 to 71: a 15% increase in the incidence of breast cancer for women whose diet consisted of 40% fat compared to women whose diet consisted of 20% fat. Studies show that a healthy diet can help control breast density as well as curb obesity. As a result, clinicians are encouraged to stress the importance of healthy eating to women in this risk category.

Alcohol consumption. Alcohol is a clear risk factor for breast cancer in women. The American Cancer Society states that women who drink one alcoholic drink a day have a very slight increase in risk; however, those who consume two to five alcoholic drinks daily increase their risk of breast cancer approximately 1.5 times compared to nondrinkers. Some studies show that women who consume three to six drinks a week increase their risk of breast cancer by 15%. Moreover, women who consume two drinks daily have a 51% increased risk for breast cancer. A key factor for the link between alcohol consumption and breast cancer is the increase in circulating estrogen. For women on HRT, this risk should be considered seriously because alcohol may have an additive effect on the therapy.

Geographic and environmental factors. A woman's country of residence may increase her risk of breast cancer. For example, women in Japan have traditionally enjoyed a much lower breast cancer rate than women in the United States. However, third-generation Japanese American women have the same risk as American women in general. This may be due to dietary factors: The traditional Japanese diet is lower in fat and higher in soy than the American diet. Breast cancer rates are also lower in Africa and Scandinavia, where diets are higher in fiber content than the American diet. Estrogen-like substances found in pesticides, dry-cleaning agents, spermicides, and plastics may also play a role in the development of breast cancer. If further research bears this out, then common sense suggests that reducing women's exposure to these chemicals might help prevent breast cancer.

Homosexuality. In general, lesbians have three risk factors that are not seen as often in heterosexual women: Fewer lesbians have been pregnant, lesbians tend to have a higher body mass index, and lesbians have had more breast biopsies. The first factor was no surprise to researchers since the link between pregnancy and reduced risk of breast cancer has been shown. The other two factors, however, have researchers puzzled. More research is needed before conclusions can be made.

Genetic risk factors. Gene defects, otherwise known as mutations, inherited from parents are responsible for about 5–10% of breast cancer cases in women. This familial risk is due to the two autosomal dominant genes: BRCA1 and BRCA2 (pronounced "brack one" and "brack two"). These genes help prevent cancer in ordinary cells by producing proteins that keep cells from growing abnormally; however, women who carry harmful BRCA mutations have a 60–80% risk of developing breast cancer. Like many other conditions, breast cancer is also more prevalent in women who have a family history of the disease. Studies show that women who have a close relative, such as a mother or sister, with the disease are twice as likely to develop breast cancer than those with no family history of breast cancer.

Smoking. Until recently, no clear association existed between tobacco smoking and breast cancer. However, studies recently showed that smoking may increase the risk of breast cancer. Women who smoke have a 16% greater risk for developing breast cancer than do nonsmokers, and this risk is greater in older women who smoke. Secondhand smoke can also cause breast cancer in premenopausal women. In fact, the U.S. Surgeon General states that there is suggestive (one step below casual) evidence linking secondhand smoke with breast cancer.

Overnight work. Women who work nights at least three times a week for 6 years are twice as likely to develop breast cancer than are day workers. This increase may be attributed to changes in the levels of melatonin because of artificial light. Recently, the World Health Organization listed shift work as a cause of disruption to circadian rhythm and a probable carcinogen.

Genetics and Breast Cancer Prevention

Some recent advances in breast health have been in the area of prevention, which includes genetics. Two recently identified genes are thought to be responsible for the majority of cases of familial breast cancer: the BRCA1 gene, which was identified in families with high clusters of both breast and ovarian cancers and also found in about 5% of breast cancers in the general population, and the BRCA2 gene, which is found in the same percentages as BCRA1 but is not associated with ovarian cancer. The discovery of these two genes has allowed providers to estimate the chances of some women's risk for developing the disease, which, in turn, provides women with more treatment options.

One preventive treatment is prophylactic mastectomy, either total or subcutaneous, for women at high risk for breast cancer. Specific indications for prophylactic bilateral mastectomy include a family or personal history of breast cancer, multiple previous breast biopsies, unreliable physical exams due to nodular breasts, findings of dense breast tissue on mammography, mastodynia, and extreme fear of cancer. Considering the drastic nature of this treatment, women should consider this procedure carefully before consenting to surgery, including the effect of surgery on the woman's body image and sexuality, the irreversibility of the surgery, and the actual risk of developing breast cancer if surgery is forgone (a woman without breast cancer at the time of evaluation has a 50% chance of carrying the gene that causes the cellular mutation of normal cells into malignant ones). The provider and patient should also consider the risks involved in breast reconstruction (because most of these women are young they generally choose to have reconstructive surgery).

Prophylactic mastectomy can be an effective preventive measure, with success rates as high as 95%. According to some experts, the following women should consider prophylactic mastectomy as a course of prevention:

• women who test positive for BRCA 1 and BRCA 2 mutations
• women with previous unilateral breast cancer and younger than 40 years of age
• women who had lobular carcinoma in situ
• women with strong family history of breast cancer

Prophylactic mastectomy is not the only procedure that creates emotional issues for women. Genetic testing also has its drawbacks. Although less drastic than prophylactic mastectomy, and potentially beneficial for women who want to initiate a preventive course of treatment, genetic testing can increase anxiety, depression, family conflict, and stress, no matter the result of the test. A positive test may elicit strong responses similar to those one has after receiving a cancer diagnosis, even though the test shows only a predisposition to cancer, not active cancer.

Other problems with genetic testing include false negatives, which provide inaccurate reassurance, and ambiguous results, which can leave women with ongoing uncertainty and psychological distress. Because of this emotional stress, some groups recommend only women with a strong family history of breast cancer be tested; only 2% of women in America fit this category.

All nurses should study the principles of human genetics, cancer genetics, and the implications of genetic testing to provide patients with the most accurate information concerning testing. Nurses should also have knowledge of the ethical, legal, social, and psychological consequences of genetic testing. Nurses should also be aware of the emotional state of their patients who undergo genetic testing and refer those with extreme distress to a mental health provider for assessment and follow-up.

Pharmacological Prevention of Breast Cancer

Medicines are currently available that may help in the prevention of breast cancer in postmenopausal women. Two of these drugs, tamoxifen and raloxifene (both approved by the Food and Drug Administration, or FDA, for the treatment of osteoporosis), have been tested in government-funded clinical trials to determine their efficacy in preventing breast cancer. Halfway through the study of tamoxifen, results were so impressive that the FDA approved the drug as a prophylactic against breast cancer.

The government then conducted a large trial with high-risk postmenopausal women to compare the efficacy of tamoxifen and raloxifene. Researchers concluded that both medications are equally effective in the prevention of breast cancer. According to the research, both tamoxifen (Nolvadex) and raloxifene (Evista) decrease the risk of breast tumors by about 50%.

Anastrozole (Arimidex) is another drug currently used to reduce the recurrence rate of certain kinds of breast cancers. It is administered following surgery with or without radiation. Recent studies of this drug tracked high-risk women for more than 3 years. The research revealed that anastrozole, compared to tamoxifen, prevented 25% more recurrences of breast cancer in women with previous hormone-related tumors. The study also showed that anastrozole reduced the spread of cancer to other parts of the body by 16%, compared to tamoxifen, and decreased the risk of a tumor in the other breast by 40%.

Exemestane is sold on the market for breast cancer under the brand name Aromasin. Like anastrozole, this class of medication is known as an aramatase inhibitor because it deprives the breast cancer of estrogen, the hormone that fuels many types of tumors in the breast. Exemestane has proven beneficial in preventing the recurrence of breast cancer after a tumor is removed. However, researchers agree that additional studies are needed to compare this drug with other breast cancer medications to evaluate long-term outcomes.

Diagnosis

Early diagnosis of breast cancer is essential in decreasing the risk of mortality. According to the American Cancer Society, deaths from breast cancer have decreased steadily since 1990—down 3.2% for women younger than 50 years of age and 2% for women 50 years and older—due to regular screening and early diagnosis. Because early diagnosis has been shown to save lives it is important to stress to patients that following the established screening guidelines is imperative to good breast health.

Several components are vital to a good early detection program:

Breast self-exams. Women should be educated beginning in their 20s regarding the benefits and limitations of breast self-exams. Previous guidelines from the American Cancer Society suggested that women perform self-exams monthly; however, the American Cancer Society recently revised their suggestion. The society now emphasizes notifying doctors about any abnormal breast conditions. Despite the change in guidelines, experts still recommend that women pay attention to any changes in their breasts.

Clinical breast exams. These exams are performed by a healthcare provider at regularly scheduled checkups or after a woman presents with a lump she has already felt during her self-exam. The goal is to find lumps before they reach 1 cm in size. If caught in time, vascular and lymphatic invasion usually can be prevented. The current general recommendation for clinical breast exams is every 3 years for women in their 20s and 30s and annually after the age of 40.

Screening mammography. Mammography remains the gold-standard in breast screening technology. The National Cancer Institute reports that mammogram screening can reduce death due to breast cancer by as much as 30%. Government legislation ensures that all women have access to the same quality standard of mammography and that they are notified of results within 1 week. This test is for asymptomatic women and should be performed annually after a woman reaches 40 years of age (some controversy exists as to the value of annual screening for women age 70 and older because, even though the likelihood of developing cancer increases with age, most of these women have slow-growing tumors that may make annual screening unnecessary). It is also recommended that a woman in her late 30s obtain a baseline screening mammography to have something with which to compare any future findings.

Diagnostic mammography. A more extensive exam, diagnostic mammography takes more views than a screening mammography and is prescribed for women with symptoms such as a suspicious lump or with other breast conditions that make detection difficult (e.g., breast implants).

Digital mammography. This diagnostic tool generates digital images that can be used to determine the existence of suspicious lumps. It does this by storing the x-ray image on a computer disk, which then converts it into digital imagery for viewing on a high-resolution computer monitor where contrast adjustment and magnification procedures are possible. The images can also be adjusted to correct for over- or underexposure without the woman having to come in for another mammogram. Digital mammography also has a wide range that allows for examination of a larger percentage of breast tissue. Because digital mammography uses digital images instead of film, radiologists can now detect small cysts and lesions hidden in dense breast tissue. Computer software programs are available to help recognize and flag suspicious areas. This test can be used as an alternative to traditional mammographic procedures. Another benefit of digital mammograms is that they expose patients to less radiation because the test requires to fewer images.

Scintimammography. In scintimammography radioactive contrast agents, known as TC-99, are injected into a woman's arm. Once inside the body, the radioactive agents travel to the breast tissue, where an image of the breast is taken with a gamma camera to detect tumor cells. Because this process also has the ability to determine the presence of cancer cells outside of the breast tissue, scintimammography may prove to be an invaluable technique in detecting metastasis and may eventually lead to the elimination of the need for node biopsy. TC-99 has been shown to detect breast cancer in about 90% of women; however, it provides a higher radiation dose than traditional mammography and cannot detect some small tumors. It is often used as a follow-up to mammography.

Fine-needle aspiration. Typically performed in the healthcare provider's office, fine-needle aspiration involves inserting a needle into the breast lump and aspirating the fluid in the lump. The fluid is then examined to determine the presence of a malignancy.

Breast biopsies. Until recently, breast biopsies were the only way to determine whether solid masses were cancerous. Biopsies can be very painful, especially if the lump is located deep in the breast near the chest wall. In recent years, about half of U.S. hospitals have begun to use a simpler and less painful procedure called the MIBB (minimally invasive breast biopsy) to acquire the same information. In this procedure, the woman lies face down with one breast exposed through a hole in the examining table. The exposed breast is then pressed between two plates and a local anesthetic is applied. The physician locates the mass using a digital x-ray camera with a mechanical arm that also holds a hollow biopsy needle. Once the mass is located, a switch is flipped that causes the needle in the mechanical arm to enter the mass and withdraw tissue. Although a benign biopsy rules out the existence of cancer in the tested lesion, it may indicate certain conditions that increase the woman's risk for developing breast cancer in the future. Such conditions include the presence of benign proliferative disease or atypical hyperplasia in conjunction with the benign condition known as radial scars. For this reason, even women with benign breast biopsies should carefully weigh their treatment options and those with the above risk factors should be closely followed in the future.

Sentinel lymph node biopsy. This technique uses blue dye or a nuclear medicine scanner to identify the sentinel lymph node—the node most likely to have cancer cells if the cancer has begun to spread. Once the sentinel node is identified, it is then biopsied. Research to date suggests that if the sentinel node is negative, then other axillary lymph nodes will be negative as well, thus eliminating the need for more extensive axillary dissection. Further studies are being conducted to confirm these findings.

Ultrasound. A diagnostic technique that can detect tumors too small to be seen on mammograms, ultrasound can also help distinguish fluid-filled cysts from the more ominous solid mass. Ultrasound is usually performed if suspicious findings are discovered on a mammogram, especially in women with very dense breast tissue. When used in conjunction with mammography, ultrasound detects as many as 93% of breast cancer cases in high-risk women (e.g., those with BRCA1 or BCRA2 mutations).

Magnetic resonance imaging (MRI). In this procedure, high radio frequencies and a special dye are used to produce breast images based on water content. MRI appears to be effective in detecting invasive lobular carcinoma, a form of cancer that is hard to detect with mammography. Although MRI is more sensitive in finding tumors than mammograms, it frequently produce false positives. For this reason, radiologists often recommend mammograms along with MRI. However, recent data show that full-body MRI is beneficial in detecting breast cancer that has metastasized to other parts of the body. Some experts recommend physicians incorporate full-body MRI into the standard of care for metastases workup.

Tomosynthesis. Recently been approved by the FDA, tomosyntheisis involves taking a series of x-rays and then manipulating the images to create a clear, three-dimensional picture of the breasts. Although this exam uses more radiation than standard mammography, it produces sharper images for radiologists to identify potential problems.

Positron emission tomography (PET). This diagnostic tool reveals the metabolic processes of cells by using a radioactive agent to highlight tumors. Radioactive estrogen can give important information about the estrogen receptors on the cancer cells. This information has huge ramifications for treatment options, especially in cases of metastatic disease. At this time, scanners do not have the ability to detect small tumors or in situ disease. However, this test has proved beneficial in detecting inflammatory breast cancer or metastasized breast cancer. Recent technology has combined a traditional CT scan with PET scans, allowing radiologists to compare areas of high radioactivity on the PET with images on the CT scan.

Thermography (also known as DII). Based on the principle that chemical and vascular activity is higher in the areas surrounding both precancerous and malignant cells, and that this higher activity leads to higher temperatures, DII uses ultrasensitive infrared cameras to detect and analyze these hot spots. A great deal of interest is directed at this technique because if it works it could eliminate many of the uncomfortable aspects patients associate with mammography (e.g., breast compression). DII is performed without radiation, and, theoretically, it can find cancers at a much earlier stage of development than mammography can. Experts differ on the clinical ramifications of DII, and most insist that until more is known about its effectiveness, DII should not be used as the sole diagnostic tool but should be used in conjunction with traditional mammography. Recent research corroborated some of the skepticism regarding this procedure. The FDA recently stated that thermography should not be used as an alternative to mammography as a screening tool. The FDA made this statement after a study revealed that thermography missed about 50% of breast cancers, and 47% of normal breasts received a false positive.

BreastScan IR. This test draws attention to potential areas of concern that might not be detected by mammography or ultrasound. The procedure takes about 10 minutes to perform, and the results are immediately available to the physician. The breast is not touched during the procedure, so no pain is involved. BreastScan IR is considered an adjunct to regular mammograms and breast self-exams. It is not intended to function as an independent diagnostic tool.

Computer-aided detection (CAD). In this procedure, computers are used to help identify abnormal areas found on a mammogram. Radiologists use CAD to help spot changes that are hard to read on digital images. For example, CAD displays images on a video screen and uses markers that highlight questionable areas on a digital mammogram.

Oncotype DX test. Referred to as the 21-gene test, the Oncotype DX lab test is sometimes conducted to determine if chemotherapy is likely to help women with early stage breast cancer. It is also used to help predict the likelihood of breast cancer recurrence. A recent large clinical study of Oncotype DX confirmed that this test helps forecast the likelihood of breast cancer survival for 10 years.

Tumor molecular profiling. During this lab test, the physician removes a sample of the malignant breast tumor through biopsy or surgery. Pathologists test for a variety of proteins, enzymes, and genes to learn which drug therapies are likely to be beneficial to the patient. One example, known as the HER2 (human epidural growth factor) test, looks for amplification of HER2 on the surface of cells. Research has suggested that overexpression of HER2 is found in about 18–20% of breast cancer cases.

Staging of Breast Cancer

Even with all of these new and potentially better detection techniques, mammography in combination with monthly breast self-exams and annual clinical breast exams remains the best form of early detection available to date. Mammography reports usually come back as Category 0 through Category 5. Categories 0 through 2 represent normal breasts or the presence of benign breast disease. Category 3 is probably benign (90–95% of the time) but should be followed up in 6 months to be certain. Category 4 is considered suspicious and requires a biopsy. Category 5 is also suspicious because it usually means there is something noticed in one breast that is not in the other (known as asymmetry). A category 5 mammography should be repeated in 6 months.

Once the diagnosis of breast cancer has been made, the developmental stage of the tumor should be determined. Most cancers detected in the United States are at Stage 0 or Stage 1 at the time of diagnosis. This early detection results in early treatment and saved lives. Stage classifications are as follows:

• Stage 0: Also known as carcinoma in situ, Stage 0 is defined as a very small, contained tumor with no lymph node involvement and no evidence of breast cancer cells in other parts of the body.
• Stage 1: This tumor is smaller than 2 cm in diameter with no node involvement and no evidence of breast cancer cells in distant parts of the body.
• Stage 2A: This tumor is 2–5 cm in diameter with no node involvement and no evidence of breast cancer in distant parts of the body. A tumor of less than 2 cm with some node involvement but no distal body involvement is also classified as 2A.
• Stage 2B: This tumor is either 2–5 cm with some node involvement or greater than 5 cm with no node involvement.
• Stage 3: This tumor includes both small and large tumors with more extensive lymph node involvement.
• Stage 4: This stage includes any size tumor with or without lymph involvement but with metastasis.
• Stage 5: This stage is for suspicious lumps found in only one breast.

Clinical Examination

Delayed diagnosis is the most common complaint leading to lawsuits. Delays may be caused by the healthcare provider failing to be impressed by findings of a clinical breast exam, improper follow-up, misread mammograms, and negative mammogram despite a lump felt by either the patient or the healthcare provider (remember, mammograms miss about 20% of lumps). For these reasons both clinical breast exams and mammography are strongly recommended to ascertain the presence of a malignancy.

The breast self-exam, though not effective by itself, is an important part of a comprehensive early detection program and has several advantages: It is free, convenient, and has no associated physical risks, and women have more time to devote to their exams than their healthcare providers do. Though the clinician may be more skilled at detecting suspicious lumps, a woman who has come to know her breasts through several years of regular examination knows what is abnormal for her (breast self-exam is discussed further later in this course). Therefore, both clinical exam and self-exam are important to an early detection program.

Effective communication is necessary in establishing rapport between the patient and the healthcare provider. When preparing a patient for a clinical breast exam remember to:

• Clarify her expectations and concerns.
• Use basic professional terms (rather than technical ones) or lay terms.
• Explain the procedure and why it is necessary.
• Acknowledge that the procedure may be embarrassing and uncomfortable but reassure her that you will do your best to minimize these problems.
• Provide for your patient's comfort by not leaving her undressed and alone for a long period of time in a cold room.
• Encourage her to give her provider feedback during the exam.
• Encourage the provider to discuss findings after the woman is dressed and make sure the setting is private and confidential.
• Check for patient understanding of the provider's findings and reinforce any follow-up recommendations that were made by the provider.

During the examination of your patient, instruct her in self-exam techniques, providing reinforcement of accurate knowledge and proper technique. Effective clinical and self-examinations are crucial to diagnosis. The following basic steps will help you and your patient perform quality exams:

1. Perform a visual inspection of the breasts (both the frontal and lateral views) with the patient sitting. Breasts should be visually examined with the patient's arms resting by her side, her arms straight above her head, and with her hands pressing down on her hips with the elbows bent. Look for asymmetry between breasts, color and skin texture abnormalities, and dimpling. Instruct your patient in how to examine for symmetry during a self-exam. Tell your patient to look in a mirror to ascertain whether there are distinct differences between the breasts that did not exist last month. Normal breast tissue is remarkably symmetrical, and any asymmetry should be reported.
2. Examine all breast tissue, extending from the clavicle bones to the bra line and from the sternum to the axilla and into the armpit. Most tumors are found in the upper outer quadrant of the search area (in the axilla and armpit area), so this region should be inspected especially carefully (see Figure 1). The nipple area is another common site for tumor development. Look for nipple discharge or nipple retraction.
3. Palpate the breasts using an effective method. Several palpation patterns can be used when performing clinical or self-exams (see Figure 2). Many women know the circular pattern, which involves searching in concentric circles beginning with the nipple and moving toward the outer breast tissue. This method, however, misses many of the cancers that develop in the outer edges of the breast tissue perimeters. The vertical strip method is more effective in detecting smaller lumps and lumps on the perimeter of breast tissue and is currently the recommended method of palpation for both clinical and self-exams. The vertical strip method involves a systematic search of all breast tissue beginning with the outer quadrant and working inward toward the nipple, moving the fingers in vertical strips rather than in the more familiar circular pattern.

When using the vertical strip method, palpate with the pads (not the tips) of the three middle fingers of one hand. Bow your hand slightly, with the tips of the fingers in an upward position. Move your fingers in a sliding motion, without leaving the tissue surface, up and down the search area, in slightly overlapping dime-sized circles. Apply varying pressure every time your fingers move to ensure that tumors growing at all levels are detected; for example, search all breast tissue superficially, at a medium depth, and at the deepest level. Feel for asymmetrical thickenings, masses, or other abnormalities. Note the location, size, shape, consistency, texture, mobility, and tenderness of any abnormalities.

A third method, known as wedge/radial, is also effective and may be used by some clinicians. To avoid confusion, however, experts recommend that women be taught the vertical strip method for use in self-exams.

The following breast conditions or findings should receive further evaluation:

• Bloody aspirated cysts
• Aspirated cysts with residual palpable mass after aspiration
• Cysts that recur within a 6-week period after aspiration
• Asymmetrical thickening that remains following menses in an ovulating woman
• Asymmetrical thickening in a nonovulating woman
• Spontaneous nipple discharge
• Nipple retraction
• Nipple scaling that is unresponsive to treatment
• Skin erythema that is unresponsive to treatment

Treatment Options

The diagnosis of breast cancer, no matter how small the lump, is often overwhelming to both the woman and her family. The volume of information that follows a diagnosis can leave even the most self-confident women feeling indecisive. It is important to remind them that the 5-year survival rate for early cancers is high. The goal of treatment is to eradicate the disease.

Once a diagnosis of breast cancer has been made, several pretreatment tests need to be conducted, including a chest x-ray, a complete blood count (CBC), and liver function tests. A bone scan is also indicated if it is determined that the tumor has spread. Any tumor removed during a biopsy should be tested for the presence of estrogen and progesterone receptors on the cells since experts believe those tumors with estrogen receptors may pose an increased risk of recurrence.

Surgical Treatment

The choice of treatment is based on the type of cancer involved, the stage of the disease, the woman's age, her overall health status, her willingness to tolerate the side effects of a given regimen, her willingness to participate in clinical trials, and whether or not she is planning on breast reconstruction after surgery. The most common treatment for breast cancer is surgery to remove the tumor and to sample the axillary lymph nodes to determine if the disease has spread. However, if metastasis has already been determined and surgery would not improve the patient's chance for survival, then surgery is not indicated. The goal of any surgical procedure is to remove the entire tumor as well as the surrounding area of normal tissue, while saving the most breast tissue possible.

Several types of surgery are used in the treatment of breast cancer:

Lumpectomy. The lump, a border of surrounding tissue, and a few axillary lymph nodes are removed in this procedure. A biopsy of the nodes is performed to determine whether the disease has spread. Even if no nodal involvement is found, lumpectomy is usually followed by several weeks of radiation therapy. For the majority of women with early stage cancer (tumors smaller than 2 cm) this treatment is just as effective as a mastectomy. However, many women who qualify for this breast-conserving procedure are still opting for mastectomies. Experts believe this is due to regional standards of practice not catching up to the national guidelines. The individual doctor's personal preference for mastectomy may play a role in the woman's surgical choice as well. Lumpectomy is not recommended for those with large tumors or with very small breasts (too much of the breast tissue would be removed and the results would be very noticeable).

Partial mastectomy. The tumor, a large segment of breast tissue (up to one quarter of the breast), and all axillary lymph nodes are removed. This procedure is followed by a course of radiation.

Simple mastectomy. The entire breast and several lymph nodes are removed. For early tumors, simple mastectomy may be adequate, but for more advanced tumors radiation is recommended as well.

Modified radical mastectomy. The entire breast, all axillary lymph nodes, and the lining of the chest muscles (but not the muscles themselves) are removed. For those deemed at high risk for recurrence, radiation follows. If the woman is planning on postmastectomy reconstructive surgery, then her general surgeon should consult with the plastic surgeon to determine how to cut the skin during the mastectomy.

Radical mastectomy. The entire breast, all lymph nodes, and the chest wall muscles under the breast are removed. This procedure is considered overkill and is rarely done anymore.

Axillary lymph node dissection. In some cases, lymph nodes may be removed and examined to determine if the cancer has spread. This procedure can help determine adjuvant therapy options. In axillary lymph node dissection (ALND), doctors remove between 10 to 40 lymph nodes from the axilla (area under the arm). The removal of the axillary lymph nodes may cause edema in the arm, a condition known as lymphedema. Though it is rarely life threatening, lymphedema is one of the most troublesome consequences of breast cancer surgery. The frequency is higher in those women who have radical mastectomy than in those who undergo one of the less radical procedures. Radiation to the axillary area also increases the risk of developing lymphedema. Lymphedema causes swelling of the affected arm, which can severely limit arm mobility, cause increased pain, and increase the risk of postop infection. It may also serve as a constant reminder that cancer existed. This may result in devastating psychological consequences for some women. Women experiencing the symptoms of lymphedema should report them to their providers immediately.

Management of lymphedema is often difficult. Treatments such as pneumatic compression, the use of support garments, and massage therapy to induce draining are often cumbersome and ineffective, especially if they are not implemented early in the process of lymphedema development. Researchers continue to search for new methods to manage lymphedema. Most researchers, clinicians, and affected women consider this an important quality of life issue.

Sentinel lymph node biopsy. During sentinel lymph node biopsy, the surgeon locates and removes the sentinel node, which is the lymph node where a tumor drains, and, therefore is the one most likely to contain cancerous cells. Instead of testing 10 to 40 nodes, as is currently the practice, this procedure uses a radioactive tracer injected into the tumor. The tumor is then massaged to spread this tracer through the lymph vessels so that doctors can see which node a cancer cell reaches first. Instead of removing all lymph nodes within the vicinity of the tumor, only the sentinel node is removed. If a biopsy determines that this node is not malignant, then the other nodes are declared clear of cancer. Reducing the number of nodes removed greatly decreases a woman's chances of developing lymphemia.

Oncoplastic surgery. Lumpectomy and partial mastectomy are frequently used in women with early-stage breast cancer; however, these procedures can sometimes result in disfigured breasts. During oncoplastic surgery, doctors combine cancer surgery with plastic surgery to remove the cancer, while reshaping the breast at the same time. Recently, the Society of Surgical Oncology concluded that, given correct circumstances, oncoplastic surgery helps improve breast conservation in breast cancer patients.

Radiation and Chemotherapy

In addition to surgical treatment, radiation and chemotherapy can be used to treat breast cancer.

Radiation may be used before surgery to shrink tumor size, making its removal easier. Postoperative radiation therapy is used to destroy cancer cells left behind in the breast, chest wall, or lymph nodes and to relieve pain associated with bone metastasis. Patients with delayed wound healing, collagen vascular disease, or previous radiation to the same breast are not candidates for radiation therapy. Pregnant women diagnosed before the third trimester are also not good radiation candidates.

Postoperative radiation begins when the wound is fully healed (usually 2-3 weeks after surgery). Usually patients receive external beam radiation with a carefully focused beam of high-energy protons. Treatment may cause fatigue, skin irritation, pruritus, infection, and pain. However, internal radiation in the form of implants may be the treatment of choice. The duration for this treatment is only 1 week.

In most occurrences of breast cancer, radiation is prescribed 5 days a week for approximately 5 to 6 weeks; however, doctors are now using a variety of schedules:

• Hypofractionated radiation therapy—Larger doses of radiation are given over a period of 3 weeks.
• Intraoperative radiation therapy—This approach uses a single large dose of radiation in the operating room, immediately after a lumpectomy.
• 3-D conformal radiotherapy. In this technique, radiation is given to patients twice a day for 5 days.
• Brachytherapy—A small catheter that houses radioactive substances is inserted into the affected area of the breast. Brachytherapy does not damage surrounding tissue, as is often seen in conventional radiation therapy. Brachytherapy is performed as an in-patient procedure, and duration of treatment depends on the type and stage of the cancer. There are two common methods of brachytherapy. Intracavitary brachytherapy is the most widely used approach and uses radiation in the void area left from the lumpectomy. A patient undergoes intracavitary brachytherapy twice daily for 5 days. In interstitial brachytherapy, catheters with radioactive material are inserted into the breast and left in place for several days.

Chemotherapy is another option in the treatment of those women considered at high risk for recurrence. Chemotherapy is classified as adjuvant or neoadjuvant. Adjuvant chemotherapy is administered after surgery to eliminate any remaining cancerous cells. Adjuvant chemotherapy uses a combination of approaches, such as chemotherapy medications, radiation, and hormone therapy. Neoadjuvant chemotherapy is a preoperative therapy used to treat cancerous cells before surgery. Neoadjuvant therapy helps reduce the size of a tumor to make it easier for the surgeon to remove. In some cases, neoadjuvant chemotherapy allows the doctor to perform a lumpectomy or partial mastectomy, instead of a complete mastectomy.

Chemotherapy is administered by injection or orally and may involve a combination of several different drugs. It is given in cycles, with each period of drug administration followed by a recovery period. A total course of chemotherapy may extend for 4--9 months. Side effects depend on the particular drugs used and the length of treatment but often include nausea, vomiting, hair loss, decreased appetite, mouth sores, menstrual cycle disruptions, increased risk of infection, increased bleeding and bruising after minor injuries, and fatigue. Effective drugs available to help manage most of these side effects.

During chemotherapy for breast cancer, doctors prescribe a combination of medications:

• Anthracyclines. This class of drugs is used to treat early-stage breast cancer. Examples include epirubicin (Ellence) and doxorubicin (Adriamycin).
• Taxanes. These types of drugs are often used for node-positive breast cancer. Examples include pacilitaxel (Taxol) and docetaxel (Taxotere). A newer formulation of Taxol, identified as Abraxane, has shown promising results as a secondary treatment for advanced breast cancer.
• Platinum-based medications. These drugs can be used as part of a multidisciplinary approach for cancers associated with BRCA mutations and in advanced cancers. Examples include carboplatin (Paraplatin) and oxaliplatin (Eloxatin).

Other Pharmacological Treatments

Doctors may prescribe a variety of other medications in addition to, or in place of, chemotherapy and radiation.

One prescribed class of drugs—targeted agents—blocks the growth of cancerous cells by interfering with a "targeted" molecule. These drugs are often used as an antibody to a protein found in cancerous cells. These proteins, known as HER-2, account for 15–25% of early-stage breast cancers. An FDA-approved targeted agent known as trastuzumab (Herceptin) is used to treat HER-2 positive cancers. Research indicates that trastuzumab can help prevent breast cancer recurrence among women with early-stage breast cancer. One drawback of trastuzumab, however, is that it can cause heart complications. Women predisposed to heart conditions should be cautioned against taking this drug.

Bevacizumab (Avastin) is approved by the FDA for the treatment of breast cancer in patients who have not received chemotherapy. Although research has failed to prove that this medication can prolong survival, studies suggest it may help to prevent tumor growth.

Lapatinib (Tykerb) is prescribed to advance-stage breast cancer patients. It is currently being used for advanced therapy; however, scientists are investigating lapatinib's potential as an aide to adjuvant therapy. In one recent study, lapatinib prescribed with trastuzumab helped prolong the lives of women with breast cancer.

Hormonal therapies may be used to treat some tumors. These therapies include medications that have antiestrogen properties, such as tamoxifen (mentioned earlier as a method of preventing breast cancer development). This drug is taken daily p.o. for a period of 5 years following a diagnosis of breast cancer and is usually given primarily to reduce the rate of recurrence. Tamoxifen may cause hot flashes, weight gain, mood swings, blood clots, and cataracts. It may also increase a woman's risk of developing endometrial cancer, but in most cases the cost-benefit ratio of this risk deems the medication beneficial: Most endometrial cancers are caught early and have a very high survival rate, compared to the survival rate for breast cancer.

A somewhat controversial hormonal therapy, known as custom hormone preparation, is sometimes recommended to women as safer than the more conventional hormone preparations. These preparations, although not approved by the government, offer different types and amounts of estrogen (usually estriol, estrone, and estradiol) along with progestogen. The hormones are administered orally, rectally, by nasal spray, by skin cream, and by subdermal implant. Currently, no data support claims that these preparations are safer than other pharmaceutical drugs. In fact, the American Congress of Obstetricians and Gyecologists, the FDA, and the American Cancer Society have released statements concerning the lack of evidence supporting this therapy.

Determining the Need for Postoperative Treatments

Chemotherapy and radiation are serious treatments with sometimes harsh side effects. For that reason, many women would like to avoid those treatments unless they are absolutely necessary. Medical advances in bone marrow testing are helping doctors and women determine the need on an individual basis. In recent studies, scientists tested patients' bone marrow to help determine the chance for recurrence of breast cancer. The test used proteins, known as cytokeratin-specific antibodies, which target small traces of cancer cells that have spread to the bone marrow. Circulating tumor cells (CTCs), located in the bone marrow, and disseminated tumor cells (DTCs), located in the blood stream, are monitored as prognostic variables to ascertain the progress of breast cancer and to help predict the likely outcome of cancer therapy. Scientists concluded by stating that bone marrow tests for breast cancer may influence treatment options. Current research supports that women who show evidence of micrometastasis to the bone marrow are at a higher risk of recurrence; these women are better candidates for aggressive postoperative treatment, such as chemotherapy, even if all lymph nodes are clear. Conversely, women who have negative nodes and negative marrow are considered lower risk and typically do not need postoperative treatment.

Coping With Treatment

Nurses can share a great deal of information with patients to help them cope with the side effects of chemotherapy and radiation. Nurses should recommend that patients undergoing radiation:

• Nap often to conserve energy
• Engage in mild daily exercise
• Wash the affected area with mild soap and water followed by the application of oil-free and alcohol-free lotions
• Avoid shaving the irradiated areas
• Wear loose clothing to prevent skin irritation
• Avoid exposing the skin to extreme temperatures
• Avoid sun exposure
• Nurses should instruct chemotherapy patients to:
• Recognize the signs of infection
• Practice good hygiene, especially frequent hand washing
• Avoid crowds
• Eat small, bland meals to avoid nausea and vomiting
• Buy wigs early if they are on a regimen that causes hair loss
• Accept that most women on chemo gain weight

Most women can return to their normal lives a few months after treatment. For those who need help during the recovery process, the American Cancer Society provides free services to help meet the emotional, physical, and cosmetic needs that many women have following breast cancer diagnosis and treatment. Reach to Recovery, a program of the American Cancer Society, enlists volunteers to provide comfort and support to patients as well as provide practical information about breast cancer–related topics, such as prostheses and lymphedema. Because these volunteers are breast cancer survivors, they can be a source of hope for a newly diagnosed woman who may be feeling depressed or overwhelmed by what is happening to her.

Nurses can also help patients navigate the healthcare delivery system for the treatment of breast cancer. In the past few years, this system has changed significantly. Until recently, women had to travel from one medical facility to another for the different aspects of treatment and follow-up (e.g., radiations in one facility, chemotherapy in another, tests in still another). Now comprehensive breast centers are opening nationwide so that women may receive all of these services, plus support group therapy and nutritional counseling, in one place.

Alternative Medicine

In the past three decades, the use of complementary and alternative medicine (CAM) to treat a variety of illnesses has increased substantially. The specific alternative approaches often used by women with breast cancer include spiritual programs, relaxation methods, nutritional therapies, herbal and naturopathic remedies, homeopathic remedies, mental imagery, and hypnosis. Although no CAM therapies have been clinically shown to alter the course of breast cancer progression, many of these methods, including homeopathic medicine, acupuncture, and therapeutic touch, are effective in decreasing the side effects of conventional treatments.

• Homeopathic medicine. Used for the treatment of lymphedema, homeopathy is a system of medicine based on the use of natural substances to stimulate the body's own healing powers in curing disease and relieving symptoms. Homeopathic remedies are employed to relieve nausea from chemotherapy and radiation. (Nurses should always encourage their patients to look for certified homeopathic practitioners. Certifying agencies include the American Board of Homeotherapeutics, the Council for Homeopathic Certification, and the North American Society of Homeopaths. All patients using homeopathic remedies should let their physician know so that both practitioners can work together for the good of the patient. In many cases, the homeopathic practitioner is also the woman's physician; in other cases, the homeopath may be a chiropractor, naturopath, or an acupuncturist. In all of these instances, it is vital that both providers be informed about how the other is treating the patient.
• Acupuncture. Used to treat nausea associated with chemotherapy, acupuncture is part of a Chinese system of medicine developed over thousands of years. It is characterized by the stimulation of points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or to normalize physiological functions, including pain control, for the treatment of certain diseases and dysfunctions of the body. Efficacy of the procedures has been demonstrated in several controlled studies. Insurance coverage varies from state to state, depending on licensure requirements and whether medical supervision is required for the treatment. Nurses should check into the licensing laws of their own states to determine how to talk to patients about this form of therapy.
• Therapeutic touch. Developed in the 1970s by a nurse, therapeutic touch is based on the principle that the human energy system extends above the skin, enabling the practitioner to use the hands as sensors to locate problem areas within the body. Disease is seen as a condition of energy imbalance that can be assessed by moving the hands over the body at a distance of 2-4 inches above the body surface. The practitioner serves as a conduit through which blocked energy flow is corrected. This method is used without touching the body, so it is good for physical conditions in which the body cannot tolerate contact (e.g., postoperative status, severe burns). The technique is taught in more than 80 universities and is practiced by approximately 30,000 healthcare professionals worldwide. When used as a nursing intervention, its purpose is to reduce agitation, decrease pain, and promote psychological, spiritual, and physical healing. Some practitioners report that the technique has a calming effect on the practitioner as well.

Alternative approaches also help women decrease their stress levels and encourage healthier lifestyles. A recent study analyzed CAM therapies, such as massage, reflexology, and supplements, to find out the percentage of breast cancer patients who used alternative therapies. CAM therapies studied included manipulative therapies, biological therapies, mind-body and energy treatments, and alternative medical systems. According to the study, more than half of breast cancer patients use CAM therapies. Biological therapy, such as supplementation and vitamins, is the most popular among women with breast cancer. Many of these supplementation methods are intended to reduce the symptoms associated with breast cancer. Although biological-based therapy ranks highest on the study, there are no current controlled trials proving the efficacy if these products. However, researchers are currently studying alternative therapies due to their widespread use in the United States.

What prompts patients to try alternative methods is not clear, but speculation by experts suggests that a variety of reasons bring women to CAM therapies (e.g., failure of standard medicine to find a cure, changes in the healthcare delivery system, patients' need to feel empowered, cultural differences, a preference for a "natural" healing method). In general, patients who use alternative approaches also see physicians, suggesting that women see alternative care as complementary to, rather than as a substitute for, standard Western medicine. On the other hand, some studies show that many women do not report the use of alternative therapies to their physicians. When questioned about this, women report they are afraid their physicians will not understand or approve of their choices, will be indifferent to the information, or will consider the information irrelevant to conventional treatment. Nurses should know that the information is indeed relevant, and, therefore, they should ask patients directly, but in a nonthreatening manner, about their use of alternative medicine.

One study on the use of alternative therapies in women with early-stage breast cancer provided some interesting insight into why patients choose alternative methods and how they are affected by that choice. In this study, 480 women with well-established prognoses and therapeutic options were questioned about their treatment. Results showed that the use of CAM was common. Many women began to use CAM immediately following diagnosis in conjunction with surgery, chemotherapy, and radiation. The women who initiated the use of CAM after breast cancer surgery suffered from more depression, worse general mental health, lower levels of sexual satisfaction, a greater fear of recurrence, and more frequent and severe somatic complaints than women who did not use CAM or women who used CAM prior to their breast cancer diagnosis.

Researchers concluded that initiation of alternative therapies immediately after a breast cancer diagnosis may be a marker for psychosocial distress and therefore should alert providers to inquire further into a woman's psychosocial situation so that appropriate referrals can be made to help her deal with anxiety or depression related to diagnosis. Other experts speculate that women who turn to alternative therapies after diagnosis are women who are afraid to talk about their concerns for fear that the provider will consider it a waste of time or because they are embarrassed about having such feelings. Whatever the reason, all healthcare professionals should be aware of this potential marker for psychological distress and use it to assess a patient's need for a mental health referral. Most researchers agree that further studies are needed in this area.

Another study of CAM showed differences in the types of alternative therapies chosen by different ethnic groups. According to this study, Black women are more likely to choose spiritual healing methods; Chinese women are drawn to herbal remedies; Latinas choose dietary and spiritual techniques; and White women pick dietary therapies, massage, and acupuncture. This study also found that more educated women, those with higher incomes, younger women, those with private insurance, those who exercised regularly, and those who attended support groups were more likely to choose alternative therapies than women who did not fall into these categories.

Many areas of research are yielding interesting, yet inconclusive, results. One such study showed that women who drink the equivalent of five Japanese-sized cups or more of green tea per day had a decreased recurrence rate and a longer disease-free period than women who drank less than 4 cups a day. Further research is necessary before any clinical conclusions are drawn about this specific remedy, but the results of studies such as this one continue to spark interest in other dietary treatment methods.

Another question that needs further research before it can be answered adequately concerns the effect on the breast of phytoestrogen in the diet. Phytoestrogens are plant sources of estrogen and are commonly found in foods such as soy products and certain fruits and vegetables. Many experts believe that phytoestrogens may actually have a protective effect on the breast and thus reduce the risk of developing breast cancer. This is especially important at this time because many women are choosing to use dietary sources of phytoestrogens (instead of HRT) as a means of controlling the unpleasant side effects of decreased estrogen levels associated with menopause.

Mind-Body Medicine

The practice of mind body medicine crosses all healthcare disciplines and is practiced by doctors, nurses, nurse midwives, osteopaths, hypnotherapists, and exercise physiologists, among others. The interventions used in mind-body medicine can be taught effectively in one-on-one and group settings as well as in both in-patient and outpatient programs. Mind-body medicine may be used as a preventive measure to decrease the incidence of disease development or as part of a treatment plan for those who have already contracted a major illness. In the broadest sense, mind-body medicine means changing one's lifestyle to promote health and prevent illness.

The theoretical framework underlying the practice of mind-body medicine states that health is determined by an interaction between many variables in an individual's life. Such factors include genetic predispositions; environmental exposure to disease-causing agents; psychological factors, such as stress tolerance and lifestyle choices; and the social environment in which the individual lives. Some of these factors are under the individual's control, whereas others are not. Mind-body medicine operates on the principle that many of these factors are under the individual's control even if the individual does not recognize this fact. Through training, individuals are able to perceive more of these factors as under one's control and, therefore, feel a sense of empowerment over one's health. Nurses can be instrumental in bringing about this sense of empowerment.

In turn, through biofeedback mechanisms, the body affects the brain producing changes in thoughts and feelings. This mind-body feedback works primarily through the stress and relaxation responses. Therefore, most of the mind-body techniques discussed in this course involve ways to help the mind and the body work in conjunction to decrease stress.

Practitioners encourage patients to incorporate the various interventions into daily life to promote optimal health. Specific interventions may include changing daily exercise patterns, eating a healthy diet, reducing stress, and finding a social support system. Few, if any, of the techniques described in this section are used alone. Rather, they are used in conjunction with each other, depending on the specific needs of patient.

Meditation. One of the most widely used interventions in the mind-body repertoire, meditation is useful in helping patients deal with a variety of stress-producing psychological problems associated with major illnesses (e.g., decreased independence as a result of hospitalization, feelings of isolation, anxiety, depression, and changes in body image). When combined with guided imagery or therapeutic touch, meditation can be a powerful nursing intervention in a wide variety of settings and for a wide variety of illnesses (e.g., dealing with the side effects of chemotherapy and radiation in cancer patients and helping with body image disturbances following mastectomy). The most commonly practiced form of meditation for these purposes is mindfulness meditation, which stresses the importance of quieting the mind and the body so one can learn to live in the present moment. Having the patient concentrate her attention on one thing at a time helps the patient achieve mindfulness. With practice, patients are able to reduce their stress levels by maintaining longer periods of mindfulness. When one is living in the moment, it is much harder to succumb to worrisome thoughts. Practitioners of meditation caution that it may take time before tangible health benefits are seen. Patients should be encouraged to continue the practices even if they get impatient for results and want to stop.

Progressive relaxation. Another form of meditation used effectively by nurses, progressive relaxation involves the patient focusing on one part of the body at a time. The technique is usually performed with the patient in a reclining position and involves progressing through the body and focusing on one major muscle group at a time, beginning with the feet and working towards the head. The muscles in each group are clenched for a count of 10 and then relaxed for a count of 10 before moving on to the next group. Muscles that are tensed beyond their normal state usually relax beyond their normal state and, as a result, produce the physiological benefits associated with the relaxation response (e.g., slower breathing, lowered blood pressure, decreased heart rate).

Mental imagery. This technique uses the suggestive state of mind to help patients relax. During mental imagery, patients imagine specific positive changes occurring in the body (e.g., cells of the immune system attacking cancer cells). Studies show that this technique helps create positive physiological changes, which, in turn, boost immune system functioning. The sense of empowerment and personal control that accompanies this technique increases S-IgA levels that may reduce tumor size, increase the number of lymphocytes fighting the tumor, and increase natural killer cell activity.

Guided imagery. Similar to mental imagery, this technique is usually performed by a healthcare professional, not patients alone. Guided imagery is often used in support group settings where everyone is in the process simultaneously and can share their experiences with each other once the guided imagery segment of the session is over. during guided imagery sessions, individuals internalize the same words spoken by the facilitator; however, how they interpret the words varies widely. Such experiences of individuality can provide great insight into one's own psychological makeup. As a result, individuals often become kinder to themselves, which in turn reduces stress levels and leads to improved overall health.

Breath therapy. Closely related to meditation, breath therapy works to induce a state of relaxation. It is often used in conjunction with meditation, mental imagery, and autosuggestion. It helps release the tension, anxiety, pain, and strong emotions that often accompany the diagnosis of a severe illness such as breast cancer. Once negative states are released, relaxation is more easily induced.

Support groups. have emerged as a form of mind-body medicine in the past few decades, largely because of a mobile society in which people often feel isolated and without social support to help them cope with life's problems. When used in conjunction with other therapies, this method is valuable in treating many diseases. Being with others who are suffering in similar ways can help reduce the perceived isolation and loneliness that often accompany the diagnosis of breast cancer. Support groups provide a regular format for teaching new coping methods as well as guided imagery, breath therapy, and other forms of relaxation. Support groups also provide a safe environment in which to learn how to express strong emotions in a healthy way. After patients master basic relaxation techniques, the patient is usually able to leave the support group and continue these practices on her own. Some patients, however, prefer to remain a part of the group because of the camaraderie and support they receive in the group setting. When nurses facilitate support groups, they bring assessment skills, management skills, referral expertise, and an understanding of therapeutic group process to the endeavor. Nurses are skilled at teaching appropriate self-care and healthy coping mechanisms, disseminating health information, and explaining in simple terms the medical advice given by physicians. These are valuable skills when brought to the support group process.

Yoga. This exercise induces a state of deep relaxation by helping patients understand the union between the physical, mental, and spiritual dimensions of life. Some nurses are trained as yoga teachers, but all nurses can learn about the health benefits of yoga and make appropriate referrals to local classes.

Prayer

Prayer falls into the category of nursing interventions related to the spiritual dimension of human existence. Studies show that prayer is one of the methods of treatment commonly chosen by women to help them deal with the spiritual and emotional distress of a breast cancer diagnosis. Although the exact physiological mechanism by which prayer works has not been determined, prayer has been demonstrated to stimulate healing. Experts speculate that prayer stimulates the relaxation response and, as a result, enhances the immune system. Nurses in holistic practices recognize an element of mystery in the use of prayer for healing. Many attribute this mysterious component to the assistance of a "higher power" in the healing process. This higher power is often referred to as God.

In answer to the question, "Is prayer professional?" a recent editorial in the Journal of Christian Nursing stressed the important relationship between the healing of body, the mind, and the spirit. This is the foundation of holistic medicine's call to view the patient as a whole person. The editorial's author concluded that nurses who believe in God's power to heal are ethically obligated to pray for their patients' healing. Because most of Jesus' ministry was a public one, Christian nurses must pray individually for their patients and must ask the body of Christ (the church) to pray as well. According to the editorial's author, if a Christian nurse is asked by a patient to pray with her, the nurse is ethically bound to do so.

When using prayer as a nursing intervention, nurses must ask themselves, "Whose need am I meeting? My own or the patient's?" If a nurse is attempting to meet a personal need, then a private prayer is appropriate. However, if the nurse is attempting to meet the patient's needs, then a shared prayer is the proper intervention.

Some holistic nurses report that intervention in the healing process with prayer helps patients cope with anxieties surrounding their diagnoses. Prayer is also seen as an important tool to deepen the crucial nurse-patient bond. Some holistic practitioners suggest that contacting churches and other religious bodies within the community is an important nursing intervention. Such organizations may serve as support systems for patients both in the hospital setting and at home.

Studies show that different populations and ethnic groups place varying emphasis on the use of prayer. Non-Whites are more likely to turn to prayer for help in dealing with crises than are Whites. These non-White groups demonstrate that the use of prayer or meditation, the belief in God, and a general sense of connectedness with nature and with other people contribute to a sense of inner strength and self-reliance, which can be drawn on when coping with difficult health issues.

So It is important to remember some women may have a different spiritual tradition, which is equally as important to them as the Christian tradition is to others. To appropriately intervene in the spiritual dimension the nurse must first learn about the patient's spiritual traditions, worldview, beliefs about health and wellness, and beliefs about God. Recognize that many religious traditions do not believe in the existence of God as Christians do (e.g., some traditions are polytheistic in nature). This is one reason why an understanding of multicultural issues and concerns is important to good nursing care.

Remember that members of the healthcare team are have their own emotional and spiritual concerns surrounding the diagnosis and treatment of breast cancer. These concerns often influence healthcare providers' relationships with patients. Some team members are more comfortable dealing with emotions and spiritual concerns than are other members. However, responding to emotions and spiritual issues (both the patient's and the healthcare member's) is a vital skill that can be learned. Proper training is available, so no team member needs to feel inadequate in this area.

Follow-Up Care

Because breast cancer can recur at any time (even as many as 30 years after the original diagnosis), all women who have been treated for breast cancer should continue to receive follow-up care for the rest of their lives. The type and stage of cancer involved, the treatment given, and the risk of recurrence generally determine how often survivors should be examined.

In general, experts recommend that follow-up regimens include a physical exam every Three to Four months for the first Two years following treatment. All patients should undergo regular mammography, chest x-rays, and liver function tests at the appropriate intervals recommended for the stage of their disease and their prognosis. The intervals for all of these tests gradually increase to annually after 5 years without disease recurrence.

Nursing Interventions

Many of the interventions nurses use for patients with breast cancer are related to patient education. However, some nursing interventions do not fall into that category but are still necessary and deserve separate discussion.

An important nursing intervention for treating the emotional, psychosocial, and spiritual nursing diagnoses is to make the diagnostic and treatment settings as patient centered as possible. When attempting to teach patients about an issue as emotionally laden as that of breast cancer, experts encourage making the office environment in which the learning is to take place a welcoming one. The environment is defined as the physical setting as well as the interactions that take place there. This means that the environment starts with the phone call in which the appointment is made and extends through the follow-up process, including any mailings that take place both prior to and subsequent to the office visit. If necessary, the environment may include the hospital environment in which treatment is provided as well as any postoperative, follow-up care. Problems at any point in this process may result in noncompliance with the screening guidelines or treatment recommendations.

Some of the following considerations and suggestions for change require minimal effort on the part of the healthcare staff and yet may provide significant improvement in patient-provider communication. Other changes are more extensive and require a long-term commitment for successful implementation:

Make the decor inviting to patients. Arrange furniture in a way that provides comfortable traffic patterns and adequate wheelchair access. Good lighting is important for filling out forms and for reading health education materials. Reading material should be selected to appeal to a wide variety of interests, ethnic groups, and reading levels. Signs should be welcoming in tone and encourage patients to ask questions if they are confused about any part of the process. Ideally, signs should appear in all of the major languages spoken by patients in each particular setting. A list of languages spoken by the staff as well as those languages with available translators should also be posted. Experts suggest that a sign reflecting the setting's nondiscrimination policy be posted to reassure members of various cultural subgroups that they will be treated respectfully by all staff members.

Interact with patients in a respectful manner. Procedures and policies should be explained in terms that the patient can understand. If necessary, explanations should be calmly repeated until the patient indicates understanding. If patients have to wait for long periods due to delays that occur in healthcare settings, sincere apologies should be given.

Maintain patients' privacy and confidentiality. Some health education efforts, such as demonstrating breast self-exams, watching videos, providing individual counseling, and obtaining a health history should be done in a private settings, not in open, crowded waiting rooms, to ensure patient comfort and trust. The more information you have, the better you can assess the screening or diagnostic needs of your patient, her perception of her risk level, and lifestyle changes she needs to make to comply with the recommended guidelines and treatment options.

Master the art of asking questions. To ascertain as much information as possible during the office visit ask open-ended questions, rather than closed ones. Closed questions can be easily answered with a "yes" or a "no" (e.g., have you ever had a mammogram?). Open-ended questions are worded in such a way that they cannot be answered simply and thus allows you to gather more information (e.g., what are your experiences with mammograms?). Open-ended questions can help you discover, for example, that the patient considered her first mammogram painful and embarrassing and avoided getting annual mammograms after that. You can then tailor your response to educate the patient and help her meet treatment and prevention goals.

Listen actively and respond appropriately. Repeat what your patients says to make sure you understood what she told you. Listen for the emotional content of her message and respond to the emotions. Many women are scared to be screened for breast cancer because they are afraid of the pain induced by some screening procedures or they are afraid of negative results. This can be especially true if a family member or close friend had the disease. Women who witness a family member or friend go through diagnosis and treatment have not had an opportunity to express the strong emotions involved, and, as a result, their anxiety levels remain high. Those in a high state of anxiety do not hear much of what they are told. However, if you allow them to express their feelings to you, and you respond empathically, their anxiety level will drop and they will be much more likely to hear your health education message. Obviously, a woman who has just received a diagnosis of breast cancer is going to be in an even higher state of anxiety and may hear little of what you tell her. It is a good idea to have a list of breast cancer support groups where those who have lost family members or those who have been diagnosed with breast cancer can go to express their emotional concerns about the disease.

Use positive body language. To avoid misunderstandings make sure that your body language and words send a consistent message. For example, it can be confusing if you are verbally encouraging her to be open with you, but your legs are crossed and your arms are folded across your chest, indicating that you are not open to hearing what she has to say.

Help your patient cope with depression. Patients should be told that feelings of depression are normal after a breast cancer diagnosis. Depression may manifest themselves as a loss of self-esteem, fear of rejection, moodiness, crying spells, loss of appetite, and loss of interest in sex. They patient may wonder "Why me?" or "What have I done to deserve this?" These feelings are normal for a short time after diagnosis; however, women experiencing long-term problems should be referred to a mental health professional, a support group, of a member of the clergy. Be aware of women who demonstrate hopelessness; a sense of powerlessness; disturbances in body image, self-esteem, personal identity, and sleep patterns; social isolation; fear; or dysfunctional grieving as result of the disease. You may need to refer these women to the appropriate support services.

Learn to use humor effectively. Humor can help strengthen the patient-provider bond, but you must follow guidelines regarding professionalism and socially appropriate behavior: Establish your competency and compassion before using humor. Attend to physical and emotional pain before attempting therapeutic humor. Never use humor immediately after giving a dire prognosis. Avoid ethnic, religious, sexual, and political humor, as these tend to alienate patients. Remember, individuals' sense of humor varies significantly so what is funny to one patient may not be funny to another. Once alienated you must work much harder to win patients' back. Humor is not about being a clown but about using humor to communicate empathy, understanding, and caring. Used in this way humor becomes integrated into your entire care system.

Help patients cope with stress. Studies show a relationship between stress and the development of breast cancer. Dealing positively with stress can not only improve the quality of life of a patient already diagnosed, but stress relief may also act as a preventive measure in those women at high risk who have not yet been diagnosed. Women who are screened, diagnosed, and treated for breast cancer have everyday stressors that may affect their anxiety level and, as a result, negatively affect your educational efforts. Some life stressors include children leaving home, financial concerns, marital problems, responsibility for the care of aging parents, the death of friends, and work-related issues, among others. Give patients the opportunity to express these concerns before you begin your teaching agenda. Some stress-management techniques include prayer, meditation, progressive relaxation, guided imagery, breath therapy, and support group membership.

Barriers to Receiving Care

Barriers to receiving care may occur at any point in the process; at the time, the appointment is made, during the data-gathering and health history phases, during the exam itself, during the explanation of test results, during the treatment and follow-up phases, and during the plans for rescreening. If healthcare workers are aware of these barriers, they are more likely to help patients avoid them. Some of these barriers include:

• Time constraints (e.g., time off work and time away from children to keep appointments)
• Unreliable transportation to appointments
• Language, cultural, and religious barriers
• Lack of knowledge about the disease and the screening guidelines
• Cost of exams and treatments, as well as the cost of transportation and child care
• Privacy and modesty concerns, especially if the patient has ever been teased about the size of her breasts
• Misunderstandings about insurance coverage or lack of insurance coverage
• Fears related to the disease (e.g., fear of "catching" cancer from the radiation involved in mammography, fear of a cancer diagnosis, fear of pain associated with exams)
• Illiteracy and ignorance of basic health care concepts (one in five Americans cannot read a newspaper and often cannot read appointment slips, the information on their medication bottles, discharge instructions, or consent forms and may be ashamed of their inability to read and hide it from the healthcare team; nurses are being given the responsibility of identifying patients with reading problems: e.g., ask patients to repeat in their own words what they just read can help you ensure that learning occurred, be alert to patients who make excuses when asked to read something)

The healthcare system itself may present obstacles for members of the healthcare team. Team members often have a need for a personal connection with their patients. Obstacles to this connection may leave team members feeling dissatisfied, which may, in turn, affect patient satisfaction. Some healthcare-related obstacles include:

• Low morale in healthcare workers who do not believe they have any input into how the system functions
• Scheduling problems (e.g., inadequate time for appointments and exams, resulting in providers having too little time for adequate needs assessment)
• High staff turnover rates, resulting in an inadequately trained staff who do not understand and thus cannot teach the importance of following screening guidelines
• Providers who fail to suggest screening, which is the most common reason given by women as to why they do not participate in breast cancer screening
• Lack of time due to increased paperwork or performance of other duties resulting in inadequate time and emotional energy levels necessary to good communication

The following interventions may help nurses overcome some of the barriers to care in the work setting:

• Develop a list of translators who can be called when language difficulties arise
• Provide written health education materials in several languages
• Develop a list of local agencies that patients may be referred to for shelter, transportation, child care, and food needs
• Develop good relationships with those who work in community support settings so that your patients are assured good treatment
• Use patient satisfaction surveys to identify changes that need to be made in your system
• Provide specific private areas for patient education
• Be consistent when giving recommendations related to screening guidelines
• Send reminder cards or emails or make reminder phone calls before rescreening appointments
• Provide continuing education for all healthcare team members

To help overcome barriers, often behaviors must change. The stages of change model evolved out of programs developed in the 1980s for the treatment of various substance dependencies. The basic premise of this model is that behavior change is a process, not a one-time event. The change process is cyclical and can be entered, exited, and reentered at any stage of the cycle. This model dictates that people benefit from different types of interventions at different stages in the cycle, and, therefore, specific interventions for the individual woman should be matched to her stage of the cycle. When applied to breast cancer screening services, this model is useful in helping women determine the benefits and obstacles associated with making the necessary behavior changes to ensure compliance with screening guidelines, in helping her reach a decision in favor of making those behavioral changes, and in encouraging her to continue the new behaviors over an extended period of time until the behaviors become second nature.

To move from one stage of the cycle to the next there must be a consciousness raising that provides new information to encourage healthy behaviors. This is usually best done in the context of helping relationships, such as the nurse-patient relationship. It is often helpful to use reminders to encourage long-term behavior changes. The following stages are included in the stages of change model:

Stage 1. The woman is unaware that there is a problem, and she has not given any thought to making changes. The role of the nurse in this situation is to increase the patient's awareness of the need for change by personalizing information about the risks for developing breast cancer and the benefits of making the desired changes.

Stage 2. In this stage, the woman thinks about making changes in the near future. The nurse's role is to encourage the patient to make specific plans as to the changes she intends to make.

Stage 3. This is the planning stage, and the role of the nurse is to assist the patient in making plans. The patient must state the specific behaviors she is going to make to comply with screening guidelines and treatment recommendations, including stating the time and place of screening and treatment. To reduce stress associated with these behavior changes, the nurse should encourage the patient to make the changes gradually. Once a woman becomes overwhelmed, she may discard the whole idea of breast cancer screening.

Stage 4. Here the previously planned actions are implemented. The nurse's role is to assist the patient by providing feedback, helping her solve problems, and giving her emotional support and encouragement.

Stage 5. In this stage, the woman continues the changed behavior at the recommended time intervals. The nurse encourages this sustained action by providing reminders and by assisting the patient with developing new coping strategies should any problems develop.

Occasionally a woman will relapse which means she reverts to one of the earlier stages in the cycle. The nurse's role is to recognize that this has happened and to provide health education messages and interventions that are appropriate for the stage the woman is currently in. This retailoring of the message to the patient's specific needs helps her move through the process faster and helps ensure that she will reach the stage of sustained action.

Another model, the health belief model, was developed out of a desire to increase the public's use of immunization services in the 1950s. Its premise is that people are afraid of diseases and, therefore, are motivated to make behavior changes by the degree of fear they feel and by the benefits they perceive will come to them as a result of making the changes. For the purposes of this course, the concepts involved have been tailored to breast cancer screening and include:

• The woman's opinion of her chances of getting breast cancer. Health education messages should define the populations at risk and help the patient personalize her risk level based on her personal risk factors and behaviors. If she perceives her risk level as lower than it actually is, then she needs information to understand her realistic risk level and to encourage her to take advantage of screening services. Conversely, if she perceives her risk as higher than it actually is, she needs information to give her a more realistic perception of her risk level.
• The woman's understanding of the seriousness of breast cancer and its consequences. The nurse should inform the patient about the risks and consequences associated with breast cancer.
• The woman's perception of the effectiveness of any actions that could reduce her risk of disease and its consequences. The nurse should explain the screening guidelines and then help the patient decide specifically what actions she must take to comply with those guidelines. Stress the positive benefits to be expected from long-term compliance.
• The tangible and psychological barriers that prevent the patient from accessing breast cancer screening services. These include transportation problems, the cost of child care, time off work to keep the appointment, and fear of finding cancer. The nurse's role is to identify the specific barriers for the patient and reduce those barriers by providing reassurance, giving her accurate information, and referring her to community agencies that may be able to help.
• The particular strategies the woman can use to make her ready to take action. The nurse can provide specific information about the steps required to make changes. The nurse can also continue to promote awareness and give reminders at appropriate intervals.
• The woman's confidence in her own ability to take the desired actions. The nurse's role is to provide the training and guidance necessary so the patient has the tools she needs to make the desired behavior changes.

Another theory that can help healthcare providers support change in patients is Maslow's hierarchy of needs. Maslow was a psychology researcher known for his studies on motivation. His research showed that the gratification of basic needs is necessary before motivation for learning or changing behavior can take place. This theory helps healthcare workers better understand patient concerns and priorities that may keep them from accessing healthcare services. Once these barriers are identified, strategies can then be developed to help women overcome the obstacles. The following levels of needs are included in Maslow's hierarchy:

• Level 1. Physiological needs for survival, such as food, water, oxygen, clothing, shelter, sleep
• Level 2. Safety concerns of the patient, both for herself and her family members, including drug use, fear of crime, fear of domestic violence, unsafe neighborhoods, and bad weather conditions that make venturing out feel unsafe
• Level 3. Love, affection, and belonging, which women need to feel cared for by others and to express the love and affection they feel toward those they love
• Level 4. Self-esteem, which allows women to feel respected, needed, and valued as individuals
• Level 5. Self-actualization, or the feeling that one has reached her potential, has a degree of control over her life, and has a sense of fulfillment

For many American women, preventive care, such as breast cancer screening, is seen as a luxury and will not be considered until the woman believes that the first three levels of needs are met, not only for herself but for her family members as well. Meeting these lower level needs is often beyond the control of most healthcare workers. However, we can make referrals to community agencies designed to help meet those needs (e.g., food banks, homeless shelters, child care agencies, employment agencies). If basic needs are met, women are more motivated to make the behavioral changes necessary to follow the recommended guidelines for breast cancer screening.

Cross-Cultural Considerations

Nurses play an important role in teaching women about breast cancer. Nurses teach proper technique in performing breast self-exams, provide and encourage regular clinical breast exams, and encourage regular mammograms. Women who are more likely to be underserved (e.g., the elderly, the uninsured, women of color) often need special outreach programs to help them understand the need for and the best way to access these services so that early detection and diagnosis occur.

Cultural diversity is one of the main communication issues today. Nurses must develop a clear understanding of cultural diversity issues. Essential to this process is the willingness for nurses to listen and learn from those of other cultures and then to provide services and information in diverse languages, at diverse literacy levels, and in the context of the other person's cultural beliefs. To do this, nurses must be aware of their own cultural assumptions, beliefs, values, and stereotypes, including such things as attitudes and preconceived ideas toward health and illness, the degree of control and responsibility one perceives over one's own health, and appropriate ways to establish rapport with those who believe differently. It is also important to remember that the term culture includes such factors as age, religion, sexual identity, occupation, and socioeconomic status. Many people have multicultural backgrounds that further complicate the situation both for them as they try to sort out a multicultural identity and for healthcare workers who are trying to be sensitive to cross-cultural considerations.

To be effective in cross-cultural communication, nurses must be willing to listen to the patient's perception of the problem, to explain their own perception of the problem, to acknowledge the similarities and the differences of the perceptions, to provide information regarding recommended behavior and screening guidelines, and to negotiate with the patient to encourage adherence to those guidelines.

Some resources are available to help health professionals with cross-cultural issues. State and federal grants make it possible to provide early education, screening, diagnosis, and treatment of breast cancer for low-income women. A partnership has been created between survivors of breast cancer, healthcare providers, community organizations, and others to provide information, support, and advocacy. Because of these programs, we now have added information on some of the cultural implications for communication and screening of women in the various cultural subgroups of American society. It is important to consider this information when educating women about the importance of regular exams and mammography. Although it is beyond the scope of this course to provide extensive or detailed information on each of these subgroups, some important information is provided to help nurses understand important cultural issues. For example, some ethnic groups have a mistrust of White-dominated provider settings. Other groups have modesty considerations that must be taken into account to encourage them to access the healthcare system. The role of extended family varies among subgroups as well. The cost of screening may be prohibitive for members of some groups. The nurse should understand basic information about the following populations in the United States:

American Indian women. This group has a relatively low incidence of breast cancer; however, when women in this group are diagnosed, they are usually in the later stages of the disease. Therefore, the mortality rate is higher than in women of other populations, who receive early detection screening. American Indian women often live far from settings where screening services are provided, so transportation can be a major issue. Holistic religious beliefs make it difficult for them to accept surgery that they believe may leave them "unwhole" and thus unable to enter the afterlife. In general, this group is reflective and does not like to be rushed. It may take time for them to develop trust in their provider. Show respect for their need to reflect before answering by speaking slowly and allowing time for them to respond to your questions. Understand that they want to make sure they give an accurate response.

Hispanic women. Modesty is a major concern of this group, especially if a male practitioner is providing services. Hispanic women are also likely to put their family's needs ahead of their own, and, as a result, breast cancer screening may not be high on their priority list. Family is important to women in this subgroup, so be mindful of the participation of all family members during discussions with the patient.

African American women. Mistrust of a predominantly White medical care system may keep these women from accessing services. A fatalistic attitude about disease may also keep them from adhering to follow-up guidelines.

Asian/Pacific Islander women. Language barriers can be a significant problem in this group. They also have a cultural bias toward self-care and self-medicating. They rely on providers who heal intuitively, so they may be reluctant to describe symptoms. Modesty concerns, especially with male providers, are common.

Elderly women. Some physicians fail to recommend screening for these women, and as a result they have lower screening rates than do younger women. Sometimes older women associate breast changes with age rather than with the possibility of disease. Current trends in healthcare may make it confusing for elderly women to navigate the system. Memory problems and depression may make it difficult for nurses to obtain accurate health histories from elderly patients.

Women with physical or mental impairments. One study showed that these women were less likely to get screening recommendations from their providers. Health education materials are harder to find for these women. Wheelchair and walker access may be a problem in some settings.

Women living in poverty. Cost is a major barrier to care for these women. Some may feel discouraged, hopeless, embarrassed, or even depressed by their poverty.

Lesbians. Lesbians report receiving fewer than the recommended number of mammograms and clinical exams, and they are less likely to perform self-exams. Lesbians report that many of the health education messages associated with breast cancer do not address their needs. Homophobic staff and providers may send subtle and not-so-subtle messages that these women are not welcome in a particular practice. Concerns about hostility or breaches of privacy may make lesbian women less likely to disclose their sexual preference to their providers. Because lesbians may have a higher risk for developing breast cancer, this hesitancy to reveal sexual preference may have significant healthcare ramifications.

Men. Men can get breast cancer, but many people do not know more than that. Nurses need to understand the course of breast cancer in men. According to the American Cancer Society, about 1,970 men were diagnosed with breast cancer in 2010, and about 390 of them died. Tumors in men are usually estrogen-receptor positive, which are associated with a better outcome than those that are estrogen-receptor negative. Men are generally diagnosed in later stages than women because men wait an average of Ten months after symptoms arise before seeking help. Symptoms in men usually first appear as a small, hard, painless lump in the nipple area or nipple retraction, nipple discharge, or nipple bleeding. Even though breast cancer is rare in men, those having these symptoms should seek medical care immediately. However, men who seek help often encounter a system that caters to women (e.g., in some hospitals men have had to wear pink gowns because that is all that is available). Risk factors for male breast cancer include family history in either men or women; environmental factors, such as estrogen-based medications (often taken for prostate cancer); the presence of Klinefelter's syndrome (characterized by two X and one Y chromosomes); cirrhosis of the liver; testicular disorders; radiation exposure; and benign breast disease in which the breast is enlarged. Certain occupations in which men receive high exposure to electromagnetic fields (e.g., electricians, telephone linemen, radio and communications workers) or heat may also be a factor, especially if this exposure occurred before the age of 30.

The American healthcare delivery system is a subculture as well. Some of our values may be in conflict with the values of these subculture groups. Western healthcare values organization, efficiency, scientific rather than religious explanations for illness causation, personal responsibility for preventive behaviors, and punctuality for scheduled appointments. For many women in the aforementioned subgroups, these values are not important. Nurses can help patients in these cultural subgroups feel more comfortable by acknowledging (without judgment) their cultural differences.

Patient Education

To educate women about breast cancer screening and detection it is necessary to understand the perspective each woman brings to the situation and then to determine whether she needs formal or informal teaching. Formal instruction means assessing her educational needs by asking the following questions:

• How extensive and how accurate is the information that she already has?
• Is her perception of her risk for getting the disease realistic based on her individual risk factors?
• How do the many emotional concerns surrounding the disease affect her personally?
• What obstacles does she face in following the recommended guidelines for screening and follow-up?

After the individual woman's needs have been assessed, the nurse should help her set realistic goals, use teaching strategies that help the patient attain those goals, and evaluate the results of teaching.

In selecting a teaching strategy, the nurse should focus on meeting the particular educational needs of the patient. Many nurses use informal teaching during patient education. Informal teaching occurs when nurses decrease a patient's anxiety by discussing what is involved in a diagnostic test or procedure. It may also involve teaching screening guidelines to family, friends, or neighbors. Before giving the patient any printed materials make certain that the language is clear and free of jargon, and determine whether the patient is capable of reading and understanding it. Document teaching efforts by recording who was present, what teaching materials you used, what level of comprehension the woman achieved, whether any further instruction was necessary, and whether the patient demonstrated learning.

Determine Accurate Health Messages

With the explosion of information technology in recent years, the public is often bombarded with health messages that many find overwhelming and confusing. For this reason, it is important that members of the healthcare team help patients sort through this barrage of information. Nurses are particularly suited for this role and should give women information on the benefits, risks, limitations, and controversies of the various early detection methods as well as information on new advances in breast cancer technology. To avoid confusion and noncompliance, all members of the healthcare team should work together to ensure that the messages given by one member of the team are consistent with those given by other team members.

Some practices use computer programs to present the pros and cons of the various treatment alternatives. These programs usually depict women discussing their treatment decisions and whether they were satisfied with the outcomes. These programs can spark further dialogue between the patient and her provider, which helps women feel empowered to control their own healthcare choices. Some agencies offer recorded health education messages that patients can access by telephone to inform them about available services and to remind them about the screening guidelines.

To help patients accurately understand self-examination, nurses can teach patients how to perform them (nurse practitioners may be trained to do clinical exams as well). This education can be done in a variety of settings while keeping the following points in mind:

• Explain the procedure and how it relates to her health using basic language rather than technical jargon
• When teaching the self-exam technique use the vertical strip method described earlier in this course
• Be sure to teach her the perimeters of breast tissue, the best pattern to use, and the various levels of palpation
• Tell the patient how long the procedure takes (a few minutes for small breasts, longer for larger breasts
• Stress the importance of self-exams and annual clinical exams
• Check for understanding by asking the patient to briefly summarize in her own words or demonstrate the examination technique

Because the breast is often sensitive during the 2 weeks following ovulation, experts recommend that women perform BSEs within a few days of the onset of menses. Instruct those women with irregular menstrual cycles and those who do not menstruate because they are pregnant or post menopausal to pick a day of the month on which they consistently perform the exam.

While some experts question whether skill in detecting lumps in synthetic breast models can be translated into skill in detecting lumps in one's own breast, the most effective measure of self-exam instruction to date is the ability of the patient to find lumps in the synthetic models. It seems that women who can find the synthetic lumps have a better understanding of their own breast characteristics.

It is often useful to develop a patient questionnaire to assess a woman's current self-exam practice and to help plan an individualized breast health program. Such a questionnaire should ask the following questions:

• How often do you perform regular breast self-exams? If you do not perform self-exams, why not?
• What instruction by a health professional would help you in performing regular self-exams?
• What pattern of search do you use in your exam and do you cover the entire breast area, including the nipple?
• Do you examine your breasts while lying down and while standing?
• Do you examine your breasts in a mirror?
• Do you use the pads of you fingers rather than the tips?
• Do you examine each area using three levels of palpation?

Stress that self-examination alone is not enough. Women in their 20s and 30s should have clinical breast exams at least once every Three years. Any woman over the age of 40 should obtain an annual clinical exam and a mammogram to increase the chances of detecting tumors in their early stages.

Nurses should also provide patients with accurate healthy lifestyle information. Nurses should help patients define what a healthy lifestyle means by providing information on diet, weight control, physical activity, smoking, and alcohol intake using the guidelines presented earlier in this course. Nurses should tailor the information to a patient's specific needs. For example, when giving the patient a copy of the food pyramid you might ask her what fruits and vegetables she prefers, taking into consideration her cultural background and budget constraints (see www.mypyramid.org). When talking about physical activity ask her what forms of exercise fit with her current abilities, interests, and schedule. Provide a list of community resources she can refer to later for more information, for counseling, or for classes on these topics.

When giving information on healthy eating, follow the simple dietary guidelines given by the American Cancer Society:

• eat a wide variety of foods
• choose most food from plant sources and whole grains (try to eat at least five servings of fruits and vegetables each day)
• limit intake of high-fat foods, such as meat
• maintain a healthy weight (keep body-mass index, or BMI, at 25 or less and perform aerobic exercise at least 30 minutes a day)
• limit consumption of alcoholic beverages to three drinks a week or fewer
• choose a diet moderate in salt and sugar

Nurses should also address other lifestyle-associated health messages:

• sleep at least 8 hours each night
• learn to delegate so that you don't have to do everything yourself
• reduce stress by doing only one thing at a time
• focus on the big picture rather than getting bogged down in details
• laugh daily to elevate brain endorphin levels
• develop a support system for openly sharing feelings on a regular basis
• seek balance in all aspects of life
• learn to recognize distorted thinking patterns, such as perfectionism, people pleasing, overgeneralizing, and black-and-white thinking

The incidence of breast cancer is on the rise and there is no known cure for it, especially if it is not detected until it reaches the later stages. For this reason the best outcomes result from early detection and treatment of the tumor. Early detection is aided by teaching women the risk factors that predispose them to the development of breast cancer so they are motivated to follow the early detection guidelines.

One of the major roles of the nurse in today's health care delivery system is that of health educator. Nurses are in a unique position to teach the public about risk factors for breast cancer, methods of early detection, the importance of lifestyle choices, and the differences between benign and malignant breast conditions.

To fulfill the role of health educator, however, it is imperative that today's nurses understand the many cultural differences that influence a woman's ability and willingness to comply with early detection and treatment guidelines. Some of these cultural differences are associated with various ethnic groups, whereas others are economic in nature. Nurses must be able to communicate with patients to ascertain which obstacles are preventing them from accessing care. Nurses must also be knowledgeable about community resources to which patients may be referred to help them overcome these obstacles.

In recent years, patient-provider communication has emerged as a significant factor in healthcare public relations. Studies show that those providers who take the time to communicate well have higher patient satisfaction rates and, as a result, significantly fewer lawsuits filed against them. Because nurses are often gifted in communication skills, they have a unique role to play in patient education. They can encourage patient-centered work environments, promote the use of translators for those patients who do not speak English, and remind others on the healthcare team to speak in lay terms rather than in the technical jargon often used by healthcare workers. Nurses can also play a role in determining which health care messages need to be delivered in a given situation and in determining the best method for delivering those messages. In these ways, nurses can help deliver new rays of hope to patients with breast cancer and their families.

Resources

National Breast Cancer Organization
www.networkofstrength.org

American Cancer Society
www.cancer.org

National Breast Cancer Coalition
www.stopbreastcancer.org

National Cancer Institute
www.cancer.gov

Cancer Support Community
www.thewellnesscommunity.org

Living Beyond Breast Cancer
www.lbbc.org

Suggested Readings

Berg WA, Zhang Z, Lehrer D, et al.Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk.JAMA, Apr 4 2012, 307(13) p1394-404

Bernardo LM, Abt KL, Ren D, et al.Self-reported exercise during breast cancer treatment: results of a national survey.Cancer Nurs, Jul-Aug 2010, 33(4) p304-9

Chalupka, S,Selective estrogen modulators for the primary prevention of breastcancer.AAOHN J, Jan 2011, 59(1) p48

Demshar R, Vanek R, Mazanec P,Oncologic emergencies: new decade, new perspectives.AACN Adv Crit Care, Oct-Dec 2011, 22(4) p337-48

Dolan EA, Paice JA, Wile S , Managing cancer-related pain in critical care settings.AACN Adv Crit Care, Oct-Dec 2011, 22(4) p365-78

Gates MA, Xu M, Chen WY, et al. ABO blood group and breast cancer incidence and survival. Int J Cancer, May 1 2012, 130(9) p2129-37

Held-Warmkessel J, Taming three high-risk chemotherapy complications. Nursing, Nov 2011, 41(11) p30-7