COLLABORATIVE

Treatment and prognosis for breast cancer are based on the stage of disease at diagnosis according to the TNM classification (T = tumor size, N = involvement of regional lymph nodes, M = metastasis) (Table 4). It is now recognized that treatment of breast cancer requires a multimodal approach. Surgery and radiation, either alone or in combination, control cancer in the breast and regional lymph nodes. Chemotherapy and hormonal therapy are intended to provide systemic control. Adjuvant therapy (pharmacologic treatment given to patients with no detectable cancer after surgery) is often recommended because cancer cells can break away from the primary breast tumor and begin to spread through the bloodstream, even in the early stages of disease. These cells cannot be felt or detected on x-ray.

TNM Classification: Staging for Breast Cancer

STAGE	SIZE	INVOLVEMENT
I	C 2 cm	No node involvement, no metastasis
II	Up to 5 cm	May have axillary node involvement, no metastasis
III	Varied (any size)	Extended to skin or chest wall, nodes involved (immovable axillary nodes)
IV	Varied	Distant metastasis with ipsilateral supraclavicular nodes

SURGICAL. The goal of surgery is control of cancer in the breast and the axillary nodes. Most women have a choice of surgical procedures, but it depends on the clinical stage, tumor location, contraindications to radiation (pregnancy, collagen disease, prior radiation, multifocal tumors), and the presence of other health problems. Several types of surgical therapy are commonly available, as follows.

MODIFIED RADICAL MASTECTOMY (TOTAL MASTECTOMY). The most common surgical procedure for mastectomy removes the entire breast and some or all of the axillary nodes as well as the lining over the pectoralis major muscle. At times, the pectoralis minor muscle is removed. Contralateral prophylactic mastectomy (CPM) is being implemented in ductal carcinoma in situ (DCIS) to decrease risk of cancer in the opposite breast. Rates of CPM have increased 148% from 1998 to 2005.

BREAST-PRESERVING SURGERIES. The breast-preserving surgeries combined with radiotherapy are recognized to be equivalent to modified radical mastectomy for stages I and II breast cancer for survival rates and local control.

Sentinel lymph node biopsy, a procedure using a radioactive tracer to determine which lymph nodes need to be removed during a mastectomy, is under investigation. This procedure allows fewer lymph nodes to be removed, decreasing the uncomfortable side effect of lymphedema that can occur with surgery.

COMPLICATIONS OF SURGERY. The complications of breast surgery may be infection, seroma (fluid accumulation at the operative site), hematoma, limited range of motion (ROM), sensory changes, and lymphedema. A seroma is usually prevented with the placement of a gravity drainage device (Hemovac, Jackson-Pratt) in the site for up to 7 days postoperatively. Drains are usually removed when drainage has decreased to about 30 cc per day. ROM for the lower arm is begun within 24 hours postoperation, and full ROM and other shoulder exercises are ordered by the surgeon after the drains are removed. Sensory changes include numbness, weakness, skin sensitivity, itching, heaviness, or phantom sensations that may last a year.

RADIATION THERAPY. Radiotherapy is routinely given 2 to 4 weeks after breast-preserving surgery for stages I and II breast cancer. Sometimes, it is indicated after modified radical surgery if four or more nodes are positive. The incision needs to be healed, and ROM of the shoulder should be restored. Radiotherapy may consist of an external beam to the breast for 4 to 6 weeks or by an experimental method called brachytherapy (interstitial iridium-192 implants) directly to the tumor site, or both. Radiation can be given at the same time as chemotherapy.

CHEMOTHERAPY/HORMONAL THERAPY. Combination chemotherapy is recommended for premenopausal and postmenopausal patients with positive nodes. Hormonal therapy is used to change the levels of hormones that promote cancer growth and increase survival time in women with metastatic breast cancer. Tumors with a positive ER assay (tumors that need estrogen to grow) have a response rate to hormonal therapy of 65% compared with a 10% response rate with negative ER assay. PR assays that are also positive enhance endocrine therapy response even more. There is a 77% response rate if both ER and PR are positive, as compared with a 5% response rate if both are negative.

AUTOLOGOUS BONE MARROW TRANSPLANT (ABMT). Certain patients (with chemosensitive tumors) with stage III cancer are being treated with high-dose chemotherapy preceded by removal of the patient's bone marrow, which is then restored after chemotherapy.

RECONSTRUCTION. Approximately 30% of women who have mastectomies choose to have breast reconstruction (Table 5).

Types of Breast Reconstructive Surgery

TYPE	DESCRIPTION
Saline-filled implants	A tissue expander is placed under the pectoralis muscle and expanded slowly over months with saline injections. The expander is removed and replaced with a permanent saline implant. The expander may be the adjustable type, serving a dual purpose of expanding and permanent implant.
Autologous tissue transfer	Surgical procedure uses the woman's own tissue to form a breast mound. In two procedures (latissimus dorsi flap of the transverse rectus abdominus muscle [TRAM]), the surgeon tunnels a wedge of muscle, fascia, subcutaneous tissue, and skin to the mastectomy site. In free-flap reconstruction (free tissue transfer), the surgeon uses a microvascular technique to transfer a segment of skin and subcutaneous tissue with its vascular pedicle to the chest wall.

Almost all patients who have mastectomies are candidates. It can be immediate (at the time of mastectomy) or delayed for several years.

Postoperatively, use a flow sheet every hour and assess adequate blood supply to the flap and donor site by evaluating the following: color (to verify that it is the same as skin from the donor area [not opposite breast]); temperature (warm); tissue turgor (to verify that it is not tight or tense); capillary refill (well-perfused flap will blanch for 1 to 3 seconds); and anterior blood flow using ultrasonic or laser Doppler. Unusual pain or decreased volume of drainage may indicate vascular impairment to the flap. Early detection of impaired circulation can be treated with anticoagulants or antispasmodics and possibly prevent further surgical interventions. Provide emotional support for the patient who is distraught over her appearance to reassure her the breast will look more normal with healing. The nipple and areola can be added 6 to 9 months later.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
• Cyclophosphamide + methotrexate + fluorouracil (CMF) • Cyclophosphamide + doxorubicin (Adriamycin) + fluorouracil (CAF) • Doxorubicin (Adriamycin) + cyclophoshpamide (AC) with or without paclitaxel (Taxol) • Doxorubicin followed by CMF Cyclophosphamide + epirubicin + fluorouracil	Depends on drug, stage of cancer, and patient condition	Antineoplastics	Interfere with growth of cancer; often used in combination
Tamoxifen citrate	10–20 mg PO bid or 20 mg PO qd for 5 yr	Antiestrogen	Provides hormonal control of cancer growth; adjuvant treatment after a mastectomy; also used to prevent breast cancer in high-risk women
Trastuzumab (Herceptin)	4 mg/kg loading dose; 2 mg/kg maintenance, IVPB	Recombinant DNA–derived humanized monoclonal antibody	Indicated only for HER2/neu receptive tumors; decreases breast cancer growth and stimulates immune system to more effectively attack the cancer
Acetaminophen; NSAIDs; opioids; combination of opioid and NSAIDs	Depends on the drug and the patient's condition and tolerance	Analgesics	Choice of drug depends on the severity of the pain

Other Therapies: Docetaxel, capecitabine, vinorelbine, and gemcitabine hydrochloride; antiestrogen medications include fulvestrant; letrozole (taken after 5 years of tamoxifen to lower breast cancer reoccurrence).

INDEPENDENT

The focus of nursing care for a patient with a mastectomy during the 2- to 3-day hospital stay is directed toward early surgical recovery. Teach pain management, mobility, adequate circulation, and self-care activities to prepare the patient for discharge. In the immediate postoperative period, keep the head of the bed elevated 30 degrees, with the affected arm elevated on a pillow to facilitate lymph drainage. Instruct the patient not to turn on the affected side. Place a sign at the head of the bed immediately after surgery with directions for no blood pressures, blood draws, injections, or intravenous lines on the arm of the operative side; this should help prevent circulatory impairment.

Emphasize the importance of ambulation and using the operative side within 24 hours. Initially, the arm will need to be supported when the patient is out of bed. As ambulation progresses, encourage the patient to hang her arm at her side normally, keeping her shoulders back to avoid the hunchback position and to prevent contractures. Within 24 hours, begin with exercises that do not stress the incision.

Teach the patient how to empty the drainage device (Hemovac or other), measure the drainage accurately, and observe for the color and consistency of the drainage. Create a flow sheet for record-keeping in the hospital, and send it home with the patient to use until the drain is removed. At the dressing change, begin teaching the dressing change procedure and the indications of complications such as infection (purulent drainage, redness, pain), presence of fluid collection, or hematoma formation at the incision. Be sensitive to the patient's reactions upon seeing the incision for the first time with full realization that her breast is gone. Explain that phantom breast sensations and numbness at the operative site along the inner side of the armpit to the elbow are normal for several months because of interruptions of nerve endings.

Women may have feelings of loss not only of their breast but also of lifestyle, social interactions, sexuality, and even life itself. Patients often feel more comfortable expressing their feelings with nurses than with family members or the physician. Effective coping requires expression of feelings. Discuss the services and goals of Reach to Recovery (psychological and physical support). If the patient is willing, arrange for an in-hospital visit or early home visit.