Breast cancer is a major problem in the United States. Its overall incidence rose by 54% between 1950 and 1990. In the 1990s, the incidence leveled off and stabilized (American Cancer Society [ACS], 2002). At present, there is no cure for breast cancer. Between 1990 and 1994, the mortality for breast cancer decreased by 5. 6%, the largest short-term decline in more than 40 years, suggesting that the combination of early detection and better systematic treatment option is having an effect on overall survival.
Current statistics indicate that a woman’s lifetime risk for developing breast cancer is 1 in 8, but this risk is not the same for all age groups. For example, the risk for developing breast cancer by age 35 years is 1 in 622; the risk for developing breast cancer by age 60 years is 1 in 23. Approximately 80% of breast cancers are diagnosed after the age of 50. According to the American Cancer Society, more than 193,000 cases of breast cancer are diagnosed each year, with estimated 40,000 deaths. About 1% of these cancers occur in men.
Women who are diagnosed with early-stage localized breast cancer have a 5-year survival rate of 98% (ACS, 2002). This paper discusses the pathophysiology and treatment of breast cancer and relates this pathophysiology and treatment to the impact they have on the life of the person undergoing the cancer treatment. II. Background A. Current Research in Breast Cancer Because of the incidence, significant mortality, and lack of a cure, breast cancer survivors, advocates, and activities have brought social and political attention to this disease and put in the national spotlight.
Activists have demanded and obtained increased federal funding for a national program aimed at finding a cure for breast cancer. Preventing the development of cancer through the use of medications is a relatively new and exciting area of research. In April 1998, the results of the Breast Cancer Prevention Trial were released to the general public. This nationwide, randomized, double-blind, placebo-controlled clinical trial evaluated tamoxifen (Nolvadex) versus a placebo in more than 13,000 women considered to be at high risk for the development of breast cancer.
The women who received tamoxifen had a 45% reduction in the incidence of breast cancer (Fisher et al. , 1999). These results suggested that tamoxifen was an effective chemopreventive agent. Much attention has been focused on this medication, and it is now available with FDA approval for high-risk women. Clinicians are still unclear, however, about who should receive the medication, and no consensus exists. Nurses can provide information to patients on the benefits, risks, and possible side effects of tamoxifen to help women in considering this option. Another agent that shows promise for chemoprevention is raloxifene (Evista).
This medication is FDA approved for the prevention of osteoporosis; however, in the studies that have been performed, incidental findings indicated that fewer of the women who received raloxifene developed breast cancer (Cummings, Eckert, Kreuger et. al, 1999). This has led to the hypothesis that this drug may also be an effective chemopreventive agent. Researchers are conducting another nationwide, randomized clinical trial, the Study of Tamoxifen and Raloxifene, which is comparing these two agents in postmenopausal women for the prevention of breast cancer.
Twenty-two thousand women are needed for this trial, so results will not be available until later in the decade. III. Discussion A. Prophylactic Mastectomy Some women who are at high risk for breast cancer may elect to undergo prophylactic mastectomy. This procedure can reduce the risk for cancer by 90% (Hartmann et al. , 2000), so as more appropriate term for this surgery is “risk-reducing” mastectomy. The procedure, performed by a breast surgeon, consists of a total mastectomy (removal of breast tissue only).
Possible candidates are women with a strong family history of breast cancer, a diagnosis of LCIS or atypical hyperplasia, a diagnosis of BRCA-1 or BRCA-2 gene mutation, an extreme fear of cancer (“cancer phobia”), or previous cancer in one breast. Many women opt for immediate reconstruction with the mastectomy. The woman needs to understand that this surgery is elective and not emergent. To be sure that she understands the implications of surgery, the woman should be offered a consultation with a plastic surgeon, a genetic counseling session, and a psychological evaluation.
Women who make an informed decision tend to demonstrate more satisfaction with the cosmetic results (Rowland, 2003). Nursing interventions for the woman considering a risk-reducing mastectomy include ensuring that the patient has information about reconstructive options and providing referrals to the plastic surgeon, genetic counselor, and psychological counselor. Many women need time to think over the procedure, and the nurse can be helpful in answering questions about the procedure and its implications and in assisting the patient to decide whether the surgery is an appropriate option.
The woman considering this option may wish to talk with a woman who ahs had the procedure. B. Etiology There is no single, specific cause of breast cancer; rather, a combination of hormonal, genetic, and possibly environmental events may contribute to its development. Hormones produced by the ovaries have an important role in breast cancer. Two key ovarian hormones, estradiol and progesterone, are altered in the cellular environment by a variety of factors, and these may affect growth factors for breast cancer. • Hormones The role of hormones and their relationship to breast cancer remain controversial.
Research suggests that a relationship exists between estrogen exposure and the development of breast cancer. In laboratory studies, tumor grows much faster when exposed to estrogen, and epidemiologic research suggests that women who have longer exposure to estrogen have a higher risk for breast cancer. Early menarche, nulliparity, childbirth after 30 years of age, and late menopause are known but minor risk factors. The assumption is that these factors are all associated with prolonged exposure to estrogen because of menstruation.
The theory is that each cycle (which has high levels of endogenous estrogen) provides the cells of the breast another chance to mutate, increasing the chance for cancer to develop. Estrogen itself does not cause breast cancer, but it is associated with its development. • Genetics Growing evidence indicates that genetic alterations are associated with the development of breast cancer. These genetic alterations include changes or mutations in normal genes and the influence of proteins that either promote or suppress the development of breast cancer.
Genetic alterations may be somatic (acquired) or germline (inherited). To date, two gene mutations have been identified that may play a role in the development of breast cancer. A mutation in the BRCA-1 gene has been linked to the development of breast and ovarian cancer, whereas a mutation in the BRCA-2 gene identifies risk factors for breast cancer, but less so for ovarian cancer (Houshmand, 2000). These gene mutations may also play a role in the development of colon, prostate, and pancreatic cancer, but this is far from clear at present.
It has been estimated that 1 of 600 women in the general population has either mutation; the risk foe developing breast cancer can range 50% to 90% (Kauff & Satagopan, 2002). At present, only 5% to 10% of all breast cancers are estimated to be associated with the BRCA-1 or BRCA-2 gene mutations. It is thought, however, that breast cancer is genetic and that up to 80% of women diagnosed with breast cancer before age 50 years have a genetic component to their disease (Boyd, 2005).
This is believed to be linked to either unidentified BRCA-1 or BRCA-2 carriers or less penetrating genes that have yet to be identified through genetics research. A woman’s risk for either BRCA-1 or BRCA-2 should be interpreted with caution and with an exhaustive look at all her other risk factors; this is usually carried out by a genetics counselor. Abnormalities in either of the two genes can be identified by a blood test; however, women should be counseled about the risks and benefits before actually undergoing genetic testing. The risks and benefits of a positive or negative result should be explored.
Treatment options for a positive result are long-term surveillance, bilateral prophylactic mastectomy, or chemoprevention with tamoxifen as discussed previously. A positive result can cause tremendous anxiety and fear, can unleash potential discrimination in employment and insurability, and can cause a woman to search for answers that may not be available. A negative result can produce survivor guilt in a person with a strong family history of cancer. For these women, the risk for breast cancer is similar to that of the general population, and routine screening guidelines should be followed.
The decision to pursue genetic testing must be made carefully, and women should be asked what they will do differently after they know the results. Furthermore, because testing is relatively new and health care providers have yet to determine a true benefit from a positive or negative result, genetic testing should be done under the auspices of clinical research protocols to protect the patient (because these data are kept separate from the patient’s medical record). Nurses play a role in educating patients and their family members about the implications of genetic testing.
Ethical issues related to genetic testing include possible employment discrimination, bias in insurability and possibly with insurance rates, and family members’ concerns (eg, effect on siblings, children). C. Risk Factors Although there are no specific known causes of breast cancer, researchers have identified a cluster of risk factors. These factors are important in helping to develop prevention programs. However, nearly 60% of women diagnosed with breast cancer have no identifiable risk factors other than their hormonal environment (Vogel, 2000).
Thus, all women are considered at risk for developing breast cancer during their lifetime. Nonetheless, identifying risk factors provides a means for identifying women who may benefit from increased surveillance and early treatment. In addition, further research into risk factors will help in developing strategies to prevent or modify breast cancer in the future. A high-fat diet was once thought to increase the risk of breast cancer. Epidemiologic studies of American and Japanese women showed that American women had a fivefold higher rate of breast cancer.
Japanese women who moved to the United States were shown to have breast cancer rates similar to their Caucasian counterparts. Recent cohort studies show only weak or inclusive relationships between a high-fat diet and breast cancer (Brown, 2001). Because fat intake is implicated in colon cancer and heart disease, however, women may benefit from lowering their intake of fat. Oral contraceptives were once thought to increase the risk for breast cancer. Currently, no association is thought to exist in women in the general population, but there are no data about the effect on women considered to be at high risk (Vogel, 2000).
The role of smoking in breast cancer remains unclear. Most studies suggest that smoking does not increase a woman’s risk for breast cancer. Some studies, however, suggest that smoking does increase the risk for breast cancer and that earlier a woman begins smoking, the higher the risk. Smoking does increase the risk for lung cancer, which is the leading cause of death in women with cancer (breast cancer is second). Smoking cessation is part of a healthy lifestyle, and nurses have a key role in providing women with information about smoking cessation programs.
Silicon breast implants can be associated with fibrous capsular contraction, and some women and medical professionals have claimed an association with certain immune disorders. There is no evidence, however, that breast implants are associated with an increased risk of breast cancer (Vogel, 2000). D. Protective Factors Certain factors may be protective in relation to the development of breast cancer. Regular, vigorous exercise has been shown to decrease risk, perhaps because it can delay menarche, suppress menstruation, and, like pregnancy, reduce the number of ovulatory menstrual cycles.
Also, exercise decreases body fat, where estrogens are stored and produced from other steroid hormones. Thus, decreased body fat can decrease extended exposure to estrogen. Breastfeeding is also thought to decrease risk because it prevents the return of menstruation, again decreasing exposure to endogenous estrogen. Having had a full-term pregnancy before the age of 30 years is also thought to be protective. Protective hormones are released after delivery of the fetus, with the purpose of reverting to normal the proliferation of cells in the breast that occur with pregnancy (Brown, 2001). E. Assessment and Diagnostic Findings
Techniques to determine the histology and tissue diagnosis of breast cancer include FNA, excisional (or open) biopsy, incisional biopsy, needle localization, core biopsy, and stereotactic biopsy. Other pathologic features and prognostic tests are used to identify different patient groups that may benefit from adjuvant treatment. Histologic examination of the cancer cells helps determine the prognosis and leads to a better understanding of how the disease progresses. F. Quality of Life and Breast Cancer Despite current treatment, there has been only a slight overall improvement in survival for breast cancer patients.
Consequently, quality-of-life considerations have become important issues in treatment and recovery. Quality of life is a multidimensional construct that includes functional (self-care) status, social and family functioning, and psychological and spiritual well-being. These parameters are important indicators of how well a patient is functioning after diagnosis and treatment. Breast cancer is the most frequently investigated cancer in quality-of life studies. Early psychosocial studies emphasized that the loss of the breast was the single most important factor in women’s adjustment, especially in Western cultures.
Thus, it is not surprising that study of women’s adjustment to breast cancer found similar results. A growing body of research, however, indicates that concerns related to uncertainty about the future, day-to-day issues at in work family relationships, and demands of illness are more important factors in adjusting to having breast cancer than loss of the breast alone. For example, younger women are more vulnerable to issues of psychosocial adjustment than many older women (Hoskins & Haber, 2000). They worry about their jobs and whether they will be able to keep their health care benefits.
They are concerned about their work productivity and career advancement (Wonghongkul & Moore, 2000). They face many family concerns related to whether they can have children, whether they will live to see their children grow up, and whether their disease will recur and incapacitate them (Horden, 2000). Middle-aged women worry about their disease in relation to their family and work (Walker, 1999). They also worry about their aging parents and whether they will be able to care for them in the future. They are increasingly concerned about their daughter’s risk for breast cancer.
Older women are more vulnerable top chronic health problems. Living an average of 6 years longer than men, older women face loss of their social circles, must deal with the potential for other diseases, and worry about whether they will have the resources to pay for medications. These concerns are intertwined with the effects of breast cancer on the family. Studies indicate that up to 35% of families of breast cancer patients experience significant changes in family functioning. More than 25% of children also experience problems related to their mothers’ breast cancer (Hilton, 2003).
In addition, families shoulder substantial costs in caring for the family members with advanced breast cancer. These out-of-pocket, unreimbursed expenses include lost wages and salaries and lost opportunities. When faced with any life-threatening illness, spiritual and existential concerns usually surface. Patients with breast cancer often express the need to talk about the uncertainties of their future and their hope and faith that they will be able to manage whatever crisis or challenge comes their way. IV. Conclusion The recurrence of breast cancer can be very difficult for patients and family members.
Depending on the clinical presentation, progression of the disease can have different meanings. Generally, the longer the disease-free interval, the better the prognosis. Local recurrence either in the affected breast or along the chest wall can be treated, generally with surgery, radiation, or hormonal manipulation; although a metastatic disease workup may be in order to look for further evidence of disease. Although metastatic spread of the breast cancer (to the bone, lungs, brain, or liver) cannot be cured, a variety of treatments are available (chemotherapy, radiation treatment, hormonal manipulation, or possibly come form of forgery).
In some patients, metastases progress very slowly and life functioning is generally not affected, and death from the complications of metastatic disease is inevitable. The patient with advanced breast cancer is monitored closely for signs that the tumor has recurred or that metastasis has occurred. The following studies are conducted to monitor for spread of disease. Reference: 1. American Cancer Society [ACS], 2002. Cancer facts and figures. Atlanta: American Cancer Society. 2. Boyd, J. (2005). BRCA2 as a low penetrance cancer gene.
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