THE FEMALE BREAST

BY A.C MBULO
INTRODUCTION

• The breasts or mammary glands of mammals are important for the

survival of the new born and thus of species. They are associated
functionally with the reproductive system as organs for milk production
in the post partum woman. The female sex hormones influence the
development of breasts and the production of milk. Breasts are also
associated with feelings of sexuality and are an integral component of
sexual behaviour. The breasts especially the nipples which are erectile
tissue, are erogenous areas in sexual activity.
• The breast is composed largely of glandular tissue, but also of some fat
tissue and is covered with skin. The glandular tissue is divided into
about eighteen lobes which are completely separated by bands of
fibrous tissue. Each lobe is a self contained working unit and is
composed of the following structures:
• Alveoli: Containing the milk secreting cells. Each alveolus is lined by
milk secreting cells, the ACINI which extract from the mammary blood
supply, the factors essential for milk formation. Around each alveolus
lie myoepithelial cells sometimes called basket or spider cells. When
these cells are stimulated by oxytocin they contract, releasing milk into
the lactiferous duct.

• Lactiferous tubules: small ducts which connect the alveoli.

• Lactiferous duct: a central duct into which tubules run.

• Ampulla: The widened out portion of the duct where milk is stored. The
ampullae lie under the areola.

• Blood supply: The internal mammary artery, the external mammary

artery and the upper intercostal arteries. Venus drainage is through
corresponding vessels into the internal mammary and axillary veins.
• Lymphatic drainage: The axillary glands, with some drainage into the
portal fissure of the liner and mediastinal glands. The lymphatic vessels
of each breast communicate with one another.

• Nerve supply: The function of the breast is largely controlled by

hormone activity but the skin is supplied by branches of the thoracic
nerves. There is also some sympathetic nerve supply, especially around
the areola and nipple.
• CARCINOMA OF THE BREAST

• Breast cancer is the commonest malignant disease of women worldwide. It

is estimated that 1 in 17 of all female children born will develop the disease
during their lifetime.

• Women between forty – five and fifty five are its most frequent victims, but
many factors are known to influence its frequency. While all portions of the
breast may be involved, the disease commences in the upper outer quadrant.

• Women are encouraged to self examine their breasts frequently and should
report to their doctors as soon as a lump in the breast is discovered.
• CONTRIBUTING/PREDISPOSING FACTORS

a. Geographical: It occurs commonly in the western world, England and

Wales having a high incidence.

b. Genetic: It occurs more commonly in women with a family history of

breast cancer than in the general population.
c. Endocrine: It is common in nulliparous women than in women who
have borne many children and have breast fed. It is also less common in
women who have their first child at an early age especially if associated
with late menarche and early menopause.

d. Milk Factor: An infective agent in milk has been shown to transmit

breast cancer, though not much evidence to support this phenomenon
exists.
• SPREAD OF MAMMARY CARCINOMA

a. Local Spread: The tumour increases in size and invades other portions
of the breast. It tends to involve the skin and to penetrate the pectoral
muscle and even the chest wall.

b. Lymphatic Spread: Occurs in two ways; one by emboli composed of

carcinoma cells, being swept along the lymphatic vessels by the lymph
stream and second by permeation, that is actual growth of cancer cells
along the lumen of the lymphatic channels.
• The axillary lymph nodes and the internal mammary lymph nodes are
involved comparatively. Later the supraclavicular lymph nodes, the
opposite breast and the mediastinum are possible resting places for
carcinoma cells.
c. Spread By Blood Stream:

• It is by this route that skeletal metastasis occurs in the lumbar vertebrae,

femur thoracic vertebrae and the skull; they are generally osteolytic
pathological fractures occurring most often in a rib or a vertebra. In
most instances it is by way of the blood stream that metastases arrive in
the liver, lung fields or brain from the breast, but secondary deposits
may also be carried to the liver via the lymphatics within the rectus
sheath and the falciform ligament.
CLINICAL TYPES OF BREAST CANCER

1.Scirrhous Carcinoma: The commonest form, in middle aged or elderly

women. Owing to many fibrous tissues the lump feels very hard, while its
contour tends to be irregular. As the tumour advances, it may cause in drawing
of the nipple, the overlying and tethering to the pectoral fascia deeply. In the
late cases there may be peaud’orange, ulceration of the skin and fixation to the
chest wall. Atrophic Scirrhous Carcinoma is an uncommon variant and is seen
principally in aged, thin women with small breasts. The disease runs a very
chronic course, taking about ten or more years to ulcerate through the skin.
2. Duct Carcinoma: This presents with blood stained discharge from the
nipple. It is not seen below the age of 40.

3. Medullary Carcinoma: Accounts for 5% of all breast cancer cases and

affects a somewhat earlier age group than the average. The primary
tumour is soft and circumscribed, and may attain a large size.
4. Inflammatory Carcinoma (Mastitis Carcinoma): A very rare and highly
aggressive cancer seen usually during pregnancy and lactation. The
diseased breast is often painful, a symptom occurring in some 10% of
breast cancers. The reddened skin feels abnormally warm and cutaneous
oedema, which indicates blockage of the subdermal lymphatics with
carcinoma cells, usually extends over a considerable. There may be
retraction of the nipple.
5. Paget’s Disease of the Nipple: Is a superficial manifestation of an
underlying breast carcinoma. It presents as an eczema like condition of
the nipple and areola which persists in spite of local treatment. The
nipple is eroded slowly and eventually disappears.

6. Lipomatous carcinoma: Is a true lipoma of the breast is extremely rare.

A Scirrhous ca may sometimes contract a covering of soft breast and
subcutaneous tissue around itself to mimic a lipoma.
CLINICAL STAGING OF BREAST CANCER

• The International Union Against Cancer (IUAC) has recommended a

staging system known as TNM (Tumour, Nodes, and Metastases). The
Manchester system remains in wide use and is described as;

• a. Stage I: Growth confined to the breast. An area of adherence to or

ulceration of the skin smaller than the periphery of the tumour does not
affect staging. The tumour must not be adherent to the pectoral muscles
or the chest wall.
b. Stage II: same as stage I but these are affected mobile lymph nodes in
the axilla of the same side.

c. Stage III: skin involved or peaud’orange larger than the tumour but
still limited to the breast, tumour fixed to pectoral muscle but not to chest
wall. Homolateral axillary lymph nodes matted together or fixed to chest
wall, or homolateral supraclavicular nodes mobile or fixed, or oedema of
arm.
d. Stage IV: skin involvement wide if the breast and including cancer
encuirasse, complete fixation of tumour to chest wall, distant metastases
either blood borne or lymph borne; this include involvement of the
opposite breast or axilla and deposits in bones and viscera such as l.

• Events Resulting From Lymphatic Obstruction In Late Mammary

Carcinoma:

1.Peaud’orange; is due to cutaneous lymphatic oedema where the

infiltrated skin is tethered by the sweat ducts if cannot swell.
2.Late oedema of the arm: Elemphantiasischirurgensis a troublesome
complication of radical mastectomy, especially when post operative
radiotherapy is given. The swelling appears at a time varying from
several months to many years after operation.
3.Brawny arm: can result from advanced neoplastic infiltration or not
removed or incompletely removed axillary or supra clavicular lymph
nodes. The oedema which is persistent and brawny (it does not pit) is due
to lymphatic blockage but in some cases venous obstruction is a
contributing factor.

4.Cancer-en-cuirasses: This is accompanied by a brawny arm, the chest

wall is studded with carcinomatous nodules and the skin is so infiltrated
that it has been likened to a coat armour.
MANIFESTATIONS OF BREAST CANCER

1. Breast mass or thickening

2. Unusual lump in the under arm or above the collar bone

3. Persistent skin rash near the nipple

4. Flaking or eruption near the nipple

5. Dimpling, pulling or retraction in an area of the breast

6. Nipple discharge

7. Change in nipple position

8. Burning, stinging, or prickling sensation

• OPERABLE BREAST CANCER (STAGE I AND II)

• Some authorities advocate for surgical operations of varying magnitude,

some irradiation and others a combination of surgery and irradiation.

• AIMS OF TREATMENT

1. To ensure long term control of disease in the breast (local) and lymph nodes
(regional) area.

2. As far as is consistent with I to conserve (or restore) local and function.

3. To prevent, if possible, the evolution of those occult metastases known to

be present in a proportion of patients, no matter how thorough the staging.
• INDICATIONS FOR MASTECTOMY

1. Carcinoma of the breast

2. Cosmetic reasons

• DIAGNOSTIC TESTS

1. Clinical breast examination (CBE) inspection and palpation of the breasts and
axillae performed by a trained health professional

2. Mammogramme: A low grade dose X ray study of the breast used to detect breast
lesions

3. Percutaneous needle biopsy

4. Streotactic needle biopsy to obtain cells for histological evaluation

TREATMENT

• The choice of systemic treatment depends on the woman’s age, stage of

cancer, and other individual factors. Breast cancer tends to be more
aggressive in pre-menopausal women, probably because of hormonal
factors. Thus treatment regimes for pre-menopausal women are also
more aggressive.
A. Chemotherapy or Hormonal therapy.

• Tamoxifen Citrate (Nolvadex) is an oral medication that interferes with

oestrogen activity. It is used to treat advanced breast cancer. It prevents
recurrence of oestrogen positive breast cancer in postmenopausal
women. It inhibits tumour growth by blocking the oestrogen receptor
sites of cancer cells.
B. Radiation Therapy
• Radiation therapy is typically used following breast cancer surgery to
destroy any remaining cancer cells that could cause recurrence or
metastasis. Radiation therapy is administered by means of external
beam or tissue implants.
C. Surgery - MASTECTOMY
• Surgery nowadays is toward conservative combined with chemotherapy,
hormone therapy, or radiation, depending on the stage of the tumour and
the age of the woman.
MASTECTOMY
• There are various types of mastectomy procedures for breast cancer.
1. Radical Mastectomy is the removal of the entire affected breast, the
underlying chest muscles and the lymph nodes under the arm of the affected
side.
2. Simple Mastectomy is the removal of the complete breast only.
3. Segmental Mastectomy or Lumpectomy is the removal of the tumour and
the surrounding margins of the affected breast tissue.
4. Modified Radical Mastectomy is the removal of the affected breast tissue
and lymph nodes under the arm (axillary node dissection).
PRE – OPERATIVE NURSING CARE

• Psychological Preparation

• Although each woman has individual needs, nursing diagnoses prior to

surgery are concerned with anxiety, decisional conflicts, knowledge
deficit and grief over the impending loss of a breast.
Dealing With Anxiety
• A woman with breast cancer is often anxious about the diagnoses, the
surgery, the outcome of the surgery if nodal involvement is found, and
the possible changes in sexual and family relationships. The spouse is
equally psychologically affected.
• Provide the opportunity to express thoughts and feelings. In this
process, the woman can state her fears. Once the fears are stated, the
nurse may simply listen, educate or dispel fears that stem from lack of
understanding.
• Discuss with the woman her knowledge of breast cancer. Assessing the
woman’s knowledge of breast cancer helps the nurse plan more
effective teaching.

• Encourage discussion relating to immediate concerns about resuming

her life and duties at home and the changes she has to make.
Anticipatory guidance can help plan for and cope with changes in her
life and relationships.
• Explain the surgical procedure, including information about pre-
operative medications, anaesthesia and recovery.

• Explain that it is normal to have decreased sensation in the surgical

area. Several or damaged nerves reduce sensation.
Dealing With Decisional Conflict
• The woman with breast cancer must make life changing decisions about
treatment within a relatively brief and highly stressful time. Her age,
menopausal status, and stage of cancer are only some of the factors that
affect her decisions. Culture, values, life style, socioeconomic status,
and self esteem are also considered.
1.Provide an opportunity for the woman to ask questions, answer
questions as simply and directly as possible. Make eye contact and pay
attention to body language.
2. Focus on immediate concerns, and provide up-to-date written material
for woman to review.

3. Listen to the woman in a non judgmental manner during her decision

making process.

4. If the woman wishes, provide opportunities for her to meet with other
women who have had successful breast cancer surgery.

5. Facilitate a team approach with the surgeon, anaesthetist, oncologist,

plastic surgeon and other health professionals.
Dealing With Breathing

• Breast surgery, even lumpectomy, alters the appearance of the breast.

1. Listen attentively to the expressions of grief and watch for non verbal
cues.

2. Allow time to interact and do not rash interactions.

3. Explain that it is normal to have periods of depression, anger and
denial after breast surgery.

4. If the woman wishes to do so, involve the partner in helping the

woman to cope with her grief.

5. Ensure that the woman or family members sign an informed consent

form.
Physical Preparation

• Physical preparation is meant to ensure that the patient is made fit for
surgery and recovers without many problems.

• Observations, Assessment and Investigations

• Vital signs for baseline data and to rule out extremes as for any other
patient undergoing surgery are important. Hypertension should be
identified if any and managed so together with cardiac problems.
• Blood tests such as bleeding time, haemoglobin levels, cross matching,
blood sugar tests to rule out diabetes mellitus, urinalysis to rule out
urinary tract infections, should be done. ECG should be done to rule out
cardiac disease. Chest X ray as well to rule out chest infections should
be done.

• Nutrition Assessment

• Good nutrition and nutrition status assessment play a major role in the
patient’s recovery.
IMMEDIATE PREOPERATIVE CARE
• Assist with bathing, gowning and changing into operating room gown.
Ensure that the patient takes nothing by mouth six hours before
operation or from midnight. Provide addition teaching and reinforce
prior teaching. Ensure that identification, blood and allergy bands are
correct, legible and secure.
• Complete skin and bowel preparation as ordered. Remove any
jewellery, dentures and contact lenses and store them in a safe place.
Hair should be well secured and nail polish removed.
• Insert an indwelling catheter if possible and intravenous line. Verify that
the consent form has been signed prior to the administration of pre
operative medications.
• Verify that the height and weight of the patient are recorded in the chart
for dosage calculation of anaesthesia. Have the patient empty the
bladder immediately before the pre operative medications are
administered unless an indwelling catheter is in situ.
• Administer pre operative medications as ordered. Ensure the safety of
the patient once the preoperative medications have been administered.
Obtain and record vital signs and provide an ongoing care to the client
and her family. Document all preoperative care in the appropriate
location and complete the check list before the client is transferred to
the operating theatre. Verify with the surgical team the client’s identity
and ensure that the entire client’s information is documented
appropriately.
• Help the surgical team transfer the client from the clean side to the
sterile of the room of the operating department.

• Prepare the client’s room back on the ward for post operative care;
including making the surgical bed and ensuring that anticipated supplies
and equipment are in the room.
POST OPERATIVE NURSING CARE (SPECIFIC)

• IMMEDIATE CARE

• Immediate post operative care begins when the patient has been
transferred from the operating room to the recovery room.

1. Monitor vital signs every 30 minutes until they are stable

2. Monitor the surgical site to detect significant changes

3. Assess the mental status and level of consciousness

4. Orient the patient to time, place and persons repeatedly

5. Give emotional support because the client is a vulnerable and in a

dependable position.
6.Assess the hydration status by monitoring intake and output to detect
cardiovascular or renal complications.

7.Assess the patient’s pain levels and careful administration of

analgesics; provide comfort without compounding the potential side
effects of anaesthesia.
CARE AFTER STABILISATION

• 1.Assess the surgical for bleeding, drainage, colour and odour every
4hours for 24 hours and document your findings. Circle any visible
bleeding and drainage on the dressing as baseline for subsequent
assessment. Excessive bleeding or drainage signals post operative
complications that may require emergency attention
2. Observe the incision and intravenous sites for pain, redness, swelling
and drainage. Assess the drainage system for patency and adequate
suction; note the colour and amount of drainage. Careful observation for
signs of infection is essential because the woman’s immune system is
compromised. Intravenous catheters should be placed on the uninvolved
side only.
3. Change dressings and intravenous tubing using aseptic technique.
Moist dressings and intravenous tubing provide sites for bacterial growth
and entry. Routine dressing and intravenous tubing thus should be
changed using aseptic technique to reduce risk for infection.
4. Give and encourage a protein rich diet. Discuss the woman’s
nutritional status with the dietician and request consultation for the
woman. Adequate nutrition boosts the immune system and promotes
healing.

5.Clean the site, empty the device, and record the amount, colour and
type of drainage. If the woman is discharged with a drainage system in
place, teach her and her family how to care for the drainage system.
6.When obtaining blood pressure and starting intravenous lines, use the
non surgical side. This is because compression of the arm on the surgical
side may cause lymphoedema.

7.Elevate the affected arm on a pillow higher than the shoulder, but do
not abduct it; the hand should be higher than the elbow. Elevating the
arm permits drainage, prevents swelling, and promotes circulation.
8. Encourage range of motion exercises in the affected arm. Exercise
helps develop collateral drainage.

9.Explain that lymphoedema massage and an elastic compression

bandage may help control the swelling after she has recovered from
surgery.
PSYCHOLOGICAL CARE IN REALATION TO BODY IMAGE
DISTURBANCE
• Breast surgery can change the woman’s body image. The surgical
changes may be compounded by weight gain and other side effects of
chemotherapy or hormone therapy. Self esteem also affects adjustment
to a changed body image.
1. Assess how the woman views her body. Discuss with the woman what
image of herself she had prior to surgery. Self image is related to self
esteem. Discuss whether herself image has changed.
2. Explain that redness and swelling in the scar will subside with time.
The knowledge that the scar will subside may give the woman a more
realistic view of the changes.
3. Include the partner and family if possible on discussing the plan of
care and activities of daily living. Discussing with the partner and the
family can facilitate the woman’s emotional healing process.
4. Offer pamphlets and suggest books and videos that might increase
knowledge about what lies ahead. Knowing what to expect can help the
woman cope.
5. Encourage the woman to look at her incision when she feels ready;
often the reality is not as frightening as the woman had imagined.
Explain that it is normal to be afraid to look.

6. It the woman is interested in breast reconstruction, provide written

material and encourage her to talk with a plastic surgeon and with women
who have had successful reconstruction. It is important that the woman is
fully informed about available options to make an informed decision.
HOME CARE/TEACHING AT DISCHARGE

1. At discharge, teach the woman to watch for and report to her health
care provider the manifestation of infection; fever, redness or hardness at
the surgical site or purulent drainage. Any of these manifestations should
be reported to physician/surgeon. Knowing signs and symptoms of
infection prepares the woman to seek prompt treatment if infection
occurs.
2. Explain that she may experience scaling, flaking, dryness, itching rash
or dry desquamation of the skin, particularly after radiation therapy.
Impaired skin integrity increases the risk of infection.

3. Tell the woman to avoid deodorants and talcum powder on the affected
side until the incision is completely healed. These substances may irritate
the skin and impede healing.

4. The woman with breast cancer and her family have much to learn to
provide health care at home. Thus:
a. Teach manifestations of infection and the need to report any that occur
to her health care provider.

b. Teach them the importance of activities of daily living, such as eating,

combing her hair and washing face.

c. Post mastectomy exercises as discussed with the physician and

physiotherapist.

d. The need for adequate rest and emotional support.

• Participation in a breast cancer support group and on-line information
services and bulletin boards for sources of education and support.

f. Teach about prosthesis management, if this option is chosen (a

temporally light weight prosthesis may be worn immediately after the
drains and sutures have been removed from the surgical site. A
permanent one should be purchased until the wound has completely
healed).
RECOMMENDED EXERCISES AFTER MASTECTOMY

1. Wall climbing: stand facing the wall with toes 6 – 12 inches from the
wall. Bend elbows and place palms against the wall at shoulder level.
Gradually move both arms up the wall parallel to each other incisional
pulling or pain occurs.
2. Overhead pulley: Using operated arm; toss over 6 foot rope over shower
curtain rod. Grasp one end of the rope in each hand. Slowly raise operated
arm as far as comfortably by pulling down on the rope on opposite side.

3. Rope turning: Tie the rope to the door handle. Hold the rope in hand of the
operated side. Back way from door until the arm is extended away from the
body, parallel to the floor.

4. Arm swings: Stand with feet 8 inches apart. Bend forward from the waist,
allowing arms to hang towards the floor. Swing both arms up to the sides.
COMPLICATIONS FOLLOWING MASTECTOMY

1. Infection

2. Fibrous tissue formation or kelloids

3. Emphysema

4. Lymphoedema

5. Haemorrage