3. Detail the necessary review of systems and what would be seen on physical examination for this complaint/problem.

Criteria I – Introduction (4 points)

1. Describe the common complaint/problem selected- breast cancer

2. Discuss the pathophysiology of the common complaint/problem.

3. Detail the necessary review of systems and what would be seen on physical examination for this complaint/problem.

4. Provide rationale from the literature to support your work.

In the United State, breast cancer is the leading cause of cancer death among female. Breast cancer ranks second (after lung cancer) as a cause of cancer death in women. In 2016, around 245, 229 new cases of female breast cases reported, and 41,487 women died of this disease (CDC, 2019). In 2018, approximately 63,960 cases of in situ disease and 266,120 cases of invasive disease were diagnosed.1 About 40,920 breast cancer-related deaths occurred in 2018, which represents 6.7% of all cancer-related deaths.2 Female breast cancer is most common in middle-aged and older women; median age at diagnosis is 62 years.2 In 2016, more than 3.5 mil- lion women were breast cancer survivors.3 The lifetime risk of developing breast cancer in the United States is 12.4% (1 in 8 women ). (ACS, 2019)

Breast cancer mortality was 41% higher among black women (29.2 deaths per 100,000 population) than white women (20.6 deaths per 100,000 population). Breast cancer death rates decreased during 2010–2014 among both blacks and whites, although differences in trends by race and age were found. Overall, breast cancer death rates decreased faster among white women (-1.9% per year) compared with black women (-1.5% per year). Among women aged <50 years, breast cancer death rates decreased at the same pace among black and white women, whereas white women aged ≥50 years had significantly larger decreases. The largest difference by race was observed among women aged 60–69 years: breast cancer death rates decreased 2.0% per year among white women compared with 1.0% among black women. Death rates from breast cancer have been declining since about 1990, in part due to better screening and early detection, increased awareness, and continually improving treatment options, decline in prescriptive hormone replacement therapy after menopause. (ACS, 2019).

Breast cancer is a disease in which cells in the breast grow out of control. The majority of breast cancers (95%) are sporadic; only a small proportion, particularly those diagnosed in young women, are due to a highly penetrant autosomal-dominant trait. Over the past 5 years there has been consider- able progress in the identification and localization of the genes responsible for hereditary breast cancer. Two in particular have grabbed the headlines; these are BRCA1 and BRCA2. Subtypes of breast cancer include those driven by specific hormones, such as estrogen, progestogen or the protein HER2. Sixty percent of breast cancers are estrogen positive. Twenty percent of breast cancers are HER2-positive. Another 20 percent are triple-negative breast cancers, a type of breast cancer that tests negative for estrogen, progesterone and HER2. Triple-negative breast cancer is among the more aggressive forms of the disease.There are different kinds of breast cancer. The kind of breast cancer depends on which cells in the breast turn into cancer. Breast cancer can begin in different parts of the breast. A breast is made up of three main parts: lobules, ducts, and connective tissue. The lobules are the glands that produce milk. The ducts are tubes that carry milk to the nipple. The connective tissue (which consists of fibrous and fatty tissue) surrounds and holds everything together. Most breast cancers begin in the ducts or lobules.

Breast cancer can spread outside the breast through blood vessels and lymph vessels. When breast cancer spreads to other parts of the body, it is said to have metastasized. Most breast cancer are adenocarcinomas.

The most common kinds of breast cancer are

· Invasive ductal carcinoma. The cancer cells grow outside the ducts into other parts of the breast tissue. Invasive cancer cells can also spread, or metastasize, to other parts of the body.

· Invasive lobular carcinoma. Cancer cells spread from the lobules to the breast tissues that are close by. These invasive cancer cells can also spread to other parts of the body.

There are several other less common kinds of breast cancer, such as Paget’s disease , r medullary, mucinous, and inflammatory breast cancer.

Early inflammatory breast cancer may include persistent itching and the appearance of a rash or small irritation similar to an insect bite. The breast typically becomes red, swollen, and warm.  The skin may appear pitted like an orange peel, and nipple changes such as inversion, flattening, or dimpling may occur.

Ductal carcinoma in situ (DCIS) is a breast disease that may lead to breast cancer. The cancer cells are only in the lining of the ducts and have not spread to other tissues in the breast.

The main factors that influence your breast cancer risk are being a woman and getting older. Other risk factors include—

· Changes in breast cancer-related genes (BRCA1 or BRCA2).

· Having your first menstrual period before age 12.

· Never giving birth or being older when your first child is born.

· Starting menopause after age 55.

· Taking hormones to replace missing estrogen and progesterone

in menopause for more than five years.

· Taking oral contraceptives (birth control pills).

· A personal history of breast cancer, dense breasts, or some other

breast problems.

· A family history of breast cancer (parent, sibling, or child).

· Getting radiation therapy to the breast or chest.

· Being overweight, especially after menopause.

While  BRCA1 and BRCA2 gene mutations  may increase your odds of developing breast cancer, your odds of having either mutation are pretty small. An estimated 0.25% of the general population carries a mutated BRCA gene, or about one out of every 400 people.

If one of your parents has a BRCA mutation, you have a 50% chance of inheriting the mutated gene.

Odds can also vary depending on a person’s ethnicity. For example, people of Ashkenazi Jewish descent have a 2.5% chance of inheriting a BRCA mutation, or about 10 times the rate of the general population. It’s estimated that 55 – 65% of women with the BRCA1 mutation will develop breast cancer before age 70. Approximately 45% of women with a BRCA2 mutation will develop breast cancer by age 70.

Some things may increase your risk

The main factors that influence your breast cancer risk are being a woman and getting older. Other risk factors include—

· Changes in breast cancer-related genes (BRCA1 or BRCA2).

· Having your first menstrual period before age 12.

· Never giving birth, or being older when your first child is born.

· Starting menopause after age 55.

· Taking hormones to replace missing estrogen and progesterone

in menopause for more than five years.

· Taking oral contraceptives (birth control pills).

· A personal history of breast cancer, dense breasts, or some other

breast problems.

· A family history of breast cancer (parent, sibling, or child).

· Getting radiation therapy to the breast or chest.

· Being overweight, especially after menopause.

Pathology

Most breast cancers are epithelial tumors that develop from cells lining ducts or lobules; less common are nonepithelial cancers of the supporting stroma (eg, angiosarcoma, primary stromal sarcomas, phyllodes tumor).

Cancers are divided into carcinoma in situ and invasive cancer.

Carcinoma in situ is proliferation of cancer cells within ducts or lobules and without invasion of stromal tissue. There are 2 types:

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

· Lobular carcinoma in situ (LCIS): LCIS is often multifocal and bilateral. There are 2 types: classic and pleomorphic. Classic LCIS is not malignant but increases risk of developing invasive carcinoma in either breast. This nonpalpable lesion is usually detected via biopsy; it is rarely visualized with mammography. Pleomorphic LCIS behaves more like DCIS; it should be excised to negative margins.

Invasive carcinoma is primarily adenocarcinoma. About 80% is the infiltrating ductal type; most of the remaining cases are infiltrating lobular. Rare types include medullary, mucinous, metaplastic, and tubular carcinomas. Mucinous carcinoma tends to develop in older women and to be slow growing. Women with these rare types of breast cancer have a much better prognosis than women with other types of invasive breast cancer.

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

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

Pathophysiology

Breast cancer invades locally and spreads through the regional lymph nodes, bloodstream, or both. Metastatic breast cancer may affect almost any organ in the body—most commonly, lungs, liver, bone, brain, and skin.

Most skin metastases occur near the site of breast surgery; scalp metastases are also common. Metastatic breast cancer frequently appears years or decades after initial diagnosis and treatment.

Hormone receptors

Estrogen and progesterone receptors, present in some breast cancers, are nuclear hormone receptors that promote DNA replication and cell division when the appropriate hormones bind to them. Thus, drugs that block these receptors may be useful in treating tumors with the receptors. About two thirds of postmenopausal patients with cancer have an estrogen-receptor positive (ER+) tumor. Incidence of ER+ tumors is lower among premenopausal patients.

Another cellular receptor is human epidermal growth factor receptor 2 (HER2; also called HER2/neu or ErbB2); its presence correlates with a poorer prognosis at any given stage of cancer. In about 20% of patients with breast cancer, HER2 receptors are overexpressed. Drugs that block these receptors are part of standard treatment for these patients.

Some warning signs of breast cancer are—

· New lump in the breast or underarm (armpit).

· Thickening or swelling of part of the breast.

· Irritation or dimpling of breast skin.

· Redness or flaky skin in the nipple area or the breast.

· Pulling in of the nipple or pain in the nipple area.

· Nipple discharge other than breast milk, including blood.

· Any change in the size or the shape of the breast.

· Pain in the breast.

Symptoms of breast tumors vary from person to person. Very often breast tumor discovered by patient as breast mass or during routine physical examination or mammography. Some common, early warning signs of breast cancer include:

· Skin changes, such as swelling, redness, or other visible differences in one or both breasts

· An increase in size or change in shape of the breast(s)

· Changes in the appearance of one or both nipples

· Nipple discharge other than breast milk

· General pain in/on any part of the breast

· Lumps or nodes felt on or inside of the breast

Symptoms more specific to invasive breast cancer are:

· Irritated or itchy breasts

· Change in breast color

· Increase in breast size or shape (over a short period of time)

· Changes in touch (may feel hard, tender or warm)

· Peeling or flaking of the nipple skin

· A breast lump or thickening

· Redness or pitting of the breast skin (like the skin of an orange) 

Symptoms and Signs

Many breast cancers are discovered as a mass by the patient or during routine physical examination or mammography. Less commonly, the presenting symptom is breast pain or enlargement or a nondescript thickening in the breast.

Paget disease of the nipple manifests as skin changes, including erythema, crusting, scaling, and discharge; these changes usually appear so benign that the patient ignores them, delaying diagnosis for a year or more. About 50% of patients with Paget disease of the nipple have a palpable mass at presentation.

A few patients with breast cancer present with signs of metastatic disease (eg, pathologic fracture, pulmonary dysfunction).

A common finding during physical examination is asymmetry or a dominant mass—a mass distinctly different from the surrounding breast tissue. Diffuse fibrotic changes in a quadrant of the breast, usually the upper outer quadrant, are more characteristic of benign disorders; a slightly firmer thickening in one breast but not the other may be a sign of cancer.

More advanced breast cancers are characterized by one or more of the following:

· Fixation of the mass to the chest wall or to overlying skin

· Satellite nodules or ulcers in the skin

· Exaggeration of the usual skin markings resulting from skin edema caused by invasion of dermal lymphatic vessels (so-called peau d’orange)

Matted or fixed axillary lymph nodes suggest tumor spread, as does supraclavicular or infraclavicular lymphadenopathy.

Inflammatory breast cancer is characterized by peau d'orange, erythema, and enlargement of the breast, often without a mass. A nipple discharge is common. Inflammatory breast cancer has a particularly aggressive 

According to the American Cancer Society, when breast cancer is detected early, and is in the localized stage, the 5-year relative survival rate is 99%. Early detection includes doing monthly breast self-exams and scheduling regular clinical breast exams and mammograms.

References

American Cancer Society. Breast cancer facts & figures. 2019. https://www.cancer.org/research/cancer-facts-statistics/breast-cancer-facts-figures.html

Gorham, R. (2020). Caring for women on adjuvant therapy for breast cancer: Role of the NP in the primary care setting. Women’s Healthcare: A Clinical Journal for NPs, 8(1), 6–16.

Center for Disease Control and Prevention (2019). https://www.cdc.gov/cancer/breast/pdf/BreastCancerFactSheet.pdf

Center for Disease Control and Prevention. (2016). Leading cancer cases and deaths, female, 2016. Retrieved from https://gis.cdc.gov/Cancer/USCS/DataViz.html

Kosir, M. A. (2019). Breast Cancer. Merck Manuals Professional Edition. Retrieved

https://www.merckmanuals.com/professional/gynecology-and-obstetrics/breast-disorders/breast-cancer#