Patient Background
Mrs. Pam, is a 55-year-old Caucasian women. She reported to her primary care physician
due to increasing tenderness and sharp stabbing pain around her breast, and noticed discoloration
around the nipple. Mrs. Pam has gone through menopause, although when she did have a
menstrual cycle she never experienced breast tenderness. Her height is 5 foot 3 inches, and her
weight is 215lbs (97.7kg). This determines her body mass index (BMI) to be 38.1
Mrs. Pam currently works as an inpatient unit clerk at her local hospital. She has been in
the position for 35 years. While in this position, she is primarily sitting at a desk with her
computer and answering phones. Occasionally, she has to get up and walk something down to an
attending, nurse, or therapist. She lives a very sedentary lifestyle, and has never been a fan of
physical activity. She has had very irregular doctors’ appointments, with her last mammogram
occurring 11 years ago. She had birth to her first child are age 32, which was her last hospital
stay. She has not had blood work conducted within the last 20 years. Family history includes her
mother who was diagnosed with lung cancer, her father was diagnosed with diabetes and chronic
heart failure, and her youngest sister was diagnosed with breast cancer at 21 years of age. She
overall has lived a relatively health illness free lifestyle. She has only had a left distal radius
fracture that required open reduction and internal fixation surgery, and a brachioradialis
tenotomy.
Her primary care physician decided to order a complete blood test, mammogram, and an
MRI. Depending on the results, a biopsy would be conducted as well. After examination of the
results, the blood test presented with CA-125, which is cancer antigen 125. The mammogram
displayed a lump that had an irregular border, which lead to concern for breast cancer. The MRI
findings displayed similar imaging, which lead to a biopsy being ordered. Upon biopsy, Mrs.
Pam was diagnosed with invasive ductal carcinoma.
Breast Cancer Background
“In cancer, the cellular DNA of normal stem cells is damaged, leading to disordered cell
growth and specialization. The stem cell model for cancer proposes that tumors arise from
carcinogenic-causing events occurring within the normal stem cells of a particular tissue. A
cancer-causing insult is believed to produce a defect in the control of normal stem cell function,
resulting in abnormalities in self-renewal, differentiation, and proliferation. In other words, the
normal quality and quantity control for cell function and growth is lost…The carcinogenic event
for many cancers is unknown, but five broad categories have been identified: Environment,
heredity, oncogenes, hormones, and impaired immune system function” (Ehrman, Gordon,
Visich, & Keteyian, 2019). The most common types of breast cancers including invasive ductal
carcinoma and invasive lobular carcinoma. Two main molecular targets include estrogran
receptor alpha and epidermal growth factor 2. “Estrogen receptor alpha, is a steroid hormone
receptor and a transcription fact that, when activated by estrogen, activates oncogenic growth
pathways in breast cancer cells…Epidermal growth factor 2, a transmembrane receptor tyrosine
kinase in the epidermal growth factor receptor family that is amplified or overexpressed in
approximately 20% of breast cancers, and is associated with poor prognosis in the absence of
systemic therapy” (Waks & Winer, 2019).
With breast cancer in particular lifestyle factors, hormones, and heredity have the largest
impact on diagnosis. “In total, the high risk genes, BRCA1, BRCA2, TP53, STK11, CD1, and
PTEN account for approximately 20% of the familial risk. Moderate risk variants account for up
to 5% of the inherited familial risk…The hereditable component in familial clustering of breast
cancer has been estimated to 73% and the environmental proportion 27%...About 5-10% of
breast cancer are thought to be hereditary with 4-5% being due to already identified high
penetrance traits inherited in an autosomal dominant inheritance fashion” (Wendt & Margolin,
2019).
Majority of individuals who are diagnosed with invasive ductal carcinoma go through a
few treatment options. First, would be an axillary lymph node dissection. This can range from 1-
75 lymph nodes being removed, although the mean number is 15. Second, is radiotherapy
treatment. “The radiation energy was generally 6-MV photons, but higher energy photons were
used as indicated for women with large breast size or with a large separation between the medial
and lateral chest wall” (Santiago et. al., 2005). In the study conducted by Santiago et. al., 49%
received adjuvant systemic therapy (chemotherapy and/or hormones) and 26% received regional
lymph node irradiation. In addition, there is a possibility of a mastectomy or bilateral
oophorectomy, which could occur after diagnosis, or in some cases before diagnosis if an
individual is at higher risk.
While an individual cannot prevent the hereditary risk factors of breast cancer, there are
some tasks that can assist in the prevention of occurrence. Obesity increases the risk for multiple
cancers, as well as other underlying health conditions. Participation in a physical activity
program is beneficial for all individuals. “Exercise appears to be safe for most breast cancer
patients, and improves their physiological and psychological well-being… A meta-analysis of
prospective studies which evaluated the association between physical activity and breast cancer
risk involving 63,786 individuals demonstrated a 12% reduction in risk among those who were
physical active vs. those who were not. Stronger associations with physical activity and breast
cancer risk were found in subjects with a BMI <25, premenopausal women, and estrogen and
progesterone receptor-negative breast cancer…Women with dense breasts on mammogram have
an increased risk of developing breast cancer, and increased density makes breast cancer
detection when reading two dimensional mammograms more difficult” (Sauter, 2018).
Plan of Care
Upon diagnosis of invasive ductal carcinoma of the breast, a plan of care was established.
The first priority was the patient’s well-being. Mrs. Pam was in denial when she first received
the diagnosis. She was aware of her family history, and her poor lifestyle habits and self-care
habits, but she didn’t want to believe she was following down the road of her parents. She did
state she was aware of the possible risk factors of ignoring doctor appointments, living a
sedentary lifestyle, and her family history. She did not have a spiritual presence, and did not wish
to speak with Father John within the hospital premise. The patient was first given information
about the diagnosis, and what was expected. Discussion was also had that a support system,
whether friends or family would be beneficial in the treatment plan. Her sister would be the
greatest resource due to her previous diagnosis with breast cancer as well. The patient was given
instruction to begin adding aerobic activity into their lifestyle to assist with a decrease in weight,
body fat percentage, and increase aerobic capacity. “Palliative care focuses on relief of
symptoms across the physical and psychosocial domains and promotes shared decision-
making…Positive benefits include cancer-related fatigue severity, emotional well-being,
functional status, and overall quality of life” (Chandrasekar, Tribett, & Ramchandran, 2016). The
patient was also recommended to participate in a yoga or flexibility training regimen to help
clear the mind, and allow the body to relax upon competition of any physical activity and
increase range of motion. Discussions were also had with Mrs. Pam about how to manage the
pain occurring from the lung cancer. “Pain usually does not occur in the early breast cancer. A
painless lump may be the first symptom. In later stages, pain may occur due to involvement of
deeper structures like muscles, ribs, etc., resulting in severe excruciating pain which increases
with chest movements. Patients undergoing mastectomy may develop chronic neuropathic pain
which may be either phantom breast pain, or intercostobrachial neuralgia, or neuroma pain
(including scar pain) or pain due to other nerve injury. During radiotherapy, there may be active
painful skill lesions at the radiation site and later cervical or brachial plexopathy may develop.”
Pharmacotherapy can include the use of non-steroidal anti-inflammatory drugs, anticonvulsants,
opiods, anti-depressants, and corticosteroids. (Satija et. al., 2014).
Mrs. Pam was made aware of the recommended treatment options. The patient would like
to undergo surgery, although it would be necessary to decrease body weight and body fat
percentage prior to this happening. Therefore, the next option was chemotherapy and radiation
therapy. Chemotherapy uses a combination of drugs to either destroy cancer cells or slow down
the growth of the cancer cells. Radiation therapy uses high energy rays to kill cancer cells. In
addition, a hormonal therapy treatment is also conducted.
Source
Chandrasekar, D., Tribett, E., & Ramchandran, K. (2016). Integrated Palliative Care and Oncologic
Care in Non-Small-Cell Lung Cancer. Current Treatment Options in Oncology, 17(5).
Ehrman, J.K., Gordon, P. M., Visich, P. S., & Keteyian, S. J. (2019). Clinical Exercise Physiology.
Champaign, IL: Human Kinetics.
Santiago, R. J., Harris, E. E., Qin, L., Hwang, W., & Solin, L. J. (2005). Similar long-term results of
breast-conservation treatment for Stage I and II invasive lobular carcinoma compared with
invasive ductal carcinoma of the breast. Cancer, 103(12), 2447-2454. doi:10.1002/cncr.21071
Satija, A., Singh, S., Kashyap, K., & Bhatnagar, S. (2014). Management of total cancer pain: A case
of young adult. Indian Journal of Palliative Care, 20(2), 153. doi:10.4103/0973-1075.132651
Sauter, E. R. (2018). Breast Cancer Prevention: Current Approaches and Future Directions.
European Journal of Breast Health. doi:10.5152/ejbh.2018.3978
Waks, A. G., & Winer, E. P. (2019). Breast Cancer Treatment. Jama, 321(3), 288.
doi:10.1001/jama.2018.19323
Wendt, C., & Margolin, S. (2019). Identifying breast cancer susceptibility genes
– a review of the genetic background in familial breast cancer. Acta
Oncologica, 58(2), 135-146. doi:10.1080/0284186x.2018.1529428
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