Aminoglutethimide

Today, most women with breast cancer are treated with combination therapy using both local and systemic treatment. Decisions about local management (surgery and/or radiation therapy) and/or systemic treatment (chemotherapy or hormonal therapy) are made based on individual characteristics of the patient and the disease as well as preferences of the woman.

Local Treatment

The goal of local treatment is to eradicate local disease. Procedures most often used in local management of breast cancer are mastectomy, with or without reconstruction, and breast-conserving surgery combined with radiation therapy.

Modified Radical Mastectomy-This procedure involves excision of the tumor, entire breast, and axillary lymph nodes, leaving the pectoralis muscles intact. The major drawbacks to a modified radical mastectomy are cosmetic appearance, altered body image and self concept. After mastectomy, a temporary prosthesis may be worn. In 4 to 6 weeks, a woman can be fitted for a permanent prosthesis. A wide choice of material, shapes, sizes, and colors of prosthesis are available.

Even though women may be prepared for and knowledgeable about mastectomy, the actual experience may be physically hard and emotionally difficult to accept. Thus, side effects are numerous and include physical, psychological, and emotional sequelae. Infection, seroma, and hematoma may occur at the incision site. In addition, impaired arm and shoulder mobility and chest wall tightness may occur due to the disruption in lymphatic and venous drainage. Women should be encouraged to do hand and arm exercises to increase range of motion and decrease tightness in the affected arm.

Approximately 15% to 20% of women develop lymphedema after treatment. Lymphedema is a troublesome and traumatic effect of therapy. But there is no way of predicting who will or will not develop lymphedema. Several interventions ranging from nothing to aggressive surgical procedures have been used with limited success. The most common interventions include elevation, compression sleeves, exercises, and pneumatic compression.

All women should be instructed in arm and hand care after treatment. Since lymphedema may occur many years after treatment, women should follow good hand and arm care for the rest of their lives. They should be taught to use meticulous skin, nail, and cuticle care; avoid constricting sleeves or jewelry on the affected side; avoid heat, sunburns, and hot saunas to the affected extremity; and avoid strenuous exertion of the affected limb.

Psychologically, the loss of a breast is related to altered body image and self-concept. Women may experience difficulties in adjusting to the change in their appearance, they may not want to look at the mastectomy site for several weeks, and they may have up and down emotional periods relating to the loss of their breast. Several programs are available through the American Cancer Society, specifically Reach to Recovery, which is a visitation program with specific assistance in prosthesis selection, and Look Good . . . Feel Better, which provides help with cosmetics and support.

Breast Reconstruction-Women may elect to have reconstructive surgery after mastectomy. This offers considerable psychologic benefit. Some concerns that women may have about reconstructive surgery are cost, safety, and whether to have the reconstruction done at the time of mastectomy or delayed until 6 months or up to a year after surgery. Cost to the patient may vary depending on the insurer, but it is considered rehabilitative surgery and therefore is often reimbursed. Side effects with reconstruction include infection and potential for an unsatisfactory reconstructive result.

If a woman decides to have reconstructive surgery at the time of the mastectomy, she avoids future surgery, although the total operative time is lengthened. Some women have found that immediate reconstruction lessens the feelings of loss and disfigurement. Occasionally, reconstruction cannot be done because skin and muscles are too tight. Other women benefit by a waiting period before another surgical procedure. Not all women desire reconstruction, and not all are candidates for reconstructive surgery.

Primary Radiation Therapy-When

radiation is the primary treatment of choice, a wide local excision that removes the entire tumor is followed by a course of radiation therapy to treat residual microscopic disease. The objectives of this treatment are to conserve the breast, decrease the chance of recurrence, and eradicate residual cancer. External beam radiation is given daily over a 4 1/2-week period to the entire breast region. In addition, a concentrated radiation dose or "boost" is given over about a 2Y2-week period to the primary tumor site.

Radiation therapy is generally well tolerated, and women may continue working during treatment. Side effects are temporary and usually consist of a mild to moderate skin reaction and fatigue. Fatigue may last for several weeks after treatment is completed. Patients may become discouraged and they need reassurance that it is normal. The woman should also be given specific instructions on how to manage and cope with fatigue.

Patient self-care instructions should address maintainence of skin integrity. They include use of a mild soap with minimal rubbing; avoidance of perfumed soaps or deodorants; use of hydrophilic lotions for dryness; and avoidance of tight clothes underwire bras, and excessive temperatures or ultraviolet light. After the treatment ends, patients should minimize exposure of the treated area to the sun for 1 year. They also need reassurance that minor twinges and shooting pain in the breast are normal reactions after radiation treatment.

Systemic Therapy

Chemotherapy-Chemotherapy is given to eradicate micrometastatic disease. Chemotherapy regimens for breast cancer combine several chemotherapeutic agents to increase tumor cell kill and to minimize drug resistance. Chemotherapeutic agents used most often in combination are cyclophosphamide, methotrexate , flourouracil, and doxorubicin. Less commonly used are Vincristine and prednisone. Decisions regarding chemotherapy are based on the patient's age, physical status, disease status, and whether she is participating in a clinical trial.

Common physical side effects of chemotherapy for breast cancer include nausea, vomiting, taste changes, alopecia, mucositis, fatigue, and bone marrow depression. Less commonly occurring side effects include hemorrhagic cystitis and weight gain. In addition, younger women receiving chemotherapy may experience irregular menses which could lead to sterility. Side effects vary depending on the chemotherapeutic agents used. Nausea is usually well controlled with the administration of combination antiemetics. For hair loss, many women purchase a wig prior to hair loss and use stylish hats or scarves. Reassurance that new growth will occur when treatment is completed is helpful, although the color and texture of the hair may differ. The ACS Look Good . . . Feel Better program provides useful tips for applying make-up during chemotherapy. Taking time to explain side effects and possible solutions may alleviate some of the anxiety of women who are uncomfortable asking questions.

Emotional responses to chemotherapy may have a negative effect on self-esteem, sexuality, and well being. These side effects, when combined with having to deal with a potentially life-threatening diagnosis, can be overwhelming. However, the majority of women with breast cancer today are treated in an environment where a multidisciplinary approach to holistic care is used. In addition, numerous support and advocacy groups in the community are available for patients and their families. Important aspects of care include communication, support groups, encouragement to ask questions, and promoting trust with care providers.

Hormonal Therapy-Decisions about hormonal therapy for breast cancer are based on the index of estrogen and progesterone receptors provided by the hormone receptor assay done on the tumor specimen. Normal breast tissue contains receptor sites for estrogen. However, only about one third of breast cancers are estrogen dependent or ER-positive (ER+). An ER + assay indicates that tumor growth depends on estrogen supply. Thus, measures to reduce hormone production such as hormonal therapy may limit disease progression.

Hormonal therapy can be ablative or additive. Ablative therapy includes removal of endocrine glands that produce hormones (i.e., ovary, pituitary, or adrenal glands). Oophorectomy is a treatment option for premenopausal women with estrogendependent tumors. Additive therapy usually consists of tamoxifen treatment as first-line therapy followed by progestins, aminoglutethimide, estrogens, or androgens for secondand third-line therapy. With tamoxifen, patients may experience nausea, vomiting, hot flashes, depression, vaginal dryness, and itching, and menstrual irregularities. Recent studies have also shown an increased risk of endometrial cancer and deep venous thrombosis.

Bone Marrow Transplantation

Since the doses of chemotherapy and radiation therapy are limited by the degree of marrow toxicity, autologous bone marrow transplantation (ABMT) is being used in women who are at high risk for recurrence. Studies indicate that ABMT induces a response in 50% to 80% of women, 30% of whom have a complete response for several years. Initially, mortality rates were high with ABMT due to sepsis. However, the use of growth factors to stimulate the bone marrow have led to an overall decline in mortality from BMT. The procedure involves the removal of bone marrow from the patient, after which high doses of chemotherapy are given. The patient's bone marrow, spared from the effects of chemotherapy, is then reinfused intravenously and engrafts to "rescue" the marrow from the toxic effects of chemotherapy. This highly specialized procedure requires intensive patient preparation, education, and support.

Treatment Summa

Several local and systemic treatments are used for breast cancer depending on the particular woman and her specific disease characteristics. Treatment for breast cancer has changed dramatically and is often given in some combination of local treatment and systemic therapy. Side effects may be- specific to each treatment. In addition, women experience significant emotional and psychological side effects, which may linger long after treatment ends.

LONG-TERM EFFECTS

Since women are living longer with breast cancer, they may experience a number of sequelae that may be related to treatment, disease, or social issues. These factors must be weighed against the overall improvements in treatment allowing longer periods of survival. Efforts are in progress to improve survival and minimize late effects.

NURSING CONSIDERATIONS

Nurses have a tremendous role in the care of women with breast cancer and their families. Opportunities exist in teaching and support with regard to prevention, screening, and early detection of the disease. In addition, nurses have made great strides in decreasing symptoms associated with treatment. Efforts continue in the care of women with recurrent, advanced, or end-stage disease and nurses are working to improve the overall quality of survival. Nurses can use their talents and skills in all areas of nursing practice, education, administration, and research to reduce the burden of breast cancer.

References

Dow, K.H. (Ed). (1996) Contemporary issues in breast cancer. Sudbury, MA: Jones and Bartlett.

Gross, J. (Ed.) (1991). Breast cancer. Seminars in Oncology Nursing, 7(3), entire issue. Harris, J., Lippman, M., Veronesi, U., & Willett, W. (1992). Review article: breast cancer. New England Journal of Medicine, 327, 319-327: 390-397: 473-480.

Knobf, M., (1990). Symptoms and rehabilitation needs of patients with early stage breast cancer during primary therapy. Cancer, 66, 1392-1401.

Knobf, M., & Stahl, T. Reconstructive surgery in primary breast cancer treatment. Seminars in Oncology Nursing, 7, 200-206.

Schover L. (1991). The impact of breast cancer on sexuality, body image and intimate relationships. CA-A Cancer Journal for Clinicians, 41, 112-120.

Varricchio, C., & Johnson, K. (1993). The use of tamoxifen in the prevention and treatment of breast cancer. In S. Hubbard, P. Green, & M Knobf (Eds.), Current issues in cancer nursing practice. Philadelphia: J.B. Lippincott.

Varricchio, Pierce, Walker, & Ades. American Cancer Society A Cancer Source Book for Nurses, seventh edition. Jones and Bartlett Publishers. 1997.

Copyright Georgia Nurses Association Feb-Apr 1999
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