1. Breast Cancer Welcome and Introductions Introduce yourself
Introduce the American Cancer Society
Relate any pertinent or personal experiences, expertise, and or motivation you have for volunteering to address this group
Acknowledge this this program can provide awareness and an introduction to the information available about this important topic.
Use a group facilitated activity in beginning the program.
Introduction
Pre-test

2. Cancer: cancer is not just one disease but rather a group of diseases.
All forms of cancer cause cells in the body to change and grow out of control.
Most types of cancer cells form a lump or mass called a tumor.
The tumor can invade and destroy healthy tissue. Cells from the tumor can break away and travel to other parts of the body. There they can continue to grow.
This spreading process is called metastasis. When cancer spreads, it is still named after the part of the body where it started.
For example, if breast cancer spreads to the lungs, it is still breast cancer, not lung cancer.

3. What Is Cancer?
Cancer is the name given to a large number of diseases.
Cancer: cancer is not just one disease but rather a group of diseases.
All forms of cancer cause cells in the body to change and grow out of control.
Most types of cancer cells form a lump or mass called a tumor.
The tumor can invade and destroy healthy tissue. Cells from the tumor can break away and travel to other parts of the body. There they can continue to grow.
This spreading process is called metastasis. When cancer spreads, it is still named after the part of the body where it started.
For example, if breast cancer spreads to the lungs, it is still breast cancer, not lung cancer.

4. Normal Breast Structure
What Is Breast Cancer?
Most kinds of cancer are named after the part of the body where the cancer first starts.
Breast cancer begins in the breast tissue.
Inside the breasts are glands that produce and release milk after a woman has a baby.
The glands that make the milk are called lobules and the tubes that connect them to the nipple are called ducts.
The breast itself is made up of lobules, ducts, and fatty, connective, and lymphatic tissue.
Lymph is a clear fluid that contains immune system cells and tissue waste products.
The fluid is carried in lymph vessels that lead to small, pea-sized collections of tissue called lymph nodes.
Most lymphatic vessels of the breast lead to lymph nodes under the arm. They are called axillary's nodes.

5. Over 75% of women who are diagnosed with breast cancer are age 50 or older.
Men can get breast cancer, although this is very rare. For every man who is diagnosed, over 100 women are found to have breast cancer.
Most women—about 80%—who get breast cancer do not have a sister or mother who has breast cancer.

6. Excluding skin cancer, breast cancer is the most common cancer in women.
1990s the breast cancer death rate declined by the largest amount in over 65 years.
Heart disease is the leading killer of women.
Approx 97% of women diagnosed with breast ca at an early stage survive 5 yrs or more.
There is no single cause of breast cancer. Research has shown that several different factors increase the risk of breast cancer.
Genetic and lifestyle differences increase the risk for some cancers.

7. Breast Cancer Facts 2nd leading cause of death 2nd most common cancer
Incidence increases with age
All women are at risk
Over 75% of women who are diagnosed with breast cancer are age 50 or older.
Men can get breast cancer, although this is very rare. For every man who is diagnosed, over 100 women are found to have breast cancer.
Most women—about 80%—who get breast cancer do not have a sister or mother who has breast cancer.
Excluding skin cancer, breast cancer is the most common cancer in women.
1990s the breast cancer death rate declined by the largest amount in over 65 years.
Heart disease is the leading killer of women.
Approx 97% of women diagnosed with breast ca at an early stage survive 5 yrs or more.
There is no single cause of breast cancer. Research has shown that several different factors increase the risk of breast cancer.
Genetic and lifestyle differences increase the risk for some cancers.

8. Breast Cancer Risk Factors that cannot be changed
Age
GENDER - All
women are
at risk
Reproductive
History
Family/Personal
History
Menstrual
History
Let’s talk about the most common risk factors that cannot be changed.
Besides being a woman, you are at risk
As you get older
If you or close blood relatives have had or have this disease. A woman with breast cancer has 3 to 4 times a greater chance of developing a new cancer.
Depending on your race: we talked before that white women are more frequently diagnosed with breast cancer than black women. But black women die more of this disease. Asian, Hispanic, and American Indian women are at lower risk.
Treatment w/ DES (Diethylstilbestrol)- Between 1940 and 1960, some pregnant women were given DES to lower their chances of miscarriage. Recent studies show that these women have a 35% increased risk of getting breast cancer.
Radiation: women who have had chest radiation treatment have a greater risk of breast cancer.
Genetic factors: about 1 case of breast cancer in 10 is linked to changes/mutations in certain genes.
Menstrual history: women having her menstrual periods before 12 years of age or who went through menopause after age 50 have a slightly higher risk.
Reproductive history: women that have no children or who have their first child after 30 have a 40% higher risk.
Race
Radiation
Treatment with
DES
Genetic
Factors

9. Let’s talk about the most common risk factors that cannot be changed.
Besides being a woman, you are at risk
As you get older
If you or close blood relatives have had or have this disease. A woman with breast cancer has 3 to 4 times a greater chance of developing a new cancer.
Depending on your race: we talked before that white women are more frequently diagnosed with breast cancer than black women. But black women die more of this disease. Asian, Hispanic, and American Indian women are at lower risk.

10. Treatment w/ DES (Diethylstilbestrol)- Between 1940 and 1960, some pregnant women were given DES to lower their chances of miscarriage. Recent studies show that these women have a 35% increased risk of getting breast cancer.
Radiation: women who have had chest radiation treatment have a greater risk of breast cancer.
Genetic factors: about 1 case of breast cancer in 10 is linked to changes/mutations in certain genes.
Menstrual history: women having her menstrual periods before 12 years of age or who went through menopause after age 50 have a slightly higher risk.
Reproductive history: women that have no children or who have their first child after 30 have a 40% higher risk.

11. Breast Cancer Risk Factors that can be controlled
Obesity
Obesity
All
women are
at risk
All
women are
at risk
Not having
children
Not having
children
Exercise
Exercise
Breastfeeding
Breastfeeding
Now let’s take a look at the risk factors that can be controlled:
Obesity: Being overweight increases the risk, especially after reaching menopause if that weight gain took place during adulthood.
Exercise: Exercise can lower breast cancer risk by about 60% in adults. More research is being done to confirm these findings.
Breastfeeding: Studies have shown that breastfeeding lowers breast cancer risk, especially is breastfeeding lasts 1½ to 2 years. One study found that having several children and breastfeeding could reduce the risk of breast cancer by half. This may be because breastfeeding lowers a woman’s total number of menstrual periods.
Alcohol: Alcohol is clearly linked with an increased risk of breast cancer. Those who have 2 to 5 drinks daily have about 1½ times the risk of women who drink no alcohol.
HRT: It has become clear that long term use (several years) of combined HRT (estrogens together with progesterone) for the relief of menopause symptoms may slightly increase the risk of breast cancer as well as the risk of heart disease, blood clots, and strokes. The breast cancers are also found at a more advanced stage. As well, HRT seems to reduce the effectiveness of mammograms.
Birth control pills: studies have found that women now using birth control pills have a slightly increases risk of getting breast cancer.
Not having children before the age of 30 increases a woman’s risk by 40%.
Birth Control
Pills
Birth Control
Pills
Hormone
Replacement
Therapy
Hormone
Replacement
Therapy
Alcohol
Alcohol

12. Now let’s take a look at the risk factors that can be controlled:
Obesity: Being overweight increases the risk, especially after reaching menopause if that weight gain took place during adulthood.
Exercise: Exercise can lower breast cancer risk by about 60% in adults. More research is being done to confirm these findings.
Breastfeeding: Studies have shown that breastfeeding lowers breast cancer risk, especially is breastfeeding lasts 1½ to 2 years. One study found that having several children and breastfeeding could reduce the risk of breast cancer by half. This may be because breastfeeding lowers a woman’s total number of menstrual periods.

13. Alcohol: Alcohol is clearly linked with an increased risk of breast cancer. Those who have 2 to 5 drinks daily have about 1½ times the risk of women who drink no alcohol.
HRT: It has become clear that long term use (several years) of combined HRT (estrogens together with progesterone) for the relief of menopause symptoms may slightly increase the risk of breast cancer as well as the risk of heart disease, blood clots, and strokes. The breast cancers are also found at a more advanced stage. As well, HRT seems to reduce the effectiveness of mammograms.
Birth control pills: studies have found that women now using birth control pills have a slightly increases risk of getting breast cancer.
Not having children before the age of 30 increases a woman’s risk by 40%.

14. A Good Breast Health Plan
Mammograms
Clinical Breast Examination (CBE)
Self Awareness (Monthly Self Exams) (BSE)
Mammography refers to x-ray of the breast. Mammography is used to detect and diagnose breast disease both in women who have breast symptoms (problems such as a lump, pain or nipple discharge) and women who are asymptomatic (no breast complaints).
Early diagnosis is the key to surviving breast cancer. Mammography can prevent thousands of breast cancer deaths each year. Regular screening mammograms are the best way to detect breast cancer early, when it is easiest to treat.
When having a mammogram, women should ask their doctor when they can expect to receive the results. Regulations facilities to send women their results within 30 days.
Older women are at highest risk for breast cancer, yet they are the least likely to get mammograms.
The ACS can tell women where they can get a mammogram. Call ACS-2345.
By law, all mammography facilities must be certified by the U.S. Food and Drug Administration.
They must meet standards for the equipment used, people who work there, and records that are kept.
Mammography can detect cancers several years before it can felt through a clinical exam.
Breast abnormalities are discovered in one of three ways: by a woman herself, by her HCP during a physical exam, or by a mammogram. Many breast cancers are found by the woman herself, but the smallest cancers are found by mammograms.
Low-cost and free mammograms are available to low-income women through their local or state health department.
Annual mammograms are covered by Medicare and Medicaid.
Most breast lumps are not cancer.
Clinical Breast Examination
A clinical breast examination (CBE) is an examination of your breasts by a health professional, such as a physician, nurse practitioner, nurse, or physician assistant.
For this examination, you undress from the waist up. The health professional will first inspect (look at) your breast for changes in size or shape.
Then, using the pads of the fingers, the examiner will gently palpate (feel) your breasts. Special attention will be given to the shape and texture of the breasts, location of any lumps, and whether such lumps are attached to the skin or to deeper tissues.
The area under both arms and above and below the collar bones will also be examined.
During the CBE is a good time for the health professional to teach breast self-examination to the woman who does not already know how to examine her breasts.
Ask your doctor or nurse to teach you and watch your technique.
Breast Self-Examination (BSE)-
Performing monthly breast self-examinations, beginning at age 20

15. Mammography refers to x-ray of the breast
Mammography refers to x-ray of the breast. Mammography is used to detect and diagnose breast disease both in women who have breast symptoms (problems such as a lump, pain or nipple discharge) and women who are asymptomatic (no breast complaints).
Early diagnosis is the key to surviving breast cancer. Mammography can prevent thousands of breast cancer deaths each year. Regular screening mammograms are the best way to detect breast cancer early, when it is easiest to treat.
When having a mammogram, women should ask their doctor when they can expect to receive the results. Regulations facilities to send women their results within 30 days.

16. Older women are at highest risk for breast cancer, yet they are the least likely to get mammograms.
The ACS can tell women where they can get a mammogram. Call ACS-2345.
By law, all mammography facilities must be certified by the U.S. Food and Drug Administration.
They must meet standards for the equipment used, people who work there, and records that are kept.
Mammography can detect cancers several years before it can felt through a clinical exam.
Breast abnormalities are discovered in one of three ways: by a woman herself, by her HCP during a physical exam, or by a mammogram. Many breast cancers are found by the woman herself, but the smallest cancers are found by mammograms.
Low-cost and free mammograms are available to low-income women through their local or state health department.
Annual mammograms are covered by Medicare and Medicaid.
Most breast lumps are not cancer.

17. Clinical Breast Examination
A clinical breast examination (CBE) is an examination of your breasts by a health professional, such as a physician, nurse practitioner, nurse, or physician assistant.
For this examination, you undress from the waist up. The health professional will first inspect (look at) your breast for changes in size or shape.
Then, using the pads of the fingers, the examiner will gently palpate (feel) your breasts. Special attention will be given to the shape and texture of the breasts, location of any lumps, and whether such lumps are attached to the skin or to deeper tissues.
The area under both arms and above and below the collar bones will also be examined.
During the CBE is a good time for the health professional to teach breast self-examination to the woman who does not already know how to examine her breasts.
Ask your doctor or nurse to teach you and watch your technique.

18. Breast Self-Examination (BSE)-
Performing monthly breast self-examinations, beginning at age 20
During the CBE is a good time for the health professional to teach breast self-examination to the woman who does not already know how to examine her breasts.
Ask your doctor or nurse to teach you and watch your technique.

19. Mammography
Average-size lump found by woman practicing occasional breast self-exam (BSE)
Average-size lump found by woman practicing regular breast self-exam (BSE)
This is the most common method to detect breast cancer.
Breast cancer takes years to develop.
When breast cancer is detected early, the 5-year survival rate is about 97%.
Having regular screening is the key to early detection.
Average-size lump found by first mammogram
Average-size lump found by getting regular mammograms

20. This is the most common method to detect breast cancer.
Breast cancer takes years to develop.
When breast cancer is detected early, the 5-year survival rate is about 97%.
Having regular screening is the key to early detection.

21. Warning Signs Warning signs and symptoms: Painless lump or thickening
Thickening or swelling that persist
Nipple pain or retraction
Breast skin irritation or dimpling
Spontaneous discharge
Women should seek immediate medical advice is they have any of these warning signs:
A mass/lump that is painless, hard, and has irregular edges is more likely to be cancerous, but some rare cancers are tender, soft, and rounded.
A change in the size or shape of the breast.
A change in the way the skin of the breast, areola, or nipple looks or feels (for example, scaly, warm, swollen, red)
Many of these breast symptoms are due to benign breast conditions but only a doctor can really give you a diagnosis
Early breast cancer
may not have symptoms.

22. Women should seek immediate medical advice is they have any of these warning signs:
A mass/lump that is painless, hard, and has irregular edges is more likely to be cancerous, but some rare cancers are tender, soft, and rounded.
A change in the size or shape of the breast.
A change in the way the skin of the breast, areola, or nipple looks or feels (for example, scaly, warm, swollen, red)
Many of these breast symptoms are due to benign breast conditions but only a doctor can really give you a diagnosis

23. American Cancer Society Screening Recommendations
Annual mammograms, starting at age 40
Clinical breast exams
every year starting at age 40
every 3 years for women age
20-39
Self-breast exams monthly, starting at age 20
Mammography can prevent thousands of deaths.
Older women are less likely to get mammograms, and are at highest risk of getting breast cancer.
The American Cancer Society can tell women where they can get a mammogram when called at ACS-2345
Low cost and free mammograms are available at all health departments- we will talk about this in a few moments
Annual mammograms are covered by Medicare and Medicaid

24. Mammography can prevent thousands of deaths.
Older women are less likely to get mammograms, and are at highest risk of getting breast cancer.
The American Cancer Society can tell women where they can get a mammogram when called at ACS-2345
Low cost and free mammograms are available at all health departments- we will talk about this in a few moments
Annual mammograms are covered by Medicare and Medicaid

25. Breast Cancer Treatments
Surgery
Chemotheraphy
Radiation Therapy
Hormone Theraphy
Immunotherapy
TREATMENT OPTIONS:Treatment choices for the person with cancer depend on the stage of the tumor, that is, if it has spread and how far.
Treatment options may include surgery, radiation, chemotherapy, hormone therapy, and immunotherapy:
Surgery is the oldest form of treatment for cancer. Surgery offers the greatest chance for cure for many types of cancer.
Radiation therapy uses high-energy particles or waves, such as x-rays or gamma rays, to destroy or damage cancer cells and may be recommended for the treatment of some types of breast cancer.
Chemotherapy is the use of medicines (drugs) to treat cancer. Systemic chemotherapy uses anticancer drugs that are usually given into a vein or by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment potentially useful for cancer that has spread and may be recommended for the treatment of some types of breast cancer.
Hormone Therapy is treatment with hormones, drugs that interfere with hormone production or hormone action, or surgical removal of hormone-producing glands to kill cancer cells or slow their growth . may be recommended for the treatment of some types of breast cancer.
Decision about treatment should be made with HCP.

26. Nutrition Guidelines
Eat a variety of healthful foods, with an emphasis on plant sources.
Adopt a physically active lifestyle.
Maintain a healthful weight throughout life.
If you drink alcoholic beverages, limit consumptions.
Scientific evidence suggests that about one-third of the cancer deaths that occur in the US each year are due to nutrition factors. Many dietary factors can affect cancer risk: types of foods, food preparation methods, portion sizes, food variety, and overall caloric balance.
ACS Recommendations for Individual Choices
Eat a variety of healthful foods, with an emphasis on plant sources.
·   Eat five or more servings of a variety of vegetables and fruits each day.
·   Choose whole grains in preference to processed (refined) grains.
·   Limit consumption of red meats, especially those high in fat and processed.
·   Choose foods that maintain a healthful weight.
2. Adopt a physically active lifestyle.
Adults: engage in at least moderate activity for 30 minutes or more on 5 or more days of the week; 45 minutes or more of moderate to vigorous activity on 5 or more days per week may further enhance reductions in the risk of breast and colon cancer.
Children and adolescents: engage in at least 60 minutes per day of moderate-to vigorous physical activity at least 5 days per week.
3.  Maintain a healthful weight throughout life.
· Balance caloric intake with physical activity.
· Lose weight if currently overweight or obese.
4. If you drink alcoholic beverages, limit consumption.

27. Chief Complaint I have pain in my breast and under my arm.
Case Study
Chief Complaint
I have pain in my breast and under my arm.

28. History of patient illness
Diana Jackson is 69 yo,black woman,whose history date back to 3-4 weeks ago when she noticed a painful lump in the upper quadrant of her left breast ,including the axillary area.
A mammogram was done that was suggestive of malignancy.
NOTE: she didnot have regular mammogram previously (here,we can realise the importance of routine mammogram in early detection of breast cancer)

29. Patient medical history
1-Angioplasty 5 years ago ,pt denies any chest pain since .
2-HT,canot rememmber sice when.
3-Cholecystectomy.
4-Hysterectomy at age 45
5-No family history of cancer

30. Social History Quitted smoking 18 y ago
She denies any tobacco or drug use
Endocrine hx
Menopause at 45 ,1st child at 17 yo, HRT stopped 3-4 weeks when she felt the pain

31. Medication 1-Adalat xl 90 mg od 2-Zestril 20 mg od 3-Paxil 30 mg od
4-Tylenol 3 (2 tabs prn for back pain )
Allergy :no known allergy
Gen. : Moderately obese 69 yo African- American ,awake ,alert,no acute distress.

32. Vital Signs
BP =130/84
RR=88
P=77
T=37.1
HT=165 cm
WT=78 kg
BSA= 28.65

33. Breast : the right one appears normal The,left one ,we noticed the following:
Skin retraction with arms elevated ,no nipple retraction or discharge expressible,edema of skin in the left upper quadrant w/o associated erythema ,hard 5x5 cm mass in the upper outer quadrant not fixed to skin ,no ulceration,2 cmfirm,tender palpable mass in axilla (lymph node enlargement)
Other organs are ok ,no thing abnormal (lung ,liver,abdomen ,spines )

34. Mammogram : Advanced carcinoma associated diffused skin thickening and retraction
-Lymphadenopathy with an enlarged lymph node approximately 2 cm in diameter suggested metastatic node -The size of malignant mass was 8x9 cm Ultrasound and Biopsy : -Solid mass favouring malignancy, abnormal lymph node apperance and evaluation suggested malignancy. CONCLUSION : Breast canrcinoma,ductal type

35. Questions 1-Identify drug therapy related problems?
Patient had angioplasty ,so she has coronary problem (MI OR ANGINA ) so ,she should be on an anti-thrombus medication which can be aspirin 80 mg od.
Patient is using tylenol 3 for back pain and she has risk of having constipation and straining and this is not good at all for people with coronary problems ,better to use plain tylenol
Patient was on HRT although she has coronary problem (this is contra indication )

36. What is the patient stage of cancer?
According to National Cancer Institute ,it is stage 111A because the mass is larger than 5 cm and it is extended to the lymph node.

37. What is the goal of treatment of this patient?
The goal is to eradicate the tumour and prevent spreading of the disease to the adjacent organs or bones(chest wall).

38. What is the prognosis for this patient based on the tumor size and node status ?
The disease is metastatic and liable to extend to the chest wall and lung as well as other organs if not treated aggressively.

39. List the general treatment options available for this patient ?
It may include the following :
Breast conservative surgery to remove only the tumor and some surrounding breast tissues ,followed by lymph node dissection and radiation therapy . OR
Modified radical mastectomy with or w/o breast reconstraction surgery
THEN

40. Adjuvant Therapy
This is the treatment given after surgery to increase the chance of cure ,and it may include :
1-Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy.
2-Systemic chemo therapy with or w/o hormonal therapy
3-Hormonal therapy.
4-TRUSTAZUMAB (Herceptin) inj. Combined with systemic chemo therapy.

41. Modified Radical Mastectomy
It is surgery done for patien with breast cancer in which the breast ,most or all of the lymph nodes under the arm and the lining over the chest muscles are removed .some times the surgeon removes part of the chest wall muscles.

42. Breast Conservative Surgery
An operation to remove the breast cancer but not the breast it self . It may be:
Lumpectomy(removal of the lump).
Quadrantectomy(removal of quarter of the breast).
Segmental mastectomy(removal of the cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor).

43. Outline the optimum therapy plan for this patient?
1-Breast conservative surgery.
2- Femara 2.5 mg tablet od
Side effects :
hot flushes
night sweats
nausea
vomiting
muscle, joint, or bone pain
excessive tiredness
headache
dizziness
muscle weakness

44. If patient felt Chest pain Difficulty in breathing
Contact the doctor immidiately
Treatment is for 5 years with regular monitoring for any signs of metastasis of the tumor.

45. FEMARA MAO It is aromatase inhibitor
It act by inhibition of conversion of androgens which are the main source of estrogens after menopause

46. Iused
Hormonal therapy because the tumour is mainly due to long term use of HRT
In the case study they used chemotherapy and hormonal therapy (anastrozole –Arimidix ) but they didnot mension the chemotherapy regimen an dno surgery was done.

47. According to the case study
The patient came back after finishing the chemo. And starting on Arimidix ,complaining from pain in her back and left
hip and CT scan for the abdomen ,bone scanning ,other additional lab tests ,chest x-ray were done.
The conclusion was metastasis in bone and lung

48. New Plan
The physician decided to start chemo. On Xeloda (Capecitabine ) tab.
Stopping Arimidix is stated .
The patient did well with Xeloda ,and after sex courses ,the lung nodules were no longer detactable

49. BUT
The patient had PALMAR PLANTAR ERYTHRODYSESTHESIA and is unable to walk long distances due to pain in her feet ,her hands were peeled and cracked
This is called hand and foot syndromes and is a common and serious side effect of Xeloda tab.and should be treated and the medication my be resumed after symptoms

50. Continue Subside but dose should be lowered
The physicain decided to stop and watching the patient off therapy .
18 month later ,the patient came with new pain in the right hip and left rib cage
Investigation was done and bone metastasis was revealed

51. Another new plan The physician decided to start on
Faslodex inj. (Fluvestrant ) which is estrogen recetor antagonist.

52. Clinical Pearl
Breast cancer in early stage is a very highly curable cancer (stage 1 has 70% to 90% disease free survival ) but in advanced stages the spread of disease virtually eliminate the possibility of cure (in stage 4 ,up to 10 % survival with minimal disease but are rarely cured ).

53. SO
This is very evidence supporting routine screening and patient education efforts,

54. THANK YOU
Moustafa Bekheet