Breast Cancer RISKS,TREATMENT, PERIOPEKA1'IVE
PATLENT C A R E
Parricia S t e i n , RN; Richard T. Zera, MD
I
n the United States, breast cancer occurs in
one out of 10 wo1neii.l It is estimated that there would be approximately 15 1,000 new cases of breast cancer in 1990, and more than 44,000 of those women would die from the disease. Until the age of 54, the leading cause of cancer-related deaths in women is breast cancer. The toll of breast cancer is exceeded only by lung cancer i n women aged 55 to 74 and colorectal cancer in women older than 75 as a malignancy-related cause of death. Given these facts, a nurse can expect to take care of'patients with breast cancer frequently or even find oneself with the disease. This article provides an overview of measures for early detection of breast cancer, diagnosis, and treatment. It also provides nursing diagnoses and a nursing care plan for the breast cancer patient.
M
any factors are evident in the etiology of breast cancer. Geuetic, hormonal, dietary, and environmental factors influence each case. Familial factors clearly identify some patients at higher risk. A woman with a first-degree relative (ie. mother or sister) with breast cancer is estimated to have a two to three times higher rish than the general population.' The menopausal status at which the relative is diagnosed is important. Higher rish is ;it t r i but a b 1e t o a p re m e 11o p a u 5 ;i 1 d i ag 11o s i s . Additional risk is noted if both the relative's breasts are involved. For example, the sister of a preinenopausal woniaii with bilateral breast ciliiceI is estimated to have a 30% risk of devel-
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The causative role of exogenous estrogen (ie, birth control pills or postmenopausal estrogen) remains controversial.
oping breast cancer by age 70. Her risk is reduced to approximately 17% if her sister developed a postmenopausal unilateral cancer.’ Hormonal influences also are implicated in the development of this disease. A woman with breast cancer is more likely to have had an early menarche and to be nulliparous or to have had her first full-term pregnancy after age 35. In addition, the late onset of natural menopause is considered a risk factor. Pregnancy before the age of 20 appears to offer some protection against breast cancers. This suggests that early full differentiation or “maturing” of breast e p i t h e l i u m i s i m p o r t a n t , a n d that later endocrine stimulation of this tissue may be a secondary promoter of cancer development. Removal of the ovaries either surgically or with radiotherapy before age 40 has been found to diminish the potential for breast cancer by as much as 75%. The causative role of exogenous estrogen in breast cancer (ie, birth control pills [BCPs], postmenopausal estrogen) remains controversial. Most BCPs contain both estrogen and progesterone. This balanced hormonal influence at worse appears to have no net effect on the incidence of breast cancer.(’ One study suggests that BCPs may offer a protective e f f e ~ t The . ~ postmenopausal use of estrogen/progesterone combinations continues to appear safe.x Unopposed estrogen use (ie, without progesterone) appears to be more of a problem. Estrogen, when used alone, appears to increase the risk of breast cancer by 2.5 times.’ As a rule, women who have had breast cancer should not receive estrogen. Dietary influence on the development of breast cancer centers primarily on high fat intake. In animals this has been shown to increase the incidence of chemically induced m a m m a r y c a r c in o m as. 1n h u m an s , both intake of dietary fat and excess body weight
in postmenopausal women have been shown to correlate positively with the risk of mortality from breast cancer.Io These results, however, have been considered inconclusive because other major studies dispute these findings. I I If an increased risk exists. it may be related to the increased activity of the enzyme aromatase. Aromatase is present to a large extent in peripheral adipose tissue. This enzyme converts precursors derived from the adrenal gland into estrogenic compounds. Obesity, therefore, may be associated with increased conversion of these precursors to an unopposed estrogenic compound. In addition, obesity is associated with increased output of these adrenal precursors. This suggests a causal link between diet, obesity, and breast cancer via these abnormalities and the presence of unopposed estrogens from an endogenous source. Preliminary results suggest that dietary influences also may prevent breast cancer. Certain foods (eg, some types of soy beans) contain phytoestrogens, which are plant-derived compounds with weak anti-estrogenic (ie, estrogen blocking) effects.” In animals, these agents decrease the incidence of chemically induced mammary cancer. Environmental factors that may contribute to breast cancer include radiation and certain chemical compounds. Although therapeutic radiation to the chest wall and breast has been associated with an increase of breast cancer, diagnostic mammography has not been shown to carry an increased risk. This is particularly true with improvements in current techniques and a lack of observed risk for radiation after the age of 40.” No discussion of breast cancer risk would be complete without a discussion of benign breast disease. T h e American College of Pathologists Consensus Statement discusses 939
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fibrocystic disease and the risk of invasive breast c a n ~ e r . The ’ ~ term fibrocystic disease covers a broad range of histologic diagnoses that include diagnoses with no added risk such as sclerosing adenosis, florid adenosis, apocrine metaplasia, duct ectasia, fibroadenoma, mild hyperplasia (ie, two to four epithelial cells in depth), mastitis, and periductal mastitis Diagnoses with slightly increased risk (ie, 1.5 to 2 times) include moderate, florid, solid, or papillary hyperplasia, and papilloma with fibrovascular core. Diagnoses with moderately increased risk (ie, up to 5 times) include atypical hyperplasia, ductal hyperplasia, and lobular hyperplasia. These catagories can be divided into proliferative lesions and nonproliferative lesions. Proliferative lesions are associated with an increased risk of subsequent invasive carcinoma. Where proliferation of ductal or lobular breast epithelium occurs in association with atypia, the risk of breast cancer increases to 5 times that of the “normal” female population.I5 Some authors would include a high risk category that includes lobular carcinoma in situ and ductal carcinoma in situ, although these are not considered benign fibrocystic disease. Many issues under the broad definition of fibrocystic disease have not been settled. For example, although apocrine metaplasia is in the “ n o increased risk” c a t e g o r y , when found in women older than 45 the associated risk of subsequent carcinoma increases 2.7 times.I6 Other nonfibrocystic conditions also may cause breast lumps. Inflammatory conditions, such as breast abscesses, fat necrosis, lipomas (ie, benign fatty tumors), and lesions of the skin (eg, sebaceous cysts) also
may cause breast lumps.”
Diagnosis reast cancer is a histologic diagnosis. Physical or mammographic findings may strongly suggest this diagnosis, but examination of tissues either as cytologic or histologic specimens is necessary for confirmation. T h e physical examination of a patient involves inspection and palpation. With careful attention, it is not unusual to see contour changes, nipple retraction or skin dimpling related to a n u n d e r l y i n g mass. Occasionally, the entire breast may be elevated relative to the opposite breast. Skin erythema may be the hallmark of inflammatory breast cancer. In more advanced cases, edema of the skin may be visible. Palpation of the breast is done in both sitting and supine positions. Inspection and palpation should be done with the arms at the sides as well as with arms raised above the head. The most common physical finding is a lump or mass which generally is hard and nontender. Examination of the cervical, supraclavicular, and axillary lymph nodes is important and should include attention to the number of nodes palpable, the nature of the nodes (ie, hard versus rubbery), and whether the node is fixed to underlying structures or to the skin. Arm edema is an ominous sign usually associated with advanced nodal involvement. The use of screening mammography (ie, xray examination of the breasts in asymptomatic women) has increased dramatically the number of patients who have no significant physical findings. Screening mammography increases survival rates in all women over 40.’* Sadly, mammography is not used enough in the United States. Much of the blame lies with physicians who fail to recommend the test to their patients. l9 Features shown on mammography that merit further evaluation and clinical correlation are 941
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asymmetry of the breasts, a discrete mass or density, particularly if it distorts the breast, calcifications within a mass, and 0 clusters of microcalcifications. Evaluation of physical or mammographic findings may include ultrasonography. This procedure can reliably determine if a mass is solid or cystic and generally is considered more useful in premenopausal women. If a mass is palpable, an alternative may be the use of fine needle aspiration (FNA). Fine needle aspiration using a 22- or 25gauge needle is rapid, inexpensive, and diagnostic as well as therapeutic for cysts. In addition, cytologic examination of the aspirate can be a highly accurate adjunct to the evaluation of a breast lump. This may obviate the need for a formal biopsy.*O The physician performing FNA should be familiar with its limitations. A suspicious mass and/or suspicious mammogram requires formal biopsy if FNA is negative for cancer. A small number of centers now have stereotactic FNA available that may allow cytologic evaluation of nonpalpable mammographic lesions. A special unit is required to perform FNA under radiographic control. The current expense of these installations, however, may limit their wider use. Biopsy techniques for mammographic lesions that are not palpable have evolved from blind biopsy of a general area in a given quadrant of the breast to “wire localization.” In the latter method, measurements taken from scout mammograms allow placement of a smallgauge needle through which a hooked wire can be passed. After confirming adequate placement by repeat mammograms with the needle and wire in place, the needle is removed leaving the wire as a guide for biopsy. After biopsy, a specimen radiograph is then taken to confirm removal of the lesion. It is our practice to approach palpable lesions by FNA. If this is not diagnostic and the lesion is suspicious on x-ray or physical examination, biopsy by Tru-cut needle or by incisional or excisional techniques should be done depend0
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Table 1
Types of Breast Cancer Carcinomas Infiltrating ductal Papillary Intraductal Mucinous Tubular Adenoid tuba1 Metaplastic Squamous cell Apocrine Secretory Giant cell Lobular carcinoma in situ Infiltrating lobular carcinoma Inflammatory Paget’s Disease Sarcomas Cystosarcoma phyllodes Stromal Fibrosarcoma Liposarcoma Angiosarcoma ing on the size of the lesion. Involvement of a pathologist is critical in handling specimens properly. It is important for the surgeon to orient excised lesions so specimens can be inked before fixation. This allows the pathologist to assess the margins of resection. In addition, proper handling of the specimen is necessary for measurement of estrogen and progesterone receptor contents, and deoxyribonucleic acid (DNA) flow cytometry. These measurements are all integral parts of the full evaluation of breast cancer specimens.
Types, Staging of Breast Cancer
B
reast cancer must be considered a generic term because there are at least fifteen histological subtypes of the disease (Table 1).*’ Infiltrating ductal carcinoma
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Table 2
The TNM Staging Systemfor Breast Cancer Stage I TINoMo Tumor size less than 2 cm May extend into pectoral fascia or muscle No distant metastasis No positive nodes Stage I1 T2NoMoor T10r2N1Mo Tumor size 2 to 5 cm May or may not extend into pectoral fascia or muscle No distant metastasis Mobile axillary nodes
Stage 111 T1or2N1Wor T1-3N2M0or T3N0M0 Tumor size greater than 5 cm May or may not extend into pectoral fascia and muscle Skin edema, infiltration or ulceration may be present Nodes fixed to skin, deeper structures, supraclavicular nodes No distant metastasis Stage IV Any TN3 any M or T4 any N any M Any TN plus M’
Definitions
T = primary tumor T 4= Tumor extension to the chest wall or skin N = regional lymph nodes NO = no growth N l = movable nodes with tumor growth N2 = homolateral axillary nodes fixed to one
represents more than 50% of histologic diagnoses. A specific subtype diagnosis offers an improved prognosis over that of infiltrating ductal carcinoma. In addition to carcinomas, there are five different sarcomas of the breast. Breast cancer is classified into four stages. Staging describes tumor size, lymph node involvement, and distant metastasis. In the “TNM’ system, T equals tumor size, N equals lymph nodes, and M equals metastasis (Table 2).
Patient Care
T
ypes of breast lesions, either cancerous or benign, can be classified into categories; Patients who have these lesions
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another or other structures and containing growth N3 = homolateral infra or supraclavicular nodes containing growth A4 = distant metastasis iW=absent MI= present, includes skin beyond the breast
cannot. The nurse must approach each patientindividually in terms of diagnosis and treatment. Several nursing diagnoses may be used to guide perioperative interventions. Potential for body image disturbance. This seems obvious, however, there are some women who feel the fear of recurrence they would experience by not having the breast removed outweighs a body image change. Although the age of a patient would seem to be a factor in considering body image issues, some younger women facing 30 to 40 years of monitoring a breast elect to have a total mastectomy. Conversely, many older women share feelings and concern about how surgery will affect their body image.22
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The perioperative nurse needs to be sensitive to issues of sexuality and femininity when working with a patient who has breast cancer. The patient who has elected a less radical procedure to preserve her breast needs support for that decision as she enters the operative suite. Potential for decisional conflict regarding cancer treatment options. This may be more fitting in some cases. There are several choices and decisions about treatment that the patient with breast cancer must make. Weighing the choices can be very stressful. 23 Potential for ineffective individual coping. This exists regardless of the patient’s age. When a woman enters her physician’s office or clinic to undergo a breast examination she often has an underlying fear that a lump found at home will be cancerous. This fear alone can cause the woman to delay seeking diagnosis and treatment because she may not be able to cope with the findings. The patient may avoid care until she is in an active problem-solving mode. This may not occur until the anxiety aroused by the discovery is recognized and acknowledged. If the patient is in denial, that denial may be controlling her anxiety and allowing the patient time to develop some means for problem solving. The shock, disbelief, and confusion associated with a diagnosis of breast cancer directly affects the patient’s receptivity to any preoperative or postoperative teaching. When preparing to do preoperative teaching, the perioperative nurse should assess the patient for signs of coping that signal a readiness to learn. Coping has been described as the way in which a patient manages to retain her courage and fighting spirit. Potential for anticipatory grieving. This can be related to concern that the patient may have had something to do with being diagnosed with breast cancer and can lead to feelings of If the patient delays going to her physician, and as a result, delays diagnosis and treatment, she may not show signs of grief until after the surgery. The patient may feel a certain amount of depression and hopelessness. The nurse should be aware that a patient who consents for 946
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surgery may not understand the full consequences of that surgery until it has occurred. Potential for altered role performance. The perioperative nurse must be sensitive to the feelings of helplessness, depression, fatigue, and insomnia that a patient may experience and how they affect the patient’s return to presurgical activities. Any woman may find her role in life greatly changed for a time. For the woman who is used to being self-sufficient, asking for and accepting help can be stressful. A woman who felt helpless and powerless before surgery may be at a complete standstill when faced with breast cancer. In a study of 43 breast cancer patients, however, 80% believed that the illness had made them grow as human beings, and 90% said it had taught them to understand others. There is no doubt that having a life-threatening illness will change a woman’s relationship with the rest of the world. The perioperative nurse needs to understand that the intraoperative phase of care is small in terms of the time spent actually dealing with the problem. (See “Nursing Care Plan for the Patient with Breast Cancer.”)
Preoperative Care
A
fter the diagnosis of breast cancer has been made, the preoperative workup .should include a history and physical examination, complete blood count, electrolyte evaluation, liver function tests, and a chest x-ray. Any signs or symptoms of metastatic disease require further evaluation that may include a total body bone scan, x-rays andlor computerized axial tomography of the head, lungs or abdomen. Surgery should be delayed until the workup is complete. Surgical options should be discussed at length with the patient. Breast conservation surgery (ie, lumpectomy with axillary dissection) is indicated for women with tumors less than 5 cm in size and those whose altered
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Nursing Care Plan for the Patient with Breast Cancer Nursing diagnoses
Patient outcomes
Nursing interventions
Potential for body image disturbance
Patient will be able to express self freely regarding postsurgical experience.
Elicit patient’s fears regarding changed body image. Acknowledge patient’s anxiety, sense of panic, and despair. Practice active listening.
Potential for decisional conflict regarding cancer treatment options
Patient will be able to make informed and intelligent decisions regarding type of surgery and adjuvant therapy as needed.
Assess patient’s ability to take in clinical information about breast cancer and treatment. Allow for questions that may be repeated often. Offer support for whatever choice the patient makes about her body and life.
Potential for ineffective coping
Patient will be able to regain and retain her courage and fighting spirit.
Acknowledge that anxiety may prevent effective coping. Acknowledge that denial may allow time to develop problem solving skills. Assist with explanations to the family about breast cancer. Allow patient to go through grieving process.
Potential for anticipatory grieving
Patient will be able to freely express grief over condition.
Assure patient that cancer is not a punishment for acts committed before the diagnosis. Allow for anger and disbelief to surface about diagnosis. Refer questions about recurrence to physician. Provide referral if needed to assist patient in grieving process.
Potential for altered role performance
Patient will be able to perform activities of daily living independently.
Assist patient with arm and hand exercises. Provide referral to Reach to Recovery for support. Teach alternative ways of meeting needs at home. Encourage patient to use arm and hand of affected side early in recovery.
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breast size following lumpectomy is acceptable cosmetically. Conversely, where breast size is so large as to preclude postoperative radiation therapy (RT), lumpectomy is contraindicated. Other contraindications to breast conservation surgery include the inability to obtain negative margins with lumpectomy, diffuse microcalcifications or density, making mammographic follow-up impossible, unavailability of RT facilities, or a patient unwilling to undergo RT. The use of postoperative RT for patients undergoing lumpectomy is important because local recurrence is significantly reduced with this therapy.25 There is as yet no well-defined group that does not require RT. The National Surgical Adjuvant Breast and Bowel Project (NSABP) is undertaking a study to determine whether patients with intraductal carcinoma may be such a group. Total mastectomy (TM) or a modified radical mastectomy with or without reconstruction remains an option that many women choose even if they are suitable candidates for breast conservation. Within some current NSABP t i als, only 25 to 30% of the patients undergo lumpectomy, yet half of the participants may be candidates for this type of surgery. Although TM is considered by many to be the gold standard of surgical therapy, within a NSABP trial that compared lumpectomy with or without radiation to TM, there were no significant differences in survival at a median of eight years follow-up.~6 Patients scheduled for surgical treatment of breast cancer are given preoperative instructions similar to those given any patient undergoing surgery. Most often, patients are admitted the morning of their surgery, and then go to an assigned room after they leave the postanesthesia care unit. Generally, each patient would be told the following: do not eat 'or drink anything after midnight or on the morning of surgery, avoid smoking at least 24 hours before surgery,
take no aspirin o r aspirin-containing medicines at least o n e week before surgery, check with your doctor about talung prescribed medications the morning of surgery, remove all makeup and nail polish, leave all valuables including jewelry, at home, do not consume alcohol for at least 24 hours before surgery, and 0 notify your physician of any change in your physical condition or if you have questions. The nurse or physician gives the patient specific written instructions about the time and date of surgery and where to report. A history and physical examination can be done in the clinic, as can the preoperative teaching. All mammograms, pathology reports, lab results, and the history and physical, should be assembled before the patient's arrival on the day of surgery. The penoperative nurse gives the patient an overview of what she can expect from the time she comes in until she is admitted to her room. The nurse instructs the patient in early ambulation, coughing and deep breathing, clinical follow-up, physical therapy, if necessary, and postmastectomy support groups such as Reach to Recovery. The nurse must assess the amount of information the patient is able to take in. Too many details or too much information can be overwhelming. When the patient arrives in the holding area, the nurse sees that all items required for surgery are assembled. The consent form is especially important. The consent can delineate several surgical options based on what might happen in relation to pathology findings, but more likely spells out exactly what is to be done. For example, the lumpectomy, mastectomy or other definitive treatment would be specified on the consent form, and an axillary dissection would be listed as a possibility. It is necessary for the nurse and surgeon to 0
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verify with the patient which breast will be operated on. The patient needs to be sure that she understands what the consent specifies and that she agrees with the planned procedure. It is helpful for the nurse to elicit the patient’s impressions about the surgery. The patient’s anxiety may be peaking at this point, and the nurse may have an opportunity to correct misunderstandings or reassure the patient. The anesthesiologist and surgeon ensure that laboratory values are within normal limits preoperatively. The nurse assists anesthesia personnel with starting an intravenous line on the unaffected side to maintain fluid volume and administer necessary medications. The anesthesiologist may order preoperative medications to allay anxiety and decrease secretions. The nurse administers a preoperative antibiotic at the surgeon’s request and fits the patient with thigh-high antiembolism stockings or automatic compression sleeves as ordered.
Inti-aoperative Patient Care
W
hen the perioperative nurse finishes an assessment of the patient and c h a r t , he o r s h e transports the patient to the operating suite. If able, the patient can move onto the operating room bed with guidance. The nurse covers the patient with a warm blanket. The patient may be asked to extend both arms on padded arm boards with palms up so the nurse can secure them with safety straps. A safety strap also is placed around the patient at least 2 inches above her knees. After the patient is induced and positioned, the nurse ensures the patient’s arms are not abducted more than 90 degrees to prevent brachial plexus injury. The nurse assesses the patient’s age, size, nutritional status, and skin condition and provides extra padding for the coccyx, heels, and other pressure points. When prepping, it is important not to scrub vigorously or with too much pressure over the tumor site. In some cases, the surgeon will request only an antiseptic paint. For the surgeon to drape the arm free for the
axillary node dissection, the nurse suspends the patient’s arm with finger traps. The nurse then preps the arm circumferentially, prepping the axilla last. The surgeon uses towels to square off the breast and axilla, and he or she may use a combination of laparotomy sheets and drape sheets to create a sterile surgical field. A sterile elastic bandage can be used to drape the distal arm.
Surgical Procedure
A
lumpectomy involves excision of the tumor with a 1- to 2-cm margin of .normal tissue surrounding it. This is generally done by sharp dissection, although s o m e s u r g e o n s m a y use e l e c t r o c a u t e r y . Following hemostasis of the biopsy site, it is recommended that the surgeon not close deep tissue. He or she may close the skin in a subcuticular fashion. Axillary d i s s e c t i o n m a y p r e c e d e t h e lumpectomy, depending on whether the surgeon has been able to diagnosis cancer preoperatively by FNA. Generally, the surgeon performs axillary dissection through a transverse incision approximately 1 cni below the axillary hairline. The incision extends from the pectoralis major muscle anteriorly to the latissimus dorsi muscle posteriorly. The surgeon removes lymphoareolar tissue between t h e two muscles. T h e dissection includes Level I a n d I1 l y m p h n o d e s ( i e , lymph nodes that extend up to the point of the medial margin of the pectoralis minor muscle). S o m e surgeons prefer to perform the lumpectomy first, reprep, redrape, and follow with the axillary dissection. The surgical team uses a separate set of instruments for each procedure to avoid possible tumor contamination of the axilla. Performing the axillary dissection second allows time for the pathologist to check the margins of lumpectomy tissue while the surgical team prepares for the second procedure. If necessary, the surgeon can re-excise the affected breast margins later. If a total mastectomy is to be done, it is gen951
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erally done on the basis of FNA diagnosis or incisional biopsy. The surgeon can perform the mastectomy immediately after the biopsy, however, many women prefer that a mastectomy be done as a separate procedure. The surgeon performs a total mastectomy through an elliptical incision that includes the nipple and areolar complex of the breast. He or she makes the incision transversely, occasionally obliquely, on the breast and develops skin flaps either with a knife, electrocautery, or laser to remove all the breast tissue and the axillary contents down to Level I1 lymph nodes. With the arm draped free and mobile, the surgeon can dissect high in the axilla by bringing the arm over the patient’s head. When the surgeon has removed the breast, the nurse must ensure that it is handed directly to the pathologist for further diagnostic studies. The circulating nurse should check with the surgeon about placing the specimen in saline or formalin. Formalin prohibits performing some studies on the breast. If estrogen and progesterone receptors or frozen sections are to be done, the tissue must be moistened with saline only. Axillary nodes may be handled similarly, although these generally are sent for permanent sections only. After a mastectomy, the surgeon places drains in the axilla and over the pectoralis muscle to eliminate dead space. He or she uses a closed suction drain with reservoirs, brings the tubes out through separate stab wounds, and sutures them in place. The surgeon closes the flaps using a two-layer closure with a deep layer and either a subcuticular stitch or skin staples. He or she uses large, loose gauze pads completely opened and bunched to create extra padding and holds them in place with foam or paper tape. The anesthesia personnel stop administering anesthetic gases, reverses any medication given in addition to the anesthesia, and monitor the patient’s emergence until extubation is possible. The nurse removes the grounding pad and checks the skin for burns, redness, or any break in skin integrity. He or she washes all prep solution off the patient and provides her with a 952
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fresh gown and warm blankets before the surgical team takes the patient to the postanesthesia care unit. The surgeon, in collaboration with a plastic surgeon, may perform breast reconstruction after the mastectomy. It is our practice to limit reconstruction at this time to women with noninvasive disease or women having a mastectomy done for prophylaxsis. Nonetheless, some surgeons believe that reconstruction is indicated for all patients and best done at the time of the original mastectomy. Reconstruction of the breast may be done by inserting silicone- or saline-filled implants in the subpectoral space. More commonly, inflatable tissue expanders placed under the pectoralis major muscle are used for reconstruction of the breast. Tissue expanders allow the surgeon to more closely match the opposite breast when the patient’s brassiere cup size is larger than a B. Separate, clean instruments are required for this portion of the case if done immediately a f t e r m a s t e c t o m y . Use of t i s s u e expanders requires a subsequent procedure to substitute an implant for the expander. Implants are indicated when there is adequate post-mastectomy skin and soft tissue and the opposite breast is relatively small (ie,
PATLENT C A R E
Parricia S t e i n , RN; Richard T. Zera, MD
I
n the United States, breast cancer occurs in
one out of 10 wo1neii.l It is estimated that there would be approximately 15 1,000 new cases of breast cancer in 1990, and more than 44,000 of those women would die from the disease. Until the age of 54, the leading cause of cancer-related deaths in women is breast cancer. The toll of breast cancer is exceeded only by lung cancer i n women aged 55 to 74 and colorectal cancer in women older than 75 as a malignancy-related cause of death. Given these facts, a nurse can expect to take care of'patients with breast cancer frequently or even find oneself with the disease. This article provides an overview of measures for early detection of breast cancer, diagnosis, and treatment. It also provides nursing diagnoses and a nursing care plan for the breast cancer patient.
M
any factors are evident in the etiology of breast cancer. Geuetic, hormonal, dietary, and environmental factors influence each case. Familial factors clearly identify some patients at higher risk. A woman with a first-degree relative (ie. mother or sister) with breast cancer is estimated to have a two to three times higher rish than the general population.' The menopausal status at which the relative is diagnosed is important. Higher rish is ;it t r i but a b 1e t o a p re m e 11o p a u 5 ;i 1 d i ag 11o s i s . Additional risk is noted if both the relative's breasts are involved. For example, the sister of a preinenopausal woniaii with bilateral breast ciliiceI is estimated to have a 30% risk of devel-
APRIL 1991, VOL S3. N O 4
A W N JOURNAL
The causative role of exogenous estrogen (ie, birth control pills or postmenopausal estrogen) remains controversial.
oping breast cancer by age 70. Her risk is reduced to approximately 17% if her sister developed a postmenopausal unilateral cancer.’ Hormonal influences also are implicated in the development of this disease. A woman with breast cancer is more likely to have had an early menarche and to be nulliparous or to have had her first full-term pregnancy after age 35. In addition, the late onset of natural menopause is considered a risk factor. Pregnancy before the age of 20 appears to offer some protection against breast cancers. This suggests that early full differentiation or “maturing” of breast e p i t h e l i u m i s i m p o r t a n t , a n d that later endocrine stimulation of this tissue may be a secondary promoter of cancer development. Removal of the ovaries either surgically or with radiotherapy before age 40 has been found to diminish the potential for breast cancer by as much as 75%. The causative role of exogenous estrogen in breast cancer (ie, birth control pills [BCPs], postmenopausal estrogen) remains controversial. Most BCPs contain both estrogen and progesterone. This balanced hormonal influence at worse appears to have no net effect on the incidence of breast cancer.(’ One study suggests that BCPs may offer a protective e f f e ~ t The . ~ postmenopausal use of estrogen/progesterone combinations continues to appear safe.x Unopposed estrogen use (ie, without progesterone) appears to be more of a problem. Estrogen, when used alone, appears to increase the risk of breast cancer by 2.5 times.’ As a rule, women who have had breast cancer should not receive estrogen. Dietary influence on the development of breast cancer centers primarily on high fat intake. In animals this has been shown to increase the incidence of chemically induced m a m m a r y c a r c in o m as. 1n h u m an s , both intake of dietary fat and excess body weight
in postmenopausal women have been shown to correlate positively with the risk of mortality from breast cancer.Io These results, however, have been considered inconclusive because other major studies dispute these findings. I I If an increased risk exists. it may be related to the increased activity of the enzyme aromatase. Aromatase is present to a large extent in peripheral adipose tissue. This enzyme converts precursors derived from the adrenal gland into estrogenic compounds. Obesity, therefore, may be associated with increased conversion of these precursors to an unopposed estrogenic compound. In addition, obesity is associated with increased output of these adrenal precursors. This suggests a causal link between diet, obesity, and breast cancer via these abnormalities and the presence of unopposed estrogens from an endogenous source. Preliminary results suggest that dietary influences also may prevent breast cancer. Certain foods (eg, some types of soy beans) contain phytoestrogens, which are plant-derived compounds with weak anti-estrogenic (ie, estrogen blocking) effects.” In animals, these agents decrease the incidence of chemically induced mammary cancer. Environmental factors that may contribute to breast cancer include radiation and certain chemical compounds. Although therapeutic radiation to the chest wall and breast has been associated with an increase of breast cancer, diagnostic mammography has not been shown to carry an increased risk. This is particularly true with improvements in current techniques and a lack of observed risk for radiation after the age of 40.” No discussion of breast cancer risk would be complete without a discussion of benign breast disease. T h e American College of Pathologists Consensus Statement discusses 939
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fibrocystic disease and the risk of invasive breast c a n ~ e r . The ’ ~ term fibrocystic disease covers a broad range of histologic diagnoses that include diagnoses with no added risk such as sclerosing adenosis, florid adenosis, apocrine metaplasia, duct ectasia, fibroadenoma, mild hyperplasia (ie, two to four epithelial cells in depth), mastitis, and periductal mastitis Diagnoses with slightly increased risk (ie, 1.5 to 2 times) include moderate, florid, solid, or papillary hyperplasia, and papilloma with fibrovascular core. Diagnoses with moderately increased risk (ie, up to 5 times) include atypical hyperplasia, ductal hyperplasia, and lobular hyperplasia. These catagories can be divided into proliferative lesions and nonproliferative lesions. Proliferative lesions are associated with an increased risk of subsequent invasive carcinoma. Where proliferation of ductal or lobular breast epithelium occurs in association with atypia, the risk of breast cancer increases to 5 times that of the “normal” female population.I5 Some authors would include a high risk category that includes lobular carcinoma in situ and ductal carcinoma in situ, although these are not considered benign fibrocystic disease. Many issues under the broad definition of fibrocystic disease have not been settled. For example, although apocrine metaplasia is in the “ n o increased risk” c a t e g o r y , when found in women older than 45 the associated risk of subsequent carcinoma increases 2.7 times.I6 Other nonfibrocystic conditions also may cause breast lumps. Inflammatory conditions, such as breast abscesses, fat necrosis, lipomas (ie, benign fatty tumors), and lesions of the skin (eg, sebaceous cysts) also
may cause breast lumps.”
Diagnosis reast cancer is a histologic diagnosis. Physical or mammographic findings may strongly suggest this diagnosis, but examination of tissues either as cytologic or histologic specimens is necessary for confirmation. T h e physical examination of a patient involves inspection and palpation. With careful attention, it is not unusual to see contour changes, nipple retraction or skin dimpling related to a n u n d e r l y i n g mass. Occasionally, the entire breast may be elevated relative to the opposite breast. Skin erythema may be the hallmark of inflammatory breast cancer. In more advanced cases, edema of the skin may be visible. Palpation of the breast is done in both sitting and supine positions. Inspection and palpation should be done with the arms at the sides as well as with arms raised above the head. The most common physical finding is a lump or mass which generally is hard and nontender. Examination of the cervical, supraclavicular, and axillary lymph nodes is important and should include attention to the number of nodes palpable, the nature of the nodes (ie, hard versus rubbery), and whether the node is fixed to underlying structures or to the skin. Arm edema is an ominous sign usually associated with advanced nodal involvement. The use of screening mammography (ie, xray examination of the breasts in asymptomatic women) has increased dramatically the number of patients who have no significant physical findings. Screening mammography increases survival rates in all women over 40.’* Sadly, mammography is not used enough in the United States. Much of the blame lies with physicians who fail to recommend the test to their patients. l9 Features shown on mammography that merit further evaluation and clinical correlation are 941
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asymmetry of the breasts, a discrete mass or density, particularly if it distorts the breast, calcifications within a mass, and 0 clusters of microcalcifications. Evaluation of physical or mammographic findings may include ultrasonography. This procedure can reliably determine if a mass is solid or cystic and generally is considered more useful in premenopausal women. If a mass is palpable, an alternative may be the use of fine needle aspiration (FNA). Fine needle aspiration using a 22- or 25gauge needle is rapid, inexpensive, and diagnostic as well as therapeutic for cysts. In addition, cytologic examination of the aspirate can be a highly accurate adjunct to the evaluation of a breast lump. This may obviate the need for a formal biopsy.*O The physician performing FNA should be familiar with its limitations. A suspicious mass and/or suspicious mammogram requires formal biopsy if FNA is negative for cancer. A small number of centers now have stereotactic FNA available that may allow cytologic evaluation of nonpalpable mammographic lesions. A special unit is required to perform FNA under radiographic control. The current expense of these installations, however, may limit their wider use. Biopsy techniques for mammographic lesions that are not palpable have evolved from blind biopsy of a general area in a given quadrant of the breast to “wire localization.” In the latter method, measurements taken from scout mammograms allow placement of a smallgauge needle through which a hooked wire can be passed. After confirming adequate placement by repeat mammograms with the needle and wire in place, the needle is removed leaving the wire as a guide for biopsy. After biopsy, a specimen radiograph is then taken to confirm removal of the lesion. It is our practice to approach palpable lesions by FNA. If this is not diagnostic and the lesion is suspicious on x-ray or physical examination, biopsy by Tru-cut needle or by incisional or excisional techniques should be done depend0
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Table 1
Types of Breast Cancer Carcinomas Infiltrating ductal Papillary Intraductal Mucinous Tubular Adenoid tuba1 Metaplastic Squamous cell Apocrine Secretory Giant cell Lobular carcinoma in situ Infiltrating lobular carcinoma Inflammatory Paget’s Disease Sarcomas Cystosarcoma phyllodes Stromal Fibrosarcoma Liposarcoma Angiosarcoma ing on the size of the lesion. Involvement of a pathologist is critical in handling specimens properly. It is important for the surgeon to orient excised lesions so specimens can be inked before fixation. This allows the pathologist to assess the margins of resection. In addition, proper handling of the specimen is necessary for measurement of estrogen and progesterone receptor contents, and deoxyribonucleic acid (DNA) flow cytometry. These measurements are all integral parts of the full evaluation of breast cancer specimens.
Types, Staging of Breast Cancer
B
reast cancer must be considered a generic term because there are at least fifteen histological subtypes of the disease (Table 1).*’ Infiltrating ductal carcinoma
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Table 2
The TNM Staging Systemfor Breast Cancer Stage I TINoMo Tumor size less than 2 cm May extend into pectoral fascia or muscle No distant metastasis No positive nodes Stage I1 T2NoMoor T10r2N1Mo Tumor size 2 to 5 cm May or may not extend into pectoral fascia or muscle No distant metastasis Mobile axillary nodes
Stage 111 T1or2N1Wor T1-3N2M0or T3N0M0 Tumor size greater than 5 cm May or may not extend into pectoral fascia and muscle Skin edema, infiltration or ulceration may be present Nodes fixed to skin, deeper structures, supraclavicular nodes No distant metastasis Stage IV Any TN3 any M or T4 any N any M Any TN plus M’
Definitions
T = primary tumor T 4= Tumor extension to the chest wall or skin N = regional lymph nodes NO = no growth N l = movable nodes with tumor growth N2 = homolateral axillary nodes fixed to one
represents more than 50% of histologic diagnoses. A specific subtype diagnosis offers an improved prognosis over that of infiltrating ductal carcinoma. In addition to carcinomas, there are five different sarcomas of the breast. Breast cancer is classified into four stages. Staging describes tumor size, lymph node involvement, and distant metastasis. In the “TNM’ system, T equals tumor size, N equals lymph nodes, and M equals metastasis (Table 2).
Patient Care
T
ypes of breast lesions, either cancerous or benign, can be classified into categories; Patients who have these lesions
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another or other structures and containing growth N3 = homolateral infra or supraclavicular nodes containing growth A4 = distant metastasis iW=absent MI= present, includes skin beyond the breast
cannot. The nurse must approach each patientindividually in terms of diagnosis and treatment. Several nursing diagnoses may be used to guide perioperative interventions. Potential for body image disturbance. This seems obvious, however, there are some women who feel the fear of recurrence they would experience by not having the breast removed outweighs a body image change. Although the age of a patient would seem to be a factor in considering body image issues, some younger women facing 30 to 40 years of monitoring a breast elect to have a total mastectomy. Conversely, many older women share feelings and concern about how surgery will affect their body image.22
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The perioperative nurse needs to be sensitive to issues of sexuality and femininity when working with a patient who has breast cancer. The patient who has elected a less radical procedure to preserve her breast needs support for that decision as she enters the operative suite. Potential for decisional conflict regarding cancer treatment options. This may be more fitting in some cases. There are several choices and decisions about treatment that the patient with breast cancer must make. Weighing the choices can be very stressful. 23 Potential for ineffective individual coping. This exists regardless of the patient’s age. When a woman enters her physician’s office or clinic to undergo a breast examination she often has an underlying fear that a lump found at home will be cancerous. This fear alone can cause the woman to delay seeking diagnosis and treatment because she may not be able to cope with the findings. The patient may avoid care until she is in an active problem-solving mode. This may not occur until the anxiety aroused by the discovery is recognized and acknowledged. If the patient is in denial, that denial may be controlling her anxiety and allowing the patient time to develop some means for problem solving. The shock, disbelief, and confusion associated with a diagnosis of breast cancer directly affects the patient’s receptivity to any preoperative or postoperative teaching. When preparing to do preoperative teaching, the perioperative nurse should assess the patient for signs of coping that signal a readiness to learn. Coping has been described as the way in which a patient manages to retain her courage and fighting spirit. Potential for anticipatory grieving. This can be related to concern that the patient may have had something to do with being diagnosed with breast cancer and can lead to feelings of If the patient delays going to her physician, and as a result, delays diagnosis and treatment, she may not show signs of grief until after the surgery. The patient may feel a certain amount of depression and hopelessness. The nurse should be aware that a patient who consents for 946
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surgery may not understand the full consequences of that surgery until it has occurred. Potential for altered role performance. The perioperative nurse must be sensitive to the feelings of helplessness, depression, fatigue, and insomnia that a patient may experience and how they affect the patient’s return to presurgical activities. Any woman may find her role in life greatly changed for a time. For the woman who is used to being self-sufficient, asking for and accepting help can be stressful. A woman who felt helpless and powerless before surgery may be at a complete standstill when faced with breast cancer. In a study of 43 breast cancer patients, however, 80% believed that the illness had made them grow as human beings, and 90% said it had taught them to understand others. There is no doubt that having a life-threatening illness will change a woman’s relationship with the rest of the world. The perioperative nurse needs to understand that the intraoperative phase of care is small in terms of the time spent actually dealing with the problem. (See “Nursing Care Plan for the Patient with Breast Cancer.”)
Preoperative Care
A
fter the diagnosis of breast cancer has been made, the preoperative workup .should include a history and physical examination, complete blood count, electrolyte evaluation, liver function tests, and a chest x-ray. Any signs or symptoms of metastatic disease require further evaluation that may include a total body bone scan, x-rays andlor computerized axial tomography of the head, lungs or abdomen. Surgery should be delayed until the workup is complete. Surgical options should be discussed at length with the patient. Breast conservation surgery (ie, lumpectomy with axillary dissection) is indicated for women with tumors less than 5 cm in size and those whose altered
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Nursing Care Plan for the Patient with Breast Cancer Nursing diagnoses
Patient outcomes
Nursing interventions
Potential for body image disturbance
Patient will be able to express self freely regarding postsurgical experience.
Elicit patient’s fears regarding changed body image. Acknowledge patient’s anxiety, sense of panic, and despair. Practice active listening.
Potential for decisional conflict regarding cancer treatment options
Patient will be able to make informed and intelligent decisions regarding type of surgery and adjuvant therapy as needed.
Assess patient’s ability to take in clinical information about breast cancer and treatment. Allow for questions that may be repeated often. Offer support for whatever choice the patient makes about her body and life.
Potential for ineffective coping
Patient will be able to regain and retain her courage and fighting spirit.
Acknowledge that anxiety may prevent effective coping. Acknowledge that denial may allow time to develop problem solving skills. Assist with explanations to the family about breast cancer. Allow patient to go through grieving process.
Potential for anticipatory grieving
Patient will be able to freely express grief over condition.
Assure patient that cancer is not a punishment for acts committed before the diagnosis. Allow for anger and disbelief to surface about diagnosis. Refer questions about recurrence to physician. Provide referral if needed to assist patient in grieving process.
Potential for altered role performance
Patient will be able to perform activities of daily living independently.
Assist patient with arm and hand exercises. Provide referral to Reach to Recovery for support. Teach alternative ways of meeting needs at home. Encourage patient to use arm and hand of affected side early in recovery.
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breast size following lumpectomy is acceptable cosmetically. Conversely, where breast size is so large as to preclude postoperative radiation therapy (RT), lumpectomy is contraindicated. Other contraindications to breast conservation surgery include the inability to obtain negative margins with lumpectomy, diffuse microcalcifications or density, making mammographic follow-up impossible, unavailability of RT facilities, or a patient unwilling to undergo RT. The use of postoperative RT for patients undergoing lumpectomy is important because local recurrence is significantly reduced with this therapy.25 There is as yet no well-defined group that does not require RT. The National Surgical Adjuvant Breast and Bowel Project (NSABP) is undertaking a study to determine whether patients with intraductal carcinoma may be such a group. Total mastectomy (TM) or a modified radical mastectomy with or without reconstruction remains an option that many women choose even if they are suitable candidates for breast conservation. Within some current NSABP t i als, only 25 to 30% of the patients undergo lumpectomy, yet half of the participants may be candidates for this type of surgery. Although TM is considered by many to be the gold standard of surgical therapy, within a NSABP trial that compared lumpectomy with or without radiation to TM, there were no significant differences in survival at a median of eight years follow-up.~6 Patients scheduled for surgical treatment of breast cancer are given preoperative instructions similar to those given any patient undergoing surgery. Most often, patients are admitted the morning of their surgery, and then go to an assigned room after they leave the postanesthesia care unit. Generally, each patient would be told the following: do not eat 'or drink anything after midnight or on the morning of surgery, avoid smoking at least 24 hours before surgery,
take no aspirin o r aspirin-containing medicines at least o n e week before surgery, check with your doctor about talung prescribed medications the morning of surgery, remove all makeup and nail polish, leave all valuables including jewelry, at home, do not consume alcohol for at least 24 hours before surgery, and 0 notify your physician of any change in your physical condition or if you have questions. The nurse or physician gives the patient specific written instructions about the time and date of surgery and where to report. A history and physical examination can be done in the clinic, as can the preoperative teaching. All mammograms, pathology reports, lab results, and the history and physical, should be assembled before the patient's arrival on the day of surgery. The penoperative nurse gives the patient an overview of what she can expect from the time she comes in until she is admitted to her room. The nurse instructs the patient in early ambulation, coughing and deep breathing, clinical follow-up, physical therapy, if necessary, and postmastectomy support groups such as Reach to Recovery. The nurse must assess the amount of information the patient is able to take in. Too many details or too much information can be overwhelming. When the patient arrives in the holding area, the nurse sees that all items required for surgery are assembled. The consent form is especially important. The consent can delineate several surgical options based on what might happen in relation to pathology findings, but more likely spells out exactly what is to be done. For example, the lumpectomy, mastectomy or other definitive treatment would be specified on the consent form, and an axillary dissection would be listed as a possibility. It is necessary for the nurse and surgeon to 0
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verify with the patient which breast will be operated on. The patient needs to be sure that she understands what the consent specifies and that she agrees with the planned procedure. It is helpful for the nurse to elicit the patient’s impressions about the surgery. The patient’s anxiety may be peaking at this point, and the nurse may have an opportunity to correct misunderstandings or reassure the patient. The anesthesiologist and surgeon ensure that laboratory values are within normal limits preoperatively. The nurse assists anesthesia personnel with starting an intravenous line on the unaffected side to maintain fluid volume and administer necessary medications. The anesthesiologist may order preoperative medications to allay anxiety and decrease secretions. The nurse administers a preoperative antibiotic at the surgeon’s request and fits the patient with thigh-high antiembolism stockings or automatic compression sleeves as ordered.
Inti-aoperative Patient Care
W
hen the perioperative nurse finishes an assessment of the patient and c h a r t , he o r s h e transports the patient to the operating suite. If able, the patient can move onto the operating room bed with guidance. The nurse covers the patient with a warm blanket. The patient may be asked to extend both arms on padded arm boards with palms up so the nurse can secure them with safety straps. A safety strap also is placed around the patient at least 2 inches above her knees. After the patient is induced and positioned, the nurse ensures the patient’s arms are not abducted more than 90 degrees to prevent brachial plexus injury. The nurse assesses the patient’s age, size, nutritional status, and skin condition and provides extra padding for the coccyx, heels, and other pressure points. When prepping, it is important not to scrub vigorously or with too much pressure over the tumor site. In some cases, the surgeon will request only an antiseptic paint. For the surgeon to drape the arm free for the
axillary node dissection, the nurse suspends the patient’s arm with finger traps. The nurse then preps the arm circumferentially, prepping the axilla last. The surgeon uses towels to square off the breast and axilla, and he or she may use a combination of laparotomy sheets and drape sheets to create a sterile surgical field. A sterile elastic bandage can be used to drape the distal arm.
Surgical Procedure
A
lumpectomy involves excision of the tumor with a 1- to 2-cm margin of .normal tissue surrounding it. This is generally done by sharp dissection, although s o m e s u r g e o n s m a y use e l e c t r o c a u t e r y . Following hemostasis of the biopsy site, it is recommended that the surgeon not close deep tissue. He or she may close the skin in a subcuticular fashion. Axillary d i s s e c t i o n m a y p r e c e d e t h e lumpectomy, depending on whether the surgeon has been able to diagnosis cancer preoperatively by FNA. Generally, the surgeon performs axillary dissection through a transverse incision approximately 1 cni below the axillary hairline. The incision extends from the pectoralis major muscle anteriorly to the latissimus dorsi muscle posteriorly. The surgeon removes lymphoareolar tissue between t h e two muscles. T h e dissection includes Level I a n d I1 l y m p h n o d e s ( i e , lymph nodes that extend up to the point of the medial margin of the pectoralis minor muscle). S o m e surgeons prefer to perform the lumpectomy first, reprep, redrape, and follow with the axillary dissection. The surgical team uses a separate set of instruments for each procedure to avoid possible tumor contamination of the axilla. Performing the axillary dissection second allows time for the pathologist to check the margins of lumpectomy tissue while the surgical team prepares for the second procedure. If necessary, the surgeon can re-excise the affected breast margins later. If a total mastectomy is to be done, it is gen951
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erally done on the basis of FNA diagnosis or incisional biopsy. The surgeon can perform the mastectomy immediately after the biopsy, however, many women prefer that a mastectomy be done as a separate procedure. The surgeon performs a total mastectomy through an elliptical incision that includes the nipple and areolar complex of the breast. He or she makes the incision transversely, occasionally obliquely, on the breast and develops skin flaps either with a knife, electrocautery, or laser to remove all the breast tissue and the axillary contents down to Level I1 lymph nodes. With the arm draped free and mobile, the surgeon can dissect high in the axilla by bringing the arm over the patient’s head. When the surgeon has removed the breast, the nurse must ensure that it is handed directly to the pathologist for further diagnostic studies. The circulating nurse should check with the surgeon about placing the specimen in saline or formalin. Formalin prohibits performing some studies on the breast. If estrogen and progesterone receptors or frozen sections are to be done, the tissue must be moistened with saline only. Axillary nodes may be handled similarly, although these generally are sent for permanent sections only. After a mastectomy, the surgeon places drains in the axilla and over the pectoralis muscle to eliminate dead space. He or she uses a closed suction drain with reservoirs, brings the tubes out through separate stab wounds, and sutures them in place. The surgeon closes the flaps using a two-layer closure with a deep layer and either a subcuticular stitch or skin staples. He or she uses large, loose gauze pads completely opened and bunched to create extra padding and holds them in place with foam or paper tape. The anesthesia personnel stop administering anesthetic gases, reverses any medication given in addition to the anesthesia, and monitor the patient’s emergence until extubation is possible. The nurse removes the grounding pad and checks the skin for burns, redness, or any break in skin integrity. He or she washes all prep solution off the patient and provides her with a 952
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fresh gown and warm blankets before the surgical team takes the patient to the postanesthesia care unit. The surgeon, in collaboration with a plastic surgeon, may perform breast reconstruction after the mastectomy. It is our practice to limit reconstruction at this time to women with noninvasive disease or women having a mastectomy done for prophylaxsis. Nonetheless, some surgeons believe that reconstruction is indicated for all patients and best done at the time of the original mastectomy. Reconstruction of the breast may be done by inserting silicone- or saline-filled implants in the subpectoral space. More commonly, inflatable tissue expanders placed under the pectoralis major muscle are used for reconstruction of the breast. Tissue expanders allow the surgeon to more closely match the opposite breast when the patient’s brassiere cup size is larger than a B. Separate, clean instruments are required for this portion of the case if done immediately a f t e r m a s t e c t o m y . Use of t i s s u e expanders requires a subsequent procedure to substitute an implant for the expander. Implants are indicated when there is adequate post-mastectomy skin and soft tissue and the opposite breast is relatively small (ie,
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